Menopause is a fact of life for all women, with 95% of females having their final menstrual period between the ages of 45 to 55. This is the period in which a woman’s ovarian estrogen production is dramatically decreasing, which results in common symptoms that not only bring discomfort but can affect the overall quality of life as well. This is why women turn to hormone replacement therapy (HRT), not only to have an easier time dealing with the symptoms but also to possibly avoid certain diseases as well.
So it’s only natural to wonder - hormone replacement therapy for older women has been found to prevent which diseases? Many of the health consequences that come with aging and menopause can be modified or improved by HRT, either by using just estrogen or combining estrogen with progestin. HRT is often used in short periods and recommended to take around the time of menopause, but there is accumulating evidence that HRT can be introduced or re-introduced to intervene with a variety of progressive conditions.
For a very long time, HRT, whether it's a synthetic hormone or bioidentical hormones, was not recommended for women over 65, for various reasons. The restriction applied to those who already went through hormone therapy AND those who haven’t experienced it. Now this limitation is easing due to growing evidence suggesting that women over 65 can have significant benefits from HRT.
While HRT may not be needed or not applicable to some women due to individual risk factors, the option to take it should always be available.
To be fair, there are legitimate medical reasons why they made age 65 as the cutoff for taking hormone therapy. But ultimately, the decision to take it boils down to two factors - your need for the hormones and your overall health. It’s very important to consider why you want to take HRT. Before, people generally believed that women have little or no use for hormones after they reach menopause. The uncomfortable symptoms of menopause and hormonal imbalance do tend to dissipate in the years after, so it was assumed that all the serious symptoms would be gone after age 65 - which is not really true, as countless older women can testify.
Now that there’s increasing evidence showing that symptoms of estrogen deficiency can and most likely do persist in women of this age group, doctors are now more open to offer hormone therapy to older women.
What spurs women to seek the benefits of HRT is the effects of the postmenopause symptoms on their bodies. These symptoms, with the common ones including hot flashes, sexual discomfort, and mood disturbances, can be devastating to one’s mind and body and affect the overall quality of life. But the case for taking HRT this late in life goes beyond the common symptoms. The loss of estrogen which jumpstarts menopause also diminishes a woman’s bone density and increases the risk for osteoporosis. This is a major cause of injury for older women and can lead to overall degraded quality of life.
So by taking HRT, which introduces exogenous estrogen into the body, addresses not just the common menopausal symptoms, but also serves as protection for bone loss and helps women fight off osteoporosis.
Just because a woman reaches the age of 65 doesn’t mean that the benefits of HRT will become less important. A 2014 study from the researchers at the University of California discovered that “women who start HRT when in their 50s and continued for 5-30 years [experienced] an increase of 1.5 quality-adjusted life-years.” In addition to this, a 2017 paper by NAMS on hormone replacement therapy stated that HRT does not need to be discontinued in women above 60 or 65 years old and can be continued beyond age 65. The paper said that this is for “persistent [vasomotor], [quality of life] issues, or prevention of osteoporosis after appropriate evaluation and counseling of benefits and risks.”
HRT has the potential to offer a wide array of health benefits at a relatively low cost. But there is still some hesitancy to continue taking HRT throughout the menopausal years. There are understandable concerns about possible certain conditions such as breast cancer risk.
There is increasing support for periods of HRT use that are tailored to a patient’s current health issues. This treats hormone therapy as a treatment rather than prevention. It will appeal to women who don’t like taking medications unless absolutely needed, those who fear the increase in breast cancer or breast cancer risk (prolonged use of HRT supposedly increases the risk factor), and those who don’t want to take medications at this stage of their lives.
In using HRT in this manner (as treatment rather than prevention), the hormones can be taken for 1 to 5 years during the perimenopausal interval to control irregular bleeding and vasomotor symptoms. Then depending on the patient’s health status, individual symptoms, and risk factors, possible use of HRT later in life can be considered particularly for the relief of urogenital symptoms and for bone protection.
There is growing evidence that supports the use of HRT in the later stages to improve a variety of progressive conditions related to aging and menopause.
These symptoms are usually the most difficult to deal with in the perimenopause and early menopausal stages, but they generally improve within 2 to 5 years. For some women, some symptoms will continue to bother them for years or decades. Randomized placebo-controlled trials came out with evidence indicating that oral and transdermal estrogen can bring quick and effective relief of vasomotor symptoms.
