At what age can hormone replacement therapy (HRT) for menopause be started?

When to Start Hormone Replacement Therapy for Menopause

Hormone replacement therapy (HRT) should ideally be started in women under 60 years of age or within 10 years of menopause onset when experiencing moderate to severe menopausal symptoms. 1

Optimal Timing for HRT Initiation

• HRT is most appropriate when started at the onset of menopausal symptoms, typically around the median age of menopause (51 years, range 41-59 years) 1, 2
• Women experiencing premature menopause (before 45 years of age) should consider HRT due to their increased risk of stroke and other health consequences 2
• The risk-benefit ratio is most favorable for women who begin HRT soon after menopause onset 3
• For women with premature ovarian insufficiency, HRT should be initiated at the time of diagnosis 1

Risk-Benefit Assessment by Age

• Women under 60 years or within 10 years of menopause onset have the most favorable benefit-risk ratio for HRT 3, 1
• Women who start HRT more than 10 years after menopause or after age 60 face higher absolute risks of cardiovascular disease, stroke, venous thromboembolism, and dementia 3
• The 2024 American Heart Association/American Stroke Association guidelines identify the ideal candidate for HRT as a woman under 60 years of age and within 10 years of menopause onset 2

Benefits of HRT When Started at Appropriate Time

• Effective relief of moderate to severe vasomotor symptoms (hot flashes, night sweats) 1, 4
• Treatment of genitourinary syndrome of menopause 3
• Prevention of bone loss and reduction in fracture risk 2
• Possible reduction in colorectal cancer risk with estrogen-progestin therapy 2

Risks of HRT to Consider

• Increased risk of stroke with estrogen-containing HRT (79 more strokes per 10,000 women with estrogen-only and 52 more with estrogen/progestin) 2
• Higher risk of breast cancer with long-term estrogen-progestin use 1
• Increased risk of venous thromboembolism, particularly with oral formulations 5
• Women with history of breast cancer, liver disease, myocardial infarction, deep vein thrombosis, or thrombophilic disorders should avoid HRT 2

Route of Administration Considerations

• Transdermal routes of HRT administration should be preferred as they have less impact on coagulation 5, 1
• Low-dose vaginal estrogen preparations can improve genitourinary symptoms with minimal systemic absorption 1
• For women with an intact uterus, combination estrogen and progestin therapy is required to prevent endometrial cancer 1
• For women without a uterus, estrogen-alone therapy can be used 1

Duration of HRT

• Expert groups recommend using the lowest effective dose for the shortest possible time 1
• Regular reassessment of the woman's health status is mandatory to evaluate ongoing benefits versus risks 5
• For women with premature menopause, HRT may be continued until the average age of natural menopause (51 years) 1

Key Considerations for Decision-Making

• Severity of menopausal symptoms significantly impacts the benefit-risk calculation 6
• Women with mild or severe symptoms may gain 3-4 or 7-8 months of quality-adjusted life expectancy, respectively 6
• Cardiovascular risk profile should be assessed before initiating HRT 7
• HRT should not be started solely for prevention of chronic conditions 1, 2

Common Pitfalls to Avoid

• Starting HRT solely for prevention of chronic conditions like osteoporosis or cardiovascular disease 1
• Failing to consider individual risk factors such as age, time since menopause, and comorbidities 4
• Not distinguishing between different HRT regimens and routes of administration, which have varying risk profiles 1
• Continuing HRT without periodic reevaluation of benefits and risks 3