Hormone Replacement Therapy in the Geriatric Patient

HRT / menopausal hormone therapy = oestrogen therapy, with a progestogen added in every woman who still has a uterus to prevent endometrial hyperplasia and carcinoma.

Licensed indications are two only: (a) relief of vasomotor and genitourinary symptoms; (b) prevention or treatment of osteoporosis where the risk–benefit balance is favourable. It is NOT indicated for prevention of cardiovascular disease, dementia or any other chronic condition.

Governing principle: the lowest effective dose, for the shortest time required, with periodic reassessment; the decision belongs to the informed woman.

The ideal age range for initiation is 50–60 years, and within 10 years of the menopause. Beyond this the balance turns unfavourable.

Meta-analysis shows women who start HRT more than 10 years after menopause have higher risks of stroke and venous thromboembolism. A WHI post-hoc analysis found that women aged 70 or older starting HRT for persisting vasomotor symptoms had a significantly increased risk of coronary heart disease — with oestrogen alone and with combined therapy.

Oestrogens are of natural origin (unlike contraceptives): estradiol (oral, transdermal patch or gel, nasal spray, vaginal), estrone, estriol, estetrol. Conjugated equine oestrogens — used in WHI — remain popular in some countries.

Progestogens are not equivalent: medroxyprogesterone acetate carries the cardiovascular and breast-cancer signal, whereas natural micronised progesterone appears substantially gentler.

Route matters: transdermal oestrogen is essentially neutral for VTE risk because it avoids hepatic first-pass metabolism — the preferred route in older women, in obesity, and in anyone with thrombotic risk.

Alternatives: tibolone; the SERM–oestrogen combination bazedoxifene with conjugated oestrogens. Low-dose vaginal oestrogen for genitourinary syndrome has negligible systemic absorption, may be continued indefinitely, and can be given alongside systemic HRT.

HRT is the most effective treatment for vasomotor symptoms, which affect 70–80% of women for an average of about 7 years; it reverses genitourinary syndrome, improves sleep, mood and quality of life.

Bone: prevents bone loss and fragility fracture; even the ultra-low-dose 0.014 mg estradiol patch preserves BMD, though less than a standard dose. Continuation is recommended for women at high fracture risk in whom alternative agents are unsuitable or poorly tolerated.

Breast cancer: increased with combined oestrogen + progestogen therapy. Crucially, long-term WHI follow-up showed oestrogen-only HRT was associated with reduced breast-cancer incidence and mortality in hysterectomised women — a favourite examiner discriminator.

Venous thromboembolism and stroke — dose- and route-dependent; oral confers greater risk than transdermal.

Coronary heart disease when started late (more than 10 years post-menopause, or after 70).

Dementia: continuous combined oestrogen + progestin started in older postmenopausal women doubled the risk of all-cause dementia (WHIMS).

Endometrial carcinoma with unopposed oestrogen in a woman with an intact uterus.

Current or past breast cancer or high breast-cancer risk; oestrogen-dependent malignancy; VTE or thromboembolic disease; active cardiovascular disease; undiagnosed postmenopausal bleeding; active liver disease.

The North American Menopause Society position is that the lowest effective dose may be continued after 65 for persistent hot flushes, quality of life or osteoporosis, provided the clinician has established that benefits outweigh risks after thorough counselling. HRT should not be stopped on the basis of age alone. Document the counselling and the woman's wish to continue, and review periodically.

This matters practically: Swedish data show 15% of women at 66 and 9% at 72 still experience hot flushes, women over 80 continue to use HRT, and many are unwilling to discontinue — with quality-of-life and economic implications as more older women remain in the workforce.

Lifestyle: dressing in layers and using a fan, cold food and drink, avoiding hot and spicy food, stopping smoking, reducing caffeine, regular exercise, relaxation techniques (paced respiration, yoga, meditation, massage). Pharmacological: clonidine (the only UK-licensed non-hormonal agent, reduces central noradrenergic tone); paroxetine (FDA-approved, the most efficacious SSRI for women not on tamoxifen); venlafaxine (preferred in breast-cancer survivors taking tamoxifen — it does not interfere with tamoxifen metabolism); gabapentin or pregabalin; and menopause-specific cognitive behavioural therapy. Phyto-oestrogen studies are of poor quality.

Saying HRT prevents heart disease — it does not; started late it causes it.

Forgetting the progestogen in a woman with a uterus.

Claiming all HRT increases breast cancer — oestrogen-alone reduced incidence and mortality in WHI.

Stopping HRT purely because the woman has turned 65.

Failing to distinguish systemic HRT from low-dose vaginal oestrogen, which is safe long-term.

Treating all progestogens as equivalent — MPA is not micronised progesterone. 15-second answer skeleton: Define (oestrogen ± progestogen) → two licensed indications → lowest dose, shortest time → window of opportunity 50–60 / within 10 years → preparations, progestogen choice, transdermal route → benefits (VMS, GSM, bone) → risks (breast, VTE, stroke, CHD if late, dementia, endometrium) → contraindications (BLOCK-U) → continuing beyond 65 (NAMS — not stopped for age alone) → non-hormonal alternatives → NK antagonists: fezolinetant and elinzanetant.