HRT in over 60s (DRAFT)

Starting HRT in over 60s

The decision to offer HRT to women over 60 should be based on individual factors. Some guiding principles are below: 

Are symptoms due to the menopause?  

• Flushes that have resolved for years and then return is not typical of menopause. Other symptoms should be explored and used to guide investigations to rule out other causes such as: 

• thyroid disorders, diabetes, rheumatological conditions such as rheumatoid arthritis, malignancy, side effects from medication, neuroendocrine disorders and infectious disease such as TB.  

Do the benefits outweigh the risk? 

1. What are the reasons for wanting HRT now? 
2. What are the ongoing symptoms? How are they affecting quality of life – minimal impact but concerned about ‘health effects of NOT having HRT’, for dry skin / nails or multiple systemic effects?  

Information to consider when counselling about first-start HRT in women over 60. 

For how long has the person been menopausal?  

• The observed reduction in cardiovascular risk pertains to women who start HRT within 10 years of their last period – this does not apply after this stage and HRT is not currently recommended for primary prevention in the absence of symptoms 

• Women who start HRT 10 years or more after their menopause have a higher risk of dementia 

• Women who have been menopausal for several years are more likely to experience side effects from oestrogen (bloating, breast tenderness, bleeding). 

Have you explained the difference in baseline risks with age? 

• Baseline absolute risk of stroke increases substantially over the age of 60yrs 

• Baseline absolute risk of VTE increases with age as illustrated below 

• • Age 40-54:    9 per 10,000 woman years 

• • Age 55–64:   22 per 10,000 woman years 

• • Age 65-79:    35 per 10,000 woman years 

• Baseline absolute risk of breast cancer increases with age. 

• • Aged 50-54: 28.0 per 10,000 women 

• • Aged 55-59: 28.6 per 10,000 women 

• • Aged 60-64: 33.8 per 10,000 women 

• Baseline absolute risk of endometrial cancer increases with age. 

Considerations for starting HRT if clear continuation of symptoms affecting quality of life since menopause transition and non-hormonal alternatives are not acceptable or efficacious; 

• Transdermal HRT is recommended due to higher VTE risk with age 

• Start with low doses e.g. half patch (12.5mcg) and titrate slowly  

• Continuous combined HRT should be used.  

• Tibolone should be avoided due to stroke risk 

• Higher than standard doses of HRT should be avoided, and alternate causes of symptoms considered if standard dosages are not providing benefits. 

If other causes for their symptoms have been excluded, and having considered the information provided women would prefer not to start HRT then discuss optimisation of lifestyle and complementary therapies. Alternatives to HRT 

Continuing HRT in over 60s

HRT should be reviewed annually, and a risk benefit discussion should form part of this review. This should be an individualised discussion and include information on the increased baseline risk of stroke, VTE, breast cancer and endometrial cancer (see above).

It is recommended that those >60 are switched on to a transdermal preparation.  

Lower doses may be sufficient in those >60 and this should be reviewed and considered with the individual at their review.  

HRT should be weaned and stopped when the risks outweigh the benefits, it is no longer needed or patient preference.  

See HRT  

Referral

Referral to a menopause specialist  

(Specialist review in primary care is appropriate if available)  

• Women > 60 requiring higher than standard doses of HRT where other causes of their symptoms have been excluded 

• Women > 70 wishing to commence HRT  

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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