Is it better to taper off Hormone Replacement Therapy (HRT) or can it be stopped abruptly?

Stopping Hormone Replacement Therapy: Abrupt Discontinuation vs. Tapering

Hormone replacement therapy (HRT) can be stopped abruptly in most women, as tapering does not significantly reduce the recurrence of menopausal symptoms compared to immediate discontinuation.

Evidence on HRT Discontinuation Methods

Randomized Controlled Trial Evidence

A randomized controlled study directly comparing tapering versus abrupt discontinuation found:

• No significant difference in the number or severity of hot flashes between tapering and abrupt discontinuation 1
• No difference in health-related quality of life outcomes between the two methods 1
• No difference in the frequency of resuming HRT between tapering and abrupt discontinuation groups 1

Observational Evidence

• Approximately 75% of women who attempt to stop HRT are able to do so without major difficulties 2
• While some observational studies suggested tapering might reduce menopausal symptom scores after discontinuation, the same studies found that women who tapered were actually more likely to resume HRT later (OR 2.06) 3
• Another observational study found no difference in the incidence of troublesome withdrawal symptoms between women who stopped abruptly (71%) versus those who tapered (29%) 4

Practical Approach to Stopping HRT

Method of Discontinuation

• Immediate cessation is often successful and avoids complicated instructions for drug reduction 5
• Women can choose their preferred cessation technique as outcomes are similar 5, 1

Factors Associated with Difficulty Stopping HRT

Women may have more difficulty stopping HRT if they:

• Develop troublesome withdrawal symptoms (strongest predictor, OR 8.8) 4
• Have had a hysterectomy 4
• Have used HRT for 10+ years 4
• Started HRT primarily for symptom management rather than health promotion 4

Special Considerations

• For women with established heart disease, guidelines recommend discontinuation of HRT, particularly during hospitalization for acute coronary events 6
• European guidelines specifically recommend that women who develop hormone-associated venous thromboembolism discontinue hormonal therapy before stopping anticoagulant therapy 7

Managing Symptoms After Discontinuation

For women who experience significant symptoms after stopping HRT:

• Consider non-hormonal pharmacologic options (SNRIs like venlafaxine, gabapentin) 6
• Recommend non-pharmacologic approaches (regular exercise, environmental modifications, dietary changes, acupuncture) 6
• For women who cannot tolerate stopping HRT despite attempts, the value of symptom relief may outweigh potential risks of continued therapy 2

When to Consider Continued HRT

While guidelines generally recommend against routine use of HRT for chronic conditions 7, some women may need to continue therapy:

• If a woman has been on HRT for more than 1-2 years and wishes to continue for another compelling indication, she should understand the increased risks of cardiovascular events and breast cancer (with combination therapy) or stroke (with estrogen alone) 7
• For women who cannot tolerate even a slow taper, the value of symptom relief likely outweighs increased risks 2

Bottom Line

The evidence suggests that abrupt discontinuation is just as effective as tapering for most women. The choice between tapering and abrupt discontinuation can be based on patient preference, as neither approach has been shown to be superior for preventing symptom recurrence or reducing the need to resume therapy.