HRT in later life or after menopause

Whether you want to start HRT or are wondering about staying on it for longer, we answer some of your frequently asked questions

Is it ever too late to start HRT?

Many women aren’t offered HRT when they develop symptoms of menopause. This might because your symptoms weren’t too bad, or you felt that you had to simply grin and bear your menopausal symptoms. You may have had significant concerns over the safety of HRT, or healthcare professionals may have advised you against it.

If, years later, you are revisiting this possibility and HRT is becoming more of an attractive option for you, it’s worth knowing that there is very little evidence regarding starting HRT for older women because this research has not been undertaken. However, most women who are otherwise fit and well do still gain benefits from taking HRT ­even if it has been more than 10 years since their menopause.

You may decide to start HRT now because your symptoms have worsened, or you were expecting them to have gone by now ­but they haven’t. You may be concerned about the long-­term risks associated with low levels of hormones that occur during the menopause in later life ­such as the risk of cardiovascular disease (disease of the heart and blood vessels) and osteoporosis (bone­ weakening disease), as well as diabetes, dementia and depression. These are all valid reasons for wanting to take HRT at this point in your life. HRT can help with symptom control and has long-term health benefits.

RELATED: My story: I started HRT when I was postmenopausal

It is important that you seek individualised advice and discuss all the treatment options available to you. If your regular healthcare professional will not consider HRT for you, you may wish to find an alternative healthcare professional who has a special interest in the menopause.

This information also applies if you were on HRT but reluctantly, ­and under doctor’s advice,­ stopped taking it. If you want to start HRT again, see another healthcare professional if you have to, and explain your reasons for wanting to start taking it again. The NICE guidelines are clear that women can continue to take HRT as long as the benefits outweigh the risks, and for most healthy women, this is for ever.

RELATED: pushing against social and political constraints on women’s health with Dr Heather Hirsch

Are there any disadvantages to starting it later in life?

Cochrane data-analysis and long-term follow-up data from the Women’s Health Initiative (WHI) showed no increase in cardiovascular events, cardiovascular mortality or all-cause mortality in women who initiated HRT more than 10 years after the menopause [1].

Some concerns were with starting older types of synthetic HRT in older women but starting body identical HRT is generally thought to be safe as these hormones are the safe structure as hormones you produced when you were younger.

However, the decision to start taking HRT is individual, and should take into account your specific benefits and risks. It is essential to have a yearly review to ensure that it is appropriate for you to continue treatment.

RELATED: PODCAST: When menopausal symptoms persist, with Dr Anna Chiles

Will I need a lower dose of HRT if I’m older?

Older women often need smaller doses of oestrogen than younger women, and there are preparations of lower doses specifically for older women. The safest way to take replacement oestrogen is through the skin in a patch, gel or spray. Even a small amount of oestrogen replacement can often alleviate your symptoms effectively and provide you with the bone and heart protection you need.

If you still have your womb (uterus) you will also need to take a progestogen, such as micronised progesterone, to protect the lining of your womb.

RELATED: HRT doses explained

I’ve been on HRT for years, how will I know when it’s time to lower my dose?

Each person is an individual and it is important that you have an annual review with your healthcare professional to ensure that you are on the correct doses and types of HRT to manage your symptoms. The aim would be to remain on the effective dose for you that maintains good symptom control and quality of life.

Does taking HRT just delay the menopause?

Many women think that taking HRT just delays the natural duration of the menopause in your body. This is not the case. If your symptoms return when you stop taking HRT it is not because you have been taking hormones, this is because you would still be having symptoms of the menopause at that time even if you had never taken HRT. An untreated menopause can cause symptoms for many years; the average length of time is around seven years but for many women, symptoms can last for decades.

RELATED: why menopause is more than just a natural transition

I have taken HRT for several years so, when should I stop it?

Many women decide to take HRT for a much longer period of time than a few years. This is often because they feel better and have more energy, and have fewer or no symptoms when they take HRT; they also want to protect their future health from long-term conditions associated with low levels of oestrogen, such as osteoporosis and cardiovascular disease.

All women taking HRT should have an annual review with their healthcare professional. If you continue to be healthy and feel the benefits of taking HRT, there is usually no reason for stopping it. Women are often surprised when their menopausal symptoms return after coming off HRT, even those women who have taken it for many years. Symptoms of the menopause can last over a decade.

A recent study highlighted the benefits of older women taking HRT, especially body identical HRT [2].

There has been some evidence that showed a small increased risk of heart attack or stroke during the first year after stopping HRT. As always, decisions around your health should be made weighing up all the relevant information and deciding what is best for you, and in discussion with your health professional.

Why does my doctor say I can only stay on HRT for five years?

Previously women have been advised that they can only remain on their HRT for a maximum of five years due to concerns about breast cancer risk but this is not based on any good quality evidence and it is nor relevant for women taking body identical hormones. Now, the guidelines are that specific time limits should not be placed on duration of use of HRT. If symptoms persist, the benefits of using HRT usually outweigh the risks and an individualised approach should be agreed with your healthcare professional.

RELATED: taking HRT forever: Ann Newson & Dr Louise Newson

I want to stop taking HRT, what is the safest way to come off it?

If you have weighed up the information and decide coming off HRT is the right decision for you, it is usually recommended that you decrease the dose of hormones gradually, every few days, over a few weeks.

References

1. Hamoda H, Panay N, Pedder H, Arya R, Savvas M. (2020), ‘The British Menopause Society & Women’s Health Concern 2020 recommendations on hormone replacement therapy in menopausal women’, Post Reproductive Health. 26(4): pp.181-209. doi:10.1177/2053369120957514
2. Baik, S. H et al. (2024), ‘Use of menopausal hormone therapy beyond age 65 years and its effects on women’s health outcomes by types, routes, and doses’, Menopause, vol. 31,5: pp.363-71. doi:10.1097/GME.0000000000002335