Groundbreaking Study Shatters Myths About Hormone Replacement Therapy for Women Over 65

Menopause symptoms don’t magically disappear as we age. In fact, many women continue to struggle with them well into their 60s, 70s, and beyond. Yet, family practice physicians, OB/GYNs, and primary care doctors often hesitate to prescribe hormone replacement therapy (HRT) to women over 65. Age is frequently seen as a barrier to HRT use, but emerging studies prove this thinking is outdated. Let’s dive into the latest research and discuss why HRT is not just safe, but essential for older women who want to safeguard their health and longevity.

 

The Persistent Impact of Menopause Symptoms

As women, we spend up to ½ our lives in a menopausal state. Arriving at menopause doesn’t always end the discomfort of hot flashes, night sweats, and insomnia.  In many cases, they remain as intense or even worsen. This ongoing discomfort can affect mental health, physical health, and overall well-being. Symptoms like vaginal dryness, sexual discomfort, and urinary issues often escalate over time. These symptoms can persist for decades, significantly impacting quality of life.

A client of mine named Carol, age 59, had struggled with osteoporosis and other menopausal symptoms for three years while trying to find a provider willing to prescribe HRT, when we first met. Misconceptions about the risks and benefits of HRT for older women create unnecessary hurdles for Carol and countless others.

 

Breaking Down the Latest Research

In April of 2024, a groundbreaking study involving over 10 million US women aged 65 and older, recently published in the journal Menopause, provided new insights into the effects of HRT on older women. This was the largest study ever run on women taking hormone replacement therapy, and it is significant that it was conducted by the NIH and the National Library of Health. Contradictory to popular belief, this research highlights significant benefits and minimal risks associated with continued HRT use.

 

Estrogen Therapy: A Game-Changer in Cancer Prevention

Key Findings from the Study:

1. Longevity: Women taking estradiol alone experienced a 21% decrease in all-cause mortality compared to those not on HRT. That’s a 21% lower death rate from any cause!
2. Cancer Protection: Estrogen therapy statistically reduced the risk of five cancers—breast, ovarian, uterine, lung, and colorectal.
3. Heart and Cognitive Health: Estrogen therapies reduced the risk of severe heart issues (like congestive heart failure, venous thromboembolism, atrial fibrillation, and acute myocardial infarction) and cognitive issues, including dementia.

Estrogen use statistically reduced the risk of all cancers studied, including breast cancer. Every form of estrogen therapy was protective against breast cancer.

 

Delivery Methods Matter

Older women did best with topical and vaginal deliveries of estrogen, with vaginal delivery being the ultimate best. Both methods effectively protected against breast cancer and supported brain health without the increased stroke risk seen with oral estrogen. Oral estrogen had a slight increased risk of ischemic stroke but offered the best breast protection.

 

Addressing Breast Cancer Concerns

The study showed that all forms of estrogen therapy were protective against breast cancer. However, combining estrogen with synthetic progestins increased the risk of breast cancer by 19%, while combining it with natural progesterone (oral) only increased the risk by 10%. Notably, lower dosages and vaginal delivery of estrogen did not show any increased risk of breast cancer in any study. Topical bioidentical progesterone showed no increase in risk of cancer alone or with estrogens.

 

Additional Findings

1. Progesterone Use: Bioidentical Progesterone, when used alone, was associated with a 10% reduction in breast cancer risk, but progestin (synthetic) increased the risk by 21%.
2. Lung Cancer: Progesterone was associated with a 19% reduced lung cancer risk, while progestin was associated with a 14% increased risk.
3. Multiple Benefits: The study highlighted reduced risks of three cancers (breast, lung, and colorectal), four cardiovascular conditions (congestive heart failure, venous thromboembolism, atrial fibrillation, and acute myocardial infarction), and dementia with estrogen replacement or combined estrogen and progesterone replacement. .

Estrogen Therapy Beyond 65

Perhaps the most profound finding was that the use of estrogen therapy beyond age 65 was associated with a significant 19% reduction in mortality from any cause.

Older women on estrogen therapies lived statistically longer and healthier lives.

 

The Women’s Health Initiative: Correcting the Record

The Women’s Health Initiative (WHI) was the original study that created widespread, undeserved alarm by falsely correlating estrogen use to breast cancer due to misinterpreted data and flawed study design. The study was not designed to look at cancer risk– it was originally designed to look at the impact of hormone replacement on cardiovascular risk, and examined only synthetic hormones. The study didn’t control for factors like smoking, past hormone use, and other risk factors compared to the test group, and also didn’t distinguish prior use of synthetic hormones like progestins–now known to be a risk factor for cancer. Subsequent reanalysis and the WHI post-intervention study reported a significant 21% decreased risk of breast cancer with conjugated equine estrogen  alone and a 28% increase with conjugated equine estrogen  plus medroxyprogesterone (synthetic progestins), giving credence to our current understanding.

