Systemic MHT in older people

Starting systemic MHT in people at age 60 years or older is contraindicated, without specialist advice. Starting systemic MHT in this age group is associated with an excess risk of 7 additional strokes and 12 additional venous thromboembolic events per 1000 users. Starting combined MHT in people older than 65 years is associated with an increased risk of dementia. The risks of coronary heart disease and all-cause mortality are not increased with starting MHT in older individuals.

If systemic MHT is already being used at age 60 years, it may be continued to manage menopausal symptoms, after reassessing the benefits and harms.

If an older person needs systemic MHT, preferably use a transdermal formulation because it has lower risks of VTE and stroke than