Should Systemic Hormone Therapy Be Continued After Age 65?

Summary and Comment |
July 10, 2015

Should Systemic Hormone Therapy Be Continued After Age 65?

  1. Robert W. Rebar, MD

A new statement from NAMS says yes.

  1. Robert W. Rebar, MD

Patterns of HT use changed markedly following the Women's Health Initiative (WHI) report that the risks of menopausal hormone therapy (HT) exceeded its benefits (JAMA 2002; 288:321) — but since then, several studies have suggested that the story is far more complicated and that HT is warranted in certain instances. In 2012, the North American Menopause Society (NAMS), noting that HT carries fewer risks in younger postmenopausal women, recommended the lowest possible dose for the shortest time necessary (generally <5 years; Menopause 2012; 19:257). Because many women experience vasomotor symptoms even after age 65, NAMS has recently issued a position statement that continuing HT past age 65 is acceptable provided the woman has been advised of increased risks after age 60, she continues to have bothersome symptoms or is unable to use any other appropriate medication, and her clinician has determined that benefits outweigh risks. Estrogen remains the most effective agent for relief of menopausal symptoms (and is effective in preventing fractures in high-risk women who cannot use other therapies).

Comment

Editorialists urge that HT be removed from the Beers list of potentially inappropriate medications for adults aged >65 (J Am Geriatr Soc 2012; 60:616) and instead be considered a medication to be used with caution (or that exceptions in commonly used quality-of-care metrics be made). Such changes might well have important implications for insurance coverage as well as evaluation of care provided by individual clinicians.

Should healthy symptomatic women be denied HT merely because of their chronologic age? The use of an indicated medication is rarely straightforward. The initial WHI report led to emotional responses and inappropriate discontinuation of HT in many women who would have otherwise benefited; accordingly, use plummeted in the months following publication of that report. Now, many clinicians continue to disregard recent findings indicating that the risks are generally not as great as initially reported — and continue to refuse to prescribe therapy, even for women who could benefit greatly. I have continued to prescribe HT to selected women for many years, even after age 65, with appropriate counseling and surveillance. This NAMS statement is both appropriate and timely.

Editor Disclosures at Time of Publication

  • Disclosures for Robert W. Rebar, MD at time of publication Editorial Boards Contraception (Deputy Editor); EndoText (Section Editor) Leadership positions in professional societies American Society for Reproductive Medicine (Member Practice Committee)

Citation(s):

Reader Comments (4)

Cynthia Weinstein MD Physician, Family Medicine/General Practice, Independent practice

Insurance companies are using this as an excuse to stop covering any HT for our Medicare patients. Women who choose to take HT are miserable without it and are now having to pay out of pocket for a treatment for their severe symptoms.

Henry Lindner, MD Physician, Other, Pennsylvania

When is the mainstream going to admit that transdermal estradiol and human progesterone have not been shown to have the risks seen with non-human oral estrogens like Premarin or non-human progestins like Provera?

Paul Verheecke Physician, Pathology, brussels

My wife is on transdermal patches since several years and not about to change, see is 69 now.

MARGARET HARDY Physician, Family Medicine/General Practice, australia

The suggestion that at age 65 a woman becomes incapable of making an informed choice to continue HRT is ludicrous. A full discussion before prescribing HRT to a woman of any age is normal practice, and women who continue to be symptomatic should not be refused optimal relief. This recommendation is well overdue. My experience post-WHI is that many women who stopped medication have returned to it for quality of life reasons.

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