 

Author’s Conclusions: Groundbreaking Findings

Here’s what the authors of the 10 million women study concluded: “Our study suggests the possibility of important health benefits with use of menopausal HT beyond age 65 years.”

“The use of Estrogen therapy can protect against risks of all-cause mortality, developing cancers (breast, lung, and colorectal), congestive heart failure, venous thromboembolism, atrial fibrilation, acute myocardial infarction (heart attack), and dementia.”

The study also noted that the use of combined estrogen and progestin therapy  does not increase risks for almost all conditions but does increase the risk of breast cancer. However, low doses of transdermal and vaginal estrogen/progesterone combination therapy  (especially E+ bioidentical progesterone) can mitigate this risk. In general, risk reductions appear to be greater with low rather than medium or high doses, vaginal or transdermal rather than oral preparations, and with E2 (bioidentical estradiol) rather than Conjugated Equine Estrogren (synthetic) as emphasized by others.

 

Conclusion

Women over 65 are still experiencing hot flashes and other menopause symptoms. Turning 65 doesn’t mean these symptoms magically disappear or that women no longer need hormone optimization. Going without hormones from the onset of menopause for 10-15 years or longer may allow serious health risks to increase, especially for cardiovascular disease and osteoporosis. Seeking trained, experienced hormone optimization specialists is essential in order to get help from practitioners who understand the nuances of hormones and health risks and how to navigate them effectively. The latest findings offer a hopeful and potentially life-changing perspective. Working with an informed practitioner who understands the science and delivery methods can help you navigate the best options for your health and longevity.

 

FAQs

What is hormone optimization?

Hormone optimization is the process of ensuring that hormone levels aren’t too high or too low but are “just right.” Just-right hormone levels reduce or eliminate menopause symptoms (some of which can persist for decades) and reduce long-term health risks (like heart disease and osteoporosis).

Is it safe to start HRT after 65?

Absolutely. A study involving 10 million women on HRT showed that HRT past 65 is not only safe but essential for a longer, healthier life.

When should women start HRT?

While the recent study focused on women aged 65 and older to highlight the benefits of HRT later in life, other research indicates that starting HRT earlier can offer additional advantages, particularly for brain health. Studies show that beginning HRT during the perimenopausal transition, specifically five or more years before actual menopause, can significantly reduce the risk of Alzheimer’s disease by 50%. This brain-protecting effect diminishes once a woman reaches menopause, emphasizing the importance of timely intervention. The earlier you start, the greater the benefits, and longer use helps mitigate progressive issues like changes in brain volume, heart risk, and bone loss. Additionally, starting HRT early can help prevent the weight gain often associated with perimenopause when combined with appropriate nutrition and exercise. By initiating HRT before menopause, women can not only alleviate menopausal symptoms but also safeguard their cognitive health and overall well-being for the future.

 

References

1. Menopause. “Use of menopausal hormone therapy beyond age 65 years and its effects on women’s health outcomes by types, routes, and doses.” PubMed
2. Brinton, R. D. “Association of Hormone Therapy With Risk of Alzheimer Disease in Women.” JAMA Neurology
3. Jensen, L. B., Vestergaard, P., Hermann, A. P., Gram, J., Eiken, P., Abrahamsen, B., Brot, C., Kolthoff, N., Sørensen, O. H., Beck-Nielsen, H. “Hormone Replacement Therapy Dissociates Fat Mass and Bone Mass, and Tends to Reduce Weight Gain in Early Postmenopausal Women: A Randomized Controlled 5-Year Clinical Trial of the Danish Osteoporosis Prevention Study.”
4. Yüksel, H., Odabaşi, A. R., Demircan, S., Karul, A., Kozaci, L. D., Köseoğlu, K. “Effects of oral continuous 17β-estradiol plus norethisterone acetate replacement therapy on abdominal subcutaneous fat, serum leptin levels and body composition.” Pages 381-387 | Received 12 Dec 2005, Accepted 05 Jun 2006, Published online: 07 Jul 2009.
5. Gambacciani, M., Ciaponi, M., Cappagli, B., Piaggesi, L., De Simone, L., Orlandi, R., Genazzani, A. R. “Body Weight, Body Fat Distribution, and Hormonal Replacement Therapy in Early Postmenopausal Women.” The Journal of Clinical Endocrinology & Metabolism, Volume 82, Issue 2, 1 February 1997.
6. Espeland, M. A., Stefanick, M. L., Kritz-Silverstein, D., Fineberg, S. E., Waclawiw, M. A., James, M. K., Greendale, G. A. “Effect of Postmenopausal Hormone Therapy on Body Weight and Waist and Hip Girths.” The Journal of Clinical Endocrinology & Metabolism, Volume 82, Issue 5, 1 May 1997.