HRT After Age 65: Not Recommended for Initiation
For women over 65, hormone replacement therapy should generally not be initiated, and if already in use, should be discontinued or continued only at the lowest possible dose for the shortest duration if severe symptoms persist. 1, 2
Primary Recommendation Against HRT Initiation After 65
The U.S. Preventive Services Task Force explicitly recommends against routine use of estrogen and progestin for prevention of chronic conditions in postmenopausal women (Grade D recommendation), with particular concern for women many years past menopause 2
Women who are more than 10 years past menopause or over age 60 face an unfavorable risk-benefit profile with HRT, where harms likely exceed any benefits 1, 2
In women ≥60 years of age or more than 10 years after natural menopause, oral estrogen-containing HRT is associated with excess risk of stroke 1
Specific Risks in Women Over 65
The Women's Health Initiative Memory Study specifically evaluated women 65 years and older (82% were 65-74 years, 18% were 75+) and found concerning results: 3
- Two-fold increased risk of developing probable dementia (with Alzheimer's disease being the most common type) 3
- 90% of probable dementia cases occurred in women older than 70 years 3
Additional risks in this age group include: 2, 4
- Coronary heart disease events (7 additional events per 10,000 women-years with combined HRT)
- Stroke (8 more strokes per 10,000 women-years)
- Venous thromboembolism (8 more events per 10,000 women-years)
- Breast cancer with long-term use (8 more cases per 10,000 women-years after 5.6 years)
When HRT Might Be Considered After 65
If a woman over 65 has severe, intolerable vasomotor or genitourinary symptoms that significantly impair quality of life, HRT may be considered only after thorough risk assessment and with specific precautions: 1, 5
- Use the absolute lowest effective dose 6, 1
- Plan for the shortest possible duration 6, 1
- Prefer transdermal routes over oral (less impact on coagulation and stroke risk) 1, 7
- For genitourinary symptoms only, use low-dose vaginal estrogen preparations instead of systemic therapy 1, 2
Absolute Contraindications in This Age Group
Do not use HRT in women over 65 with: 1, 5
- History of breast cancer or other hormone-sensitive cancers
- Coronary heart disease
- Previous venous thromboembolic event or stroke
- Active liver disease
- Antiphospholipid syndrome or positive antiphospholipid antibodies
Alternative Approaches for Common Concerns
For osteoporosis prevention/treatment (a common consideration in this age group): 2
- Weight-bearing exercise, bisphosphonates, and calcitonin are preferred over HRT
- While HRT does reduce fracture risk, this benefit is outweighed by cardiovascular, thromboembolic, and cancer risks in women 15+ years postmenopausal 2
For genitourinary symptoms: 1, 2
- Low-dose vaginal estrogen preparations (60-80% symptom improvement with minimal systemic absorption)
- Vaginal moisturizers and lubricants (up to 50% symptom reduction)
Critical Clinical Pitfall
The most common and dangerous pitfall is initiating HRT in women over 65 for chronic disease prevention (osteoporosis, cardiovascular disease, or dementia prevention) - this is explicitly contraindicated and increases morbidity and mortality 6, 1, 2