Why would a 70-year-old postmenopausal woman be prescribed vaginal progesterone?

Why Would a 70-Year-Old Be on Vaginal Progesterone?

A 70-year-old postmenopausal woman should NOT be on vaginal progesterone for chronic disease prevention, as this is explicitly contraindicated with a Grade D recommendation. 1 However, if she has an intact uterus and is taking systemic estrogen therapy for severe vasomotor symptoms, vaginal progesterone would be required for endometrial protection—though at age 70, initiating or continuing systemic hormone therapy carries unfavorable risk-benefit ratios. 2, 3

Most Likely Clinical Scenarios at Age 70

Scenario 1: Endometrial Protection During Systemic Estrogen Therapy

• If this woman has an intact uterus and is receiving systemic estrogen (oral or transdermal), she must receive concurrent progestogen to prevent endometrial hyperplasia and cancer. 2, 4
• Unopposed estrogen increases endometrial cancer risk 2.3-fold after one year, escalating to 9.5-fold after 10 years of use. 2, 3
• Adding progestogen reduces endometrial cancer risk by approximately 90% compared to unopposed estrogen. 2, 5
• Vaginal progesterone 200 mg micronized capsules can provide adequate endometrial protection when used cyclically (12-14 days per month) or continuously. 6, 7

Critical caveat: At age 70, this woman is likely more than 10 years past menopause, placing her in a high-risk category where hormone therapy increases stroke (8 additional cases per 10,000 women-years), venous thromboembolism (8 additional cases per 10,000 women-years), and potentially breast cancer with long-term use. 2, 3

Scenario 2: Misuse for Chronic Disease Prevention (Contraindicated)

• The USPSTF explicitly recommends against initiating hormone therapy in women over 65 for chronic disease prevention (osteoporosis, cardiovascular disease, dementia), as harms exceed benefits. 1, 2
• Women aged 70-79 years in the WHI trial showed no cardiovascular benefit from estrogen therapy (HR 0.95, CI 0.78-1.15) and increased stroke risk (HR 1.36, CI 1.08-1.71). 1
• If vaginal progesterone was prescribed for osteoporosis or cardiovascular prevention, this represents inappropriate prescribing—bisphosphonates, weight-bearing exercise, and calcium/vitamin D are preferred alternatives. 2, 3

Scenario 3: Confusion with Vaginal Estrogen (Not Progesterone)

• Vaginal estrogen (not progesterone) is the appropriate treatment for genitourinary syndrome of menopause at age 70, providing 60-80% symptom improvement with minimal systemic absorption. 3
• Low-dose vaginal estrogen preparations (rings, suppositories, creams) do not require concurrent progestogen because systemic absorption is negligible. 3, 8
• If the prescription is actually for vaginal estrogen but was mislabeled as "progesterone," this would be appropriate therapy for vaginal dryness, dyspareunia, or recurrent urinary tract infections. 3

What Should Happen at Age 70

If She Is Already on Systemic Hormone Therapy:

• Reassess necessity immediately and attempt discontinuation, as continuing beyond age 65-70 requires compelling justification. 2, 3
• If severe vasomotor symptoms persist despite attempts at discontinuation, reduce to the absolute lowest effective dose. 2, 3
• Switch to transdermal estradiol if using oral estrogen, as transdermal routes have lower stroke and VTE risk. 2, 3
• Continue vaginal progesterone (or switch to micronized progesterone 200 mg orally at bedtime) only if systemic estrogen is continued and uterus is intact. 2, 3

If Hormone Therapy Was Recently Initiated at Age 70:

• This represents inappropriate prescribing unless the woman has exceptional circumstances (e.g., surgical menopause at age 68 with intolerable symptoms). 2, 3
• Initiating hormone therapy after age 65 for chronic disease prevention increases morbidity and mortality. 2, 3
• Consider non-hormonal alternatives: SSRIs (reduce vasomotor symptoms without cardiovascular risk), gabapentin, or cognitive-behavioral therapy. 3

If the Prescription Is Actually for Vaginal Estrogen:

• Clarify whether the medication is vaginal estrogen (appropriate) or vaginal progesterone (unusual). 3
• Vaginal estrogen alone is safe and effective for genitourinary symptoms at age 70 without requiring progestogen. 3, 8

Common Prescribing Errors to Avoid

• Never prescribe systemic hormone therapy solely for osteoporosis prevention at age 70—bisphosphonates are first-line. 2, 3
• Never prescribe estrogen without progestogen in women with an intact uterus, regardless of age. 2, 4
• Never confuse vaginal estrogen (appropriate for genitourinary symptoms) with vaginal progesterone (only needed for endometrial protection during systemic estrogen therapy). 3, 8
• Never continue hormone therapy past age 65-70 without annual reassessment and documented attempts at discontinuation. 2, 3

Risk-Benefit Data at Age 70

For every 10,000 women aged 70-79 taking combined estrogen-progestin for one year: 1, 2

• 8 additional strokes (HR 1.36, CI 1.08-1.71)
• 8 additional pulmonary emboli (HR 2.03, CI 1.55-6.64)
• 8 additional invasive breast cancers (with long-term use)
• 5 fewer hip fractures (HR 0.67, CI 0.47-0.95)
• No cardiovascular benefit in women this age (HR 0.95, CI 0.78-1.15)

The absolute risks substantially outweigh benefits in women over 60 or more than 10 years postmenopausal. 1, 2