At what age should Hormone Replacement Therapy (HRT) be stopped?

When to Stop Hormone Replacement Therapy (HRT)

HRT should be discontinued at the average age of natural menopause (approximately 51 years) for women with iatrogenic premature ovarian insufficiency, at which point they should be re-evaluated, while for women who started HRT for natural menopausal symptoms, treatment should be individualized with periodic reassessment after age 60 or beyond 10 years of use due to increased risks. 1, 2

Age-Based Recommendations for Discontinuing HRT

For Women with Premature Ovarian Insufficiency (POI)

• Continue HRT until the average age of spontaneous menopause (45-55 years) 1
• After reaching average menopause age, re-evaluate the decision to continue or stop based on:
  • Individual risk factors
  • Family history
  • Personal symptoms
  • Quality of life considerations

For Women Who Started HRT for Natural Menopause

• For women who started HRT at natural menopause:
  • Increased risks appear after age 60 or more than 10 years post-menopause 2
  • The benefit-risk ratio becomes less favorable due to greater absolute risks of:
    • Coronary heart disease
    • Stroke
    • Venous thromboembolism
    • Dementia 2, 3

Risk-Benefit Assessment for Continuing HRT Beyond Age 60

Increased Risks with Long-Term Use

• Breast cancer risk increases with duration of use and can persist for >10 years after discontinuation 3
• Women's Health Initiative (WHI) studies showed:
  • Increased risk of myocardial infarction
  • Increased risk of stroke
  • Increased risk of invasive breast cancer
  • Increased risk of pulmonary emboli and deep vein thrombosis 3
• Women's Health Initiative Memory Study (WHIMS) showed increased risk of dementia in women ≥65 years 3

Potential Benefits of Continued Use

• Ongoing management of persistent vasomotor symptoms
• Prevention of bone loss and fractures 4
• Potential reduction in all-cause mortality when started in women <60 years 5

Approach to Discontinuation

Gradual Tapering vs. Abrupt Discontinuation

• Approximately 75% of women are able to stop HRT without major difficulty 6
• For women with persistent symptoms, consider:
  • Slowly tapering HRT dose rather than abrupt discontinuation
  • Monitoring for return of vasomotor symptoms
  • Re-evaluating annually 2

Special Considerations

• Women with ongoing severe vasomotor symptoms may benefit from continued therapy despite age
• For women who cannot tolerate discontinuation, symptom relief may outweigh increased risks 6
• For women with genitourinary symptoms only, consider switching to low-dose vaginal estrogen with minimal systemic absorption 2

Monitoring During and After Discontinuation

• Annual clinical review while on HRT 2
• Monitor for:
  • Return of vasomotor symptoms
  • Changes in bone mineral density
  • Cardiovascular risk factors
  • Abnormal bleeding (which requires evaluation)

Common Pitfalls to Avoid

• Failing to recognize that discontinuation symptoms may occur in women who started HRT for non-symptom reasons (e.g., osteoporosis prevention)
• Not addressing the increased risk of bone loss after HRT discontinuation
• Continuing HRT indefinitely without periodic reassessment of risks and benefits
• Not recognizing that vaginal bleeding is a common reason for discontinuation, particularly in older women 7

Remember that the decision to continue or discontinue HRT should be reassessed periodically, with consideration of changing risk-benefit profiles as women age, particularly after age 60 or beyond 10 years of use.