Systemic Menopausal Hormone Therapy Initiation in a 70-Year-Old
Systemic hormone therapy for menopausal symptom management can be considered in selected older women, but initiation at age 70 requires careful individualized risk–benefit assessment. [1] For chronic disease prevention, systemic hormone therapy is not recommended. [2]
Indication for Starting Systemic Therapy at Age 70
Systemic hormone therapy is indicated for the treatment of bothersome menopausal symptoms (eg, vasomotor symptoms) when benefits outweigh risks. [1] Systemic hormone therapy is not indicated for the primary or secondary prevention of chronic conditions. [2]
Cardiovascular, Stroke, and Venous Thromboembolism Safety at Older Initiation
Initiation more than 10 years after menopause onset or in women older than 60 years is associated with increased risk of stroke and venous thromboembolism (VTE). [1] In a 2015 Cochrane meta-analysis cited by NAMS, women initiating hormone therapy older than 60 years (or >10 years from menopause onset) had no evidence of effect on coronary heart disease (RR 1.07) or all-cause mortality (RR 1.06), but had increased stroke risk (RR 1.21) and increased VTE risk (RR 1.96). [1] A 2020 systematic review and meta-analysis cited by NAMS found a null effect on coronary heart disease and all-cause mortality with higher risk of stroke (summary estimate 1.17) and VTE (summary estimate 1.79) in older initiation groups. [1]
Breast Cancer Risk With Systemic Therapy
Combined estrogen plus progestogen therapy is associated with increased breast cancer risk. [1] In the Women’s Health Initiative, daily continuous combined CEE plus MPA resulted in 9 additional breast cancer cases per 10,000 person-years of therapy. [1]
Route, Dose, and Formulation Considerations in Older Initiation
Mitigation of risk through use of the lowest effective dose and use of a nonoral route of administration becomes increasingly important with age. [1] Transdermal routes and lower doses may decrease risk of VTE and stroke, but comparative randomized trial data are lacking. [1] Micronized progesterone may be less thrombogenic than other progestins. [1]
Monotherapy Versus Combination Therapy for Uterine Status
Estrogen-only therapy should be used in women without a uterus. [1] Estrogen plus progestogen therapy should be used in women with a uterus to provide endometrial protection. [1] Breast cancer risk is increased with combined therapy in available randomized trial data. [1]
Initiation Thresholds and Ongoing Continuation Guidance
Women aged older than 60 years should have hormone therapy initiation only after careful consideration of individual benefits and risks. [1] Long-term use (including beyond age 60) may be considered in healthy women at low cardiovascular and breast cancer risk with persistent vasomotor symptoms or elevated fracture risk when other therapies are not appropriate. [1] Hormone therapy does not need to be routinely discontinued solely based on age 60 or 65 years. [1]
Common Clinical Error: Using Hormones for Chronic Disease Prevention
USPSTF recommends against hormone therapy for the primary prevention of chronic conditions in postmenopausal persons (Grade D). [2] This recommendation does not apply to use for treatment of menopausal symptoms (eg, vasomotor symptoms). [2]
Practical Safety-Directed Workup Before Starting at Age 70
Risk stratification should include underlying risk for coronary heart disease, cerebrovascular accident, VTE, stroke, and breast cancer. [1] Personal and familial risk of CVD, stroke, VTE, and breast cancer should be considered when initiating hormone therapy. [1] Selection of dose, regimen, route of administration, and duration should be individualized with periodic reassessment. [1]
When Systemic Therapy Is Less Favorable at Age 70
If the clinical goal is prevention of chronic disease, systemic therapy should not be initiated. [2] If vascular risk is elevated, systemic initiation at age 70 is less favorable because older initiation is associated with higher absolute risks of stroke and VTE. [1] If uterine cancer risk is high or endometrial protection cannot be appropriately provided for a woman with a uterus, estrogen-only therapy is not appropriate. [1]