From the Guidelines
Hormone replacement therapy (HRT) in elderly individuals should be considered for the primary indication of preventing osteoporosis or cardiovascular disease, as recommended by the USPSTF unpublished data in 2002 1. The decision to start HRT in elderly patients should be based on individualized assessment of benefits and risks, considering the patient's age, time since menopause, and risk factors for chronic conditions. Some key points to consider when evaluating the need for HRT in elderly patients include:
- The prevalence of osteoporosis increases steadily with age, and up to 70% of women older than 80 years of age have osteoporosis 1.
- The decline of estrogen production is associated with reduction of bone mineral density, and bone density is estimated to decrease by 2% each year during the first 5 years after menopause, followed by an annual loss of approximately 1% for the rest of a woman's life 1.
- HRT may be beneficial in preventing osteoporotic fractures and cardiovascular disease, but the risks and benefits must be carefully weighed, particularly in elderly patients with increased risk of venous thromboembolism, stroke, and hormone-sensitive cancers.
- The median age of menopause in women in the United States is 51 years, and the average woman in the United States who reaches menopause has a life expectancy of nearly 30 years, making the prevention of chronic conditions a critical consideration in the management of menopausal symptoms 1. The use of HRT should be prescribed at the lowest effective dose for the shortest duration necessary, with regular monitoring of benefits and risks, and should not be recommended for elderly patients solely for prevention of chronic conditions or anti-aging purposes due to potential risks outweighing benefits in this population.
From the Research
Indications for Starting Hormone Replacement in Elderly
The decision to start hormone replacement therapy (HRT) in elderly women depends on various factors, including the presence of menopausal symptoms, osteoporosis, and cardiovascular disease.
- HRT has been shown to improve the quality of life and prolong life for many elderly women, whether it is initiated at menopause or much later 2.
- Estrogen replacement therapy can lower the chances of death and disability from cardiovascular disease and osteoporosis, particularly in women with low bone density or risks for cardiovascular disease, including smoking and hypertension 2.
- HRT can also prevent spinal bone loss and delay bone loss at the hip up to a very old age, potentially halving the incidence of vertebral and hip fractures 3.
- However, long-term use or use of HRT in old age is rarely practiced, and the actual benefit of a transient use for future fracture prevention remains unclear 3.
- Selective estrogen receptor modulators (SERMs), such as raloxifene, can be used as an alternative to HRT, producing beneficial estrogen-like effects on bone and lipid metabolism while antagonizing estrogen in reproductive tissue 4.
Considerations for Initiating HRT in Elderly Women
When considering HRT for elderly women, the following factors should be taken into account:
- The patient's personal history and attitudes towards HRT 2.
- The potential benefits and risks of HRT, including the risk of breast cancer and cardiovascular disease 2, 5.
- The availability of alternative treatments, such as SERMs, which may be suitable for women who are unable or unwilling to take HRT 4.
- The need for individualized treatment, taking into account the patient's unique needs and circumstances 5, 6.