What are the guidelines for Hormone Replacement Therapy (HRT) in individuals above 60?

Hormone Replacement Therapy Guidelines for Women Over 60

Hormone replacement therapy (HRT) should generally be avoided in women over 60 years of age due to unfavorable risk-benefit ratio, with limited exceptions for severe vasomotor symptoms when no contraindications exist and using the lowest effective dose for the shortest time necessary.

Risk-Benefit Assessment for Women Over 60

The benefit-risk balance of HRT becomes less favorable as women age beyond 60 years or are more than 10 years past menopause onset 1. This is due to:

• Increased absolute risks of:

  • Coronary heart disease
  • Stroke
  • Venous thromboembolism
  • Dementia 1

• Long-term HRT use is associated with:

  • Increased risk of breast cancer
  • Increased risk of ovarian cancer
  • Cardiovascular and thromboembolic morbidity 1

Appropriate Indications for HRT in Women Over 60

While generally not recommended, HRT may be considered in limited circumstances:

1. Severe vasomotor symptoms (hot flashes, night sweats) that significantly impact quality of life and do not respond to non-hormonal treatments 1

2. Genitourinary syndrome of menopause (vaginal dryness, dyspareunia) - preferably treated with low-dose vaginal estrogen rather than systemic therapy 2

Contraindications to HRT

HRT should be absolutely avoided in women over 60 with:

• History of breast cancer
• Coronary heart disease
• Previous venous thromboembolic event or stroke
• Active liver disease
• Positive antiphospholipid antibodies 3, 1

Treatment Approach When HRT is Considered

If HRT is deemed necessary for a woman over 60 after careful consideration:

1. Use lowest effective dose for the shortest possible time 1

2. Consider transdermal route rather than oral administration to reduce thrombotic risk 3, 4

3. Recommended regimens:

   • Transdermal estradiol patches 0.025-0.0375 mg/day (lowest effective dose)
   • If uterus is intact: Add micronized progesterone 200 mg daily for 12-14 days per month 3

4. Regular monitoring:

   • Initial follow-up at 3 months
   • Annual follow-up thereafter
   • Monitor blood pressure, weight, lipid profile, symptom control, bleeding patterns
   • Annual mammography 3

5. Discontinuation strategy:

   • Gradual reduction of HRT dose by 25-50% every 4-8 weeks
   • Monitor for return of vasomotor symptoms 3

Non-Hormonal Alternatives

For women over 60 with menopausal symptoms, non-hormonal approaches should be first-line:

• Weight loss if overweight
• Smoking cessation
• Limiting alcohol intake
• Regular physical activity
• Cognitive behavioral therapy for hot flashes 3
• Acupuncture for vasomotor symptoms 3

Special Considerations

Women with Risk-Reducing Surgeries

For women who underwent risk-reducing bilateral salpingo-oophorectomy (RRBSO) before natural menopause:

• HRT is recommended until the age of natural menopause (approximately 51 years)
• After age 51, standard recommendations apply - generally discontinue HRT by age 60 1

Women with HIV

For HIV-positive women over 60:

• Hormone replacement therapy is generally not recommended
• If severe menopausal symptoms exist, use should be limited to the lowest effective doses for the shortest time possible 1

Conclusion

The evidence strongly indicates that for most women over 60, the risks of HRT outweigh potential benefits. Alternative approaches to symptom management should be prioritized, with HRT reserved only for severe, refractory symptoms in the absence of contraindications, using the lowest effective dose for the shortest possible duration.