From the Guidelines
A 70-year-old woman who has been on estrogen and progesterone therapy for 30 years should discontinue these medications gradually under medical supervision rather than stopping abruptly. The main dangers of discontinuation include the return of menopausal symptoms such as hot flashes, night sweats, sleep disturbances, and mood changes, which can be particularly intense after long-term hormone use 1. Bone health is a significant concern, as stopping hormones may accelerate bone density loss, increasing fracture risk, with up to 70% of women older than 80 years of age having osteoporosis 1. This patient should have a bone density scan and may need to start medications like bisphosphonates (such as alendronate 70mg weekly) or other bone-protective agents. Cardiovascular risks may also increase after discontinuation, as estrogen provides some protection for heart health, with a 46% probability of developing coronary heart disease over her lifetime 1. Additionally, vaginal dryness, urinary issues, and sexual discomfort often worsen when hormones are stopped. A gradual tapering schedule over 3-6 months is recommended, reducing the dose by approximately 25% every few weeks. Local treatments like vaginal estrogen creams can be continued even after systemic hormone therapy is discontinued to manage urogenital symptoms. The risks of continuing hormone therapy at age 70 after such prolonged use (increased risk of breast cancer, stroke, blood clots) generally outweigh the benefits, which is why discontinuation is typically recommended despite these challenges 1.
Some key points to consider:
- The USPSTF recommends against the use of combined estrogen and progestin for the primary prevention of chronic conditions in postmenopausal women, as the harms are likely to outweigh the benefits 1.
- The decision to discontinue hormone therapy should be made on an individual basis, taking into account the woman's risk factors, medical history, and personal preferences 1.
- Alternative treatments, such as bisphosphonates and local estrogen creams, can be used to manage menopausal symptoms and prevent osteoporosis 1.
Overall, the goal is to minimize the risks associated with discontinuation while also reducing the risks associated with long-term hormone therapy, prioritizing the patient's morbidity, mortality, and quality of life.
From the FDA Drug Label
The WHI estrogen plus progestin substudy reported a statistically significant 2-fold greater rate of VTE (DVT and pulmonary embolism [PE]) was reported in women receiving daily CE (0.625 mg) plus MPA (2. 5 mg) compared to women receiving placebo (35 versus 17 per 10,000 women-years). The relative risk of invasive breast cancer was 1.24 (95 percent nCI, 1.01-1. 54), and the absolute risk was 41 versus 33 cases per 10,000 women-years, for CE plus MPA compared with placebo. The relative risk of probable dementia for estrogen plus progestin versus placebo was 2.05 (95 percent CI, 1.21-3. 48). The use of estrogen plus progestin has been reported to result in an increase in abnormal mammograms requiring further evaluation.
The dangers of a 70-year-old woman coming off estrogen and progesterone prescriptions after 30 years include:
- Venous thromboembolism (VTE): The risk of VTE may decrease after discontinuation of estrogen plus progestin therapy.
- Breast cancer: The risk of breast cancer may decrease after discontinuation of estrogen plus progestin therapy, but it is unknown whether this risk will return to normal after 30 years of use.
- Probable dementia: The risk of probable dementia may decrease after discontinuation of estrogen plus progestin therapy, but it is unknown whether this risk will return to normal after 30 years of use.
- Abnormal mammograms: The risk of abnormal mammograms may decrease after discontinuation of estrogen plus progestin therapy.
It is essential to note that the risks associated with estrogen plus progestin therapy may persist for several years after discontinuation, and the duration of exposure associated with increased risk is not consistent across all epidemiologic studies 2, 2, 2.
From the Research
Dangers of Stopping Estrogen and Progesterone Prescriptions
The dangers of a 70-year-old woman coming off estrogen and progesterone prescriptions after 30 years can be significant. Some of the potential risks include:
- Increased risk of osteoporotic fractures, as estrogen replacement therapy (ERT) is effective in preventing bone loss and fractures in postmenopausal women 3
- Increased risk of cardiovascular disease, as ERT has been shown to reduce the risk of fatal and nonfatal myocardial infarction, ischemic heart disease, and stroke by 20-40% 3
- Potential loss of protection against Alzheimer's disease, as ERT has been shown to reduce the risk of Alzheimer's disease in some studies 3
- Increased risk of tooth loss, as bone loss in the jaws may result in tooth loss, and ERT has been shown to retain more natural teeth than nonusers 3
Considerations for Stopping Hormone Replacement Therapy
When considering stopping hormone replacement therapy (HRT), it is essential to weigh the potential benefits against the risks. Some factors to consider include:
- The woman's personal history and attitudes towards HRT, as well as her individual risk factors for cardiovascular disease, osteoporosis, and other conditions 4
- The potential risks of HRT, including the risk of breast cancer, endometrial cancer, and venous thromboembolism 5
- The availability of alternative treatments, such as selective estrogen receptor modulators (SERMs), which may offer some of the benefits of HRT with fewer risks 6, 7
Importance of Medical Supervision
It is crucial for a woman to consult with her physician before stopping HRT, as the decision to stop therapy should be made on an individual basis, taking into account the woman's unique medical history and risk factors. The physician can help the woman weigh the potential benefits and risks of HRT and make an informed decision about whether to continue or stop therapy 4, 5