Starting Hormone Therapy After 60: How the Risks Change

Hot flashes don’t always clear up by 60. In the SWAN study of 1,449 women with frequent hot flashes or night sweats, the median woman had them for 7.4 years, and for 4.5 years after her last period.¹ So some women first ask about hormone therapy in their 60s, or ask again after years of saying no.

The line guidance draws

• Before 60, or within 10 years of menopause: for women with no reasons to avoid it, the Menopause Society calls the balance favorable for bothersome hot flashes and for preventing bone loss.² The NHS³ says much the same for women under 60 who aren’t at high risk of breast cancer or blood clots.³
• After 60, or more than 10 years out: the balance “appears less favorable because of the greater absolute risks of coronary heart disease, stroke, venous thromboembolism, and dementia.”²
• Less favorable isn’t a ban. The same statement says risks depend on type, dose, duration, route and timing, and that treatment should be individualized.²

What the trial numbers looked like by age

The Women’s Health Initiative randomized 27,347 women aged 50 to 79 to hormone pills or placebo.⁴ Researchers added up harmful events, including heart disease, breast cancer, stroke, blood clots in the lung, hip fracture and death, per 10,000 women per year:⁴

Harmful events per 10,000 women per year4	Age 50 to 59	Age 70 to 79
Estrogen plus progestin (women with a uterus)	12 extra	38 extra
Estrogen alone (women without a uterus)	19 fewer	51 extra

Combined therapy also raised dementia in women aged 65 and older.⁴ Every woman in these trials took a pill (conjugated equine estrogens).⁴ The NHS³ says tablets slightly raise the risk of blood clots and stroke, while patches, sprays and gels don’t raise the risk of blood clots or stroke.³ Route is one of the things to ask about. See estrogen pill vs patch and blood clot risk.

Vaginal estrogen is a separate question

Low-dose vaginal estrogen treats vaginal dryness. The NHS³ says it doesn’t increase the risk of breast cancer, blood clots or other conditions and is safe to use long term.³ The Menopause Society recommends it, or vaginal DHEA or ospemifene, when over-the-counter products haven’t helped and you don’t need systemic therapy.² The age-60 line above is about hormone therapy that reaches the whole body. See vaginal estrogen cream vs tablet vs ring.

If systemic hormones aren’t right for you

• Non-hormone options include CBT, hypnosis and prescription medicines. See what helps hot flashes without hormones and fezolinetant monitoring questions.
• Hormones don’t prevent chronic disease. The WHI investigators concluded their results don’t support hormone therapy for preventing chronic disease, only for treating symptoms in some women.⁴
• Already taking it? See stopping HRT: four discussion points.

Try: “I’m 63, eleven years past my last period, and still having hot flashes several times a day. Given my history, how does the balance look for me, and would a patch or gel change it?”

My Body Changed. Now What? covers this in Chapter 10, “The Hormone Question.” Your Change Map already holds the two facts the guidance turns on, your age and the years since your final period, and the Visit Brief has four questions ready for the appointment. See the book.