In case it’s not appropriate to use estrogen, progestins alone can be used instead although your doctor may have to give you a higher dose. If HRT is not appropriate to use at all, there are several non-hormonal options that can be used instead for controlling vasomotor symptoms. These non-hormonal options include clonidine, exercise, dietary phytoestrogens, black cohosh, and even acupuncture.
HRT must be administered for at least 5 to 10 years in order to feel the significant benefits of the treatment in the skeletal system. However, symptoms of bone loss come back when the treatment is discontinued as long-term adherence to HRT is relatively low. After 10 or more years after stopping estrogen therapy, bone loss will just catch up, so the level of bone mass in treated and untreated women will appear to be similar.
There are at least three major epidemiological studies that support this approach. These studies involve approximately 15,000 women. Each study reported bone mass preservation or protection of fracture among patients who were currently using estrogen for at least 10 years, even if they started using estrogen after age 60. The studies also showed that the benefits of estrogen were less or absent in past users or short-term users. Those who were currently using estrogen also showed neuromuscular function, improved muscle strength, and a lower risk of falling.
There are also findings showing that dose-related estrogenic side effects such as nausea, breast tenderness, and vaginal discharge can be lessened without sacrificing the full therapeutic effect of the postmenopausal hormone therapy. A study showed dose-related improvements in bone density beginning at 0.3 mg of esterified estrogen. It's yet to be seen though if these low doses can provide effective fracture protection or whether the results can apply to older women with confirmed osteoporosis.
Urogenital symptoms tend to develop more progressively in the years or even decades following menopause, which is the opposite of vasomotor symptoms, which appear early and then tend to disappear with time. Urogenital concerns can affect 30% to 50% of menopausal women and result in daily discomfort. The first symptom is usually vaginal dryness during sexual arousal. There is evidence that supports using estrogen for symptoms of vaginal atrophy and as prophylaxis for recurrent urinary tract infections.
But systemic HRT may not provide total relief for vaginal discomfort, so this means that augmentation or replacing it with local vaginal estrogen therapy may be needed. Vaginal estrogen, even in low doses, can be used to treat urogenital symptoms. It can be used even by women with contraindications or intolerance to systemic estrogen therapy. This oestrogen is absorbed systemically, although circulating levels are lower compared to oral medications in equivalent doses.
There are studies too indicating that HRT might help older women ward off recurring incidences of urinary tract infection. The researchers report that women taking HRT for improving symptoms of menopause tend to have a greater variety of bacteria in their urine. The variety includes remarkable amounts of Lactobacillus-type bacteria, a healthy kind that is known to protect against urinary tract infections. In women who don't have a UTI, the study found out that "the strongest variable that was associated with having these beneficial bacteria present was the fact they were taking estrogen therapy."
The study was conducted among 75 postmenopausal women who are patients at the Southwestern Medical Center's Urology Clinic. The researchers performed a genetic analysis on all the bacteria found in the urine of the patients, who were evenly divided into three groups: those who have never had UTI, those who have had past recurrent infections, and those who have been infected before and were currently infected.
The analysis revealed that the patients with recurrent infections tend to have fewer bacteria types in their urine and that those who didn’t have recurrent UTI actually had a ten-fold greater bacteria variety. The results also revealed that about half of the women were taking HRT for menopausal symptoms and they tend to have more of the Lactobacilli in their urine. Additionally, the researchers found out that HRT delivered via pills or patches appeared to encourage the growth of Lactobacilli compared to vaginal cream.
The researchers explained that estrogen stimulates the vaginal cells to produce more of these types of carbohydrates that Lactobacilli really likes to consume. It basically shows that estrogen makes the cells make more food for the Lactobacilli and this is why HRT might promote healthy vaginal bacteria. The results of the study suggest that HRT might be a potential treatment for recurring UTIs in women, but should be backed up by a rigorous clinical trial first.
The study also shows that using DNA analysis in testing a woman’s vaginal health has an advantage over analyzing traditional cultures. However, the researchers agree that it may be too early to start using HRT for the purpose of stopping recurring UTIs.
Postmenopausal estrogen therapy is related to endothelial vasodilation and beneficial changes in the body's lipid profile. Several studies have shown that there’s a 40% to 50% reduction in the risk of coronary heart disease (CHD) HRT users in their postmenopausal stage. The protection diminishes after the therapy is stopped, which suggests that it is controlled by direct vascular action.
There are several studies that suggest that estrogen deficiency may increase the risk of Alzheimer’s disease and that estrogen replacement may have a hand in preventing and treating the condition. The antioxidant properties of estrogen can be a major factor, as well as its ability to enhance cerebral blood flow, improve cerebral glucose metabolism, and reduce ß-amyloid deposition.
So far, the more recent findings suggest that estrogen’s antioxidant effects may be enough to slow the initiation phase of the disease, but not enough to slow down the propagation phase of neurodegeneration. The evidence is currently limited and requires backing up by large placebo-controlled trials. So doctors may not be so quick to promote the use of HRT in older women just for the purpose of neurocognitive protection. But it would not make sense to withhold offering the treatment altogether from patients who wish to try it for this purpose, as long as the risk-benefit ratio is in favor of the therapy.
The North American Menopause Society and the American College of Obstetrics and Gynecology agree that the use of hormone therapy for menopause symptoms should not be discontinued due to age. Instead, it should be individualized. They recommend that using HRT beyond the age of 60 or even 65 may be reasonable, as long as both doctor and patient agree that the benefits clearly outweigh the risks when it comes to providing symptom relief for hormonal imbalance. It was pointed out earlier that more than 40% of older women can still have persistent hot flashes that can make it difficult for them to get good sleep and thus can impair their quality of life.
For extended use of HRT, which describes using it for more than the five standard years or beyond age 60, doctors will restart the estrogen with the lowest effective dose possible to balance hormone levels and then decide later on when to stop the therapy. Studies show that 40% to 50% of women who start therapy stop within one year while 60% to 75% stop within two years. The patients usually do so without help from their doctors.
Doctors caution, however, that withdrawing from exogenous estrogen abruptly at any age can result in the return of hot flashes and other menopausal symptoms. This is why some doctors recommend tapering, or lowering the dosages gradually until the therapy stops completely.
Read more: How Long Should a Woman Be On Hormone Replacement Therapy?
The symptoms of estrogen deficiency returning after stopping hormone therapy are actually common. There is no reliable way to determine whether the symptoms will go away quickly or persist after a while, specifically among women who have recurrent vasomotor symptoms. For recurring symptoms of hot flashes, doctors however will initially suggest non-hormonal options before deciding to resume the estrogen treatment.
If you’re an older woman and you have not been exposed to significant levels of estrogen for many years, you may be particularly susceptible to the side effects that come with the hormone, which include breast tenderness, bloating, and vaginal discharge. And because of evidence suggesting that bone protection can be achieved even with lower doses, elderly women may not need or tolerate estrogen doses that were originally thought to be osteoprotective.
These side effects can be minimized by starting with half the usual dose, which can be given daily or on alternate days. This makes sense because there is no urgency to reach full therapeutic doses of HRT. The doses can be increased gradually over the following weeks until the symptoms improved, if the desired dose is reached, or if undesirable side effects happen. If you still have your uterus, your doctor may hold off on adding progestin for several weeks in order to note the difference between the side effects that can be attributed to the estrogen and progestin components.
Older women tend to have a lower incidence of breakthrough or menstrual bleeding on HRT, as compared to women who just reached their menopause. Given the age, the bleeding can be more inconvenient or distressing for older women though. In this case, it would seem logical to take continuous combined HRT since there is little rationale for using cyclic HRT instead of combination HRT.
The initial discussion about the risks and benefits of menopausal hormone replacement therapy usually happens around the time menopause hits and is triggered by the start of vasomotor symptoms. However, the chances for a second discussion between a mature woman patient and her doctor about HRT may happen again in the seventh decade or beyond. This is often triggered by an adverse health event in the patient or someone close to her. As a patient, it's only understandable to be concerned about the possible risks of developing conditions, not just breast cancer incidence or heart disease risk, but others such as venous thromboembolism, colorectal cancer, ovarian cancer, and endometrial cancer
This is the perfect opportunity to re-evaluate various lifestyle factors, the state of her musculoskeletal, cardiac, and sexual/urogenital health, and concomitant medication use.
Given that the risk-benefit ratio is in favor of menopausal hormone therapy, your doctor can suggest various strategies to minimize the side effects. These strategies include giving lower doses, initiating therapy slowly, and comparing systemic against local therapy. While it’s true that there are inevitable consequences of aging and menopause, the idea of re-initiating menopause hormone therapy should not be denied since systemic or local postmenopausal HRT can prove acceptable and appropriate in some older women and will definitely contribute to the improvement of their quality of life.
Are you looking for solutions to alleviate the discomfort of estrogen deficiency at a later stage? You have every right to know your options. Revitalize You MD will guide you on your options when it comes to HRT, bioidentical hormones, and conjugated equine estrogen for the menopausal woman and older women. If you’re in Georgia and nearby areas, call Revitalize You MD and schedule a consultation for hormone replacement therapy.
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