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Menopausal HRT Series: Should women start or stop HRT at a certain age?

Clinical Consulting Team

| 05/28/2024

Menopausal HRT Series: Should women start or stop HRT at a certain age?

by Clinical Consulting Team

This post was written by our guest author, Dr. Tori Hudson, ND.

This Menopausal HRT blog series will focus on some classic myths that can lead to depriving women of hormones they may need, prescribing insufficient doses of progesterone in combination with systemic estrogen, timing of initiation of MHT, myths on discontinuation, and the subject of bioidentical hormones and compounding. This post discusses myths around the timing of initiation of MHT.

Myth: Women who take MHT should stop by the age of 60.

There is no such guideline from the main menopause expert organizations. There is also no general rule for stopping systemic hormone therapy in a woman aged 60 or even 65 years. The Beers criteria from the American Geriatrics Society does list a warning for the use of MHT in women 65 and older. However, any routine discontinuation of systemic MHT is not cited by evidence nor supported by ACOG or NAMS. The continued use of MHT in a healthy woman older than 65 and at low risk of breast cancer and cardiovascular disease is limited by insufficient evidence for safety, risks, and benefits.

As an example, if a woman is considered healthy and has persistent vasomotor symptoms, continuing MHT is a reasonable option with a yearly evaluation. MHT is also a treatment option for osteoporosis and prevention of hip and spine fractures, and MHT would need to be continued to get fracture risk reduction. Long term MHT is not indicated or considered appropriate for reduction of dementia or CHD. However, there is an increasing amount of biologic plausibility and data on the benefits of systemic estrogen to the brain if started in perimenopause, the first 10 years of the last menstrual period, and perhaps even within the last 5 years.

If a woman has a family history of Alzheimer’s disease (AD) and has initiated MHT within the optimal window of before age 60 and before 10 years postmenopause, it is this practitioner’s opinion and recommendation that she continue MHT long term to reduce her risk of AD. This is not yet an FDA-approved use of MHT nor is it a standard of care guideline from the advisory organizations. However, given that AD is a terrible disease with no cure, and the patient is at increased risk in this scenario, MHT is an option I would want to discuss. However, if she is older than 60 or more than 10 years postmenopause, I would not initiate it, even with a family history of AD, because initiating outside of the window may increase her risk. See the next myth for more.

Women should be evaluated at minimum once per year to weigh the benefits and risks with their healthcare provider. Women can continue MHT if there are appropriate indications including severe vasomotor symptoms and/or as a treatment option for osteoporosis of the lumbar spine.

What is true, relative to stopping systemic estrogen, is that women who are on oral or sublingual estrogen need to switch to transdermal delivery by age 65. Her aging vessels and metabolism of estrogen are now more subject to higher effects of oral/sublingual estrogen on atherosclerosis and risk for DVT and stroke. The pharmacokinetics of estrogen metabolism (and of many drugs) in the liver changes with age and warrants transdermal delivery of that estrogen to mitigate the stimulation of clotting factors by oral estrogen and to mitigate more variable absorption issues.

Myth: Women can start taking MHT at any age.

This myth is in opposition to all the major organizations who offer standard of care guidelines, including: The Endocrine Society, The International Menopause Society, The North American Menopause Society (NAMS) and the American College of Obstetricians and Gynecologists (ACOG). NAMS states it well:

“The 2022 hormone therapy guidelines from NAMS state that the lowest dose of MHT for menopause symptom relief in women before age 60 or who are within 10 years of menopause can be safe and can provide significant relief. Starting after age 60 or after 10 years postmenopause can increase the risk of cardiovascular disease and Alzheimer’s Dementia. Administering MHT after age 60 or after 10 years post menopause increases the risk of cardiovascular disease, Alzheimer’s Dementia, DVT, and stroke.”

At one time, MHT was almost routinely and universally recommended, but with the publication of the Heart and Estrogen/Progestin Replacement study (HERS) and the Women’s Health Initiative (WHI) randomized trials, which reported excess cardiovascular risk, MHT use declined significantly. No medical societies or menopause specialty organizations currently recommend MHT for the primary or secondary prevention of cardiovascular disease, including the American Heart Association, ACOG, American College of Endocrinology, Endocrine Society, NAMS, and UPSTF.

Follow along in the coming months to read more of my myth-debunking in this Menopausal HRT blog series.

Become a DUTCH Provider to learn more about how hormone testing can help inform comprehensive patient treatment plans.

References

“The 2022 Hormone Therapy Position Statement of The North American Menopause Society” Advisory Panel . The 2022 hormone therapy position statement of The North American Menopause Society . Menopause 2022 Jul 1;29(7):767-794.

Hulley S, Grady D, Bush T, et al. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. Heart and Estrogen/progestin Replacement Study Research Group. JAMA 1998;280:605-613.

Manson J, Hsia J, Johnson K, et al Estrogen plus progestin and the risk of coronary heart disease. NEJM 2003;349:523-534.

Anderson G, Limacher M, Assaf A, et al. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy, the Women’s Healht Initiative randomized controlled trial. JAMA 2004;291:1701-1712.

Steinkaliner A, Dennison S, Eldridge S, et al. A decade of postmenopausal hormone therapy prescribing in the United States: long-term effect of the Women’s Health Initiative 2012; 19:616-621.

Dupont W, Page D. Menopausal estrogen replacement therapy and breast cancer. Arch Intern Med. 1991;151:67-72.

Nachtigall M, Smilen S, Nachtigal R, et al. Incidence of progestin replacement therapy. Obstet Gynecol. 1992;80:827-30.

Colditz G, Hankinson S, Hunter D, et al. The use of estrogens and progestins and the risk of breast cancer in postmenopausal women. NEJM 1995; 332:1589-93.

Willis D, Calle E, Miracle-McMahill H, et al. Estrogen replacement therapy and risk of fatal breast cancer in a prospective cohort of postmenopausal women in the U.S. Cancer causes Control. 1996;7:449-57.

This post was written by our guest author, Dr. Tori Hudson, ND.
Dr. Hudson is clinical adjunct professor at NUNM, Southwest College of Naturopathic Medicine, Bastyr University and the Canadian College of Naturopathic Medicine. Dr Hudson has been in practice for more than 36 years, is the medical director of “A Woman’s Time” in Portland, Oregon, co-owner and director of product research and education for VITANICA, and the program director for the Institute of Women’s Health and Integrative Medicine. She is also the founder and co-director of NERC (Naturopathic Education and Research Consortium), a non-profit organization for accredited naturopathic residencies. Dr. Hudson has been appointed as a faculty member of the Fellowship in Integrative Health and Medicine, Academy of Integrative Health & Medicine.

Learn More about Dr. Tori Hudson