What are the concerns with a 78-year-old female on Climara (estradiol) patch and progesterone?

Concerns for a 78-Year-Old Female on Climara Patch and Progesterone

The primary concerns for a 78-year-old female on Climara (estradiol) patch and progesterone include increased risks of breast cancer, stroke, venous thromboembolism, and cardiovascular disease that likely outweigh the benefits for most women in this age group. 1, 2

Key Risks of Hormone Therapy at Advanced Age

Cardiovascular Risks

• Stroke: The Women's Health Initiative (WHI) study demonstrated an increased risk of stroke in women receiving hormone therapy (29 vs 21 per 10,000 women-years) 2
• Venous thromboembolism (VTE): 2-fold greater rate of VTE observed in women on hormone therapy 2
• Cardiovascular disease: Increased risk of myocardial infarction, particularly in older women 2

Cancer Risks

• Breast cancer: Increased risk with long-term use of combined estrogen-progestin therapy 2
• Endometrial cancer: While progesterone helps protect against this risk, any unexplained vaginal bleeding should be immediately evaluated 1, 2

Cognitive Concerns

• Dementia: The Women's Health Initiative Memory Study reported a two-fold increase in probable dementia risk in women 65 years and older on hormone therapy, with 90% of cases occurring in women over 70 2

Age-Specific Considerations

At 78 years old, this patient falls into a high-risk category:

• The risks of hormone therapy increase significantly with age
• Benefits of hormone therapy are generally more favorable when started near menopause (around age 51), not decades later 3
• The FDA boxed warning specifically highlights increased risks in older women 2

Monitoring Recommendations

If continuing hormone therapy is deemed necessary despite the risks:

1. Regular gynecological assessment is mandatory, including:

   • Breast examination and mammography
   • Pelvic examination
   • Endometrial assessment if any vaginal bleeding occurs 1

2. Cardiovascular monitoring:

   • Blood pressure checks
   • Lipid profile
   • Assessment for signs of VTE 2

3. Immediate medical attention for:

   • Any vaginal bleeding (high suspicion for endometrial cancer) 1
   • Chest pain, shortness of breath, severe headache, vision changes, leg pain/swelling (potential cardiovascular or thrombotic events) 2

Alternative Approaches

Given the high-risk profile at age 78, consider:

• Discontinuation of hormone therapy with careful tapering if symptoms allow
• Non-hormonal alternatives for specific symptoms:
  • SSRIs/SNRIs (like paroxetine 10-12.5mg) for vasomotor symptoms 1
  • Vaginal moisturizers and lubricants for vaginal dryness 1
  • Gabapentin for hot flashes 1

Important Caveats

• Transdermal estradiol (Climara patch) has a lower risk of VTE compared to oral formulations, but risks still remain significant at advanced age 1, 3
• Natural progesterone (as opposed to synthetic progestins) may have a lower risk profile for VTE and breast cancer 1
• Despite these slightly safer formulations, the overall risk-benefit ratio at age 78 remains unfavorable 1, 2

The decision to continue or discontinue hormone therapy should be reassessed immediately, with strong consideration given to discontinuation due to the significantly increased risks at this advanced age.