From the Guidelines
Role of Hormone Replacement Therapy (HRT) in a 73-year-old Postmenopausal Woman
Hormone replacement therapy (HRT) is generally not recommended for a 73-year-old postmenopausal woman due to the potential increased risks of cardiovascular events and stroke 1.
- The Women's Health Initiative (WHI) study, as cited in 1, found that combined estrogen and progestin therapy showed a trend toward an increased risk for coronary heart disease (CHD) after 5 years of follow-up, which persisted through 8.6 years.
- Additionally, the study revealed that women's risk for stroke is statistically significantly increased with the use of postmenopausal hormone therapy, with the estrogen-only group in WHI being stopped early because of the observed increased stroke rate 1.
- However, HRT may be beneficial in reducing the risk of fractures, as the WHI study found that estrogen and progestin decreased the rates of hip, vertebral, and total fractures compared with placebo 1.
- In cases of severe menopausal symptoms that significantly impact quality of life, short-term use of low-dose HRT may be considered under close medical supervision, with a suggested regimen of low-dose estrogen-only therapy, such as 0.5mg of estradiol daily, for a limited duration, typically not exceeding 2-3 years.
- It's crucial to weigh the benefits against the risks and to monitor the patient closely for any adverse effects, with regular review and assessment of the need for continued HRT necessary, aiming to use the lowest effective dose for the shortest duration possible.
From the FDA Drug Label
The primary source of estrogen in normally cycling adult women is the ovarian follicle, which secretes 70 to 500 mcg of estradiol daily, depending on the phase of the menstrual cycle. After menopause, most endogenous estrogen is produced by conversion of androstenedione, secreted by the adrenal cortex, to estrone by peripheral tissues Estrogens act through binding to nuclear receptors in estrogen-responsive tissues. The Women’s Health Initiative (WHI) enrolled a total of 27,000 predominantly healthy postmenopausal women to assess the risks and benefits of either the use of oral 0.625 mg conjugated estrogens (CE) per day alone or the use of oral 0.625 mg conjugated estrogens plus 2. 5 mg medroxyprogesterone acetate (MPA) per day compared to placebo in the prevention of certain chronic diseases. Estrogens with or without progestins should not be used for the prevention of cardiovascular disease. Because of these risks, estrogens with or without progestins should be prescribed at the lowest effective doses and for the shortest duration consistent with treatment goals and risks for the individual woman.
The role of Hormone Replacement Therapy (HRT) in a 73-year-old postmenopausal woman is to:
- Relieve menopausal symptoms (not explicitly stated in the provided text, but a common use of HRT)
- Prevent osteoporosis: The provided text states that treatment with 0.5 mg estradiol daily for 23 days (of a 28-day cycle) prevents vertebral bone mass loss in postmenopausal women 2. However, HRT should be prescribed with caution due to the increased risks of:
- Cardiovascular disease
- Invasive breast cancer
- Pulmonary emboli
- Deep vein thrombosis
- Dementia (in women 65 years of age or older) HRT should be prescribed at the lowest effective doses and for the shortest duration consistent with treatment goals and risks for the individual woman 2.
From the Research
Role of Hormone Replacement Therapy (HRT) in a 73-year-old Postmenopausal Woman
The role of HRT in a 73-year-old postmenopausal woman is complex and depends on various factors, including her individual risk of breast cancer, coronary heart disease, venous thromboembolism, and stroke 3.
- Benefits and Risks: HRT is effective for the prevention of postmenopausal osteoporosis, but it is generally recommended as an option only for women at significant risk, for whom non-oestrogen therapies are unsuitable 4, 5.
- Long-term Use: Long-term use of HRT has been associated with substantial risks, including increased risk of breast cancer, coronary heart disease, venous thromboembolism, and stroke 3, 4, 5.
- Individualized Approach: A woman's individual risk factors, such as age, medical history, and lifestyle, should be taken into account when considering HRT 3, 6, 7.
- Alternatives to HRT: Non-oestrogen therapies, such as selective estrogen receptor modulators and phytoestrogens, may be considered as alternatives to HRT for the management of menopausal symptoms and prevention of osteoporosis 6.
- Patient Education: Patient education and counseling are essential to help women make informed decisions about HRT, weighing the benefits against the potential risks 6, 7.
- Cancer Risk: The risk of cancer, particularly breast cancer, should be carefully considered when prescribing HRT, and individual risk must be weighed against the benefits offered by HRT 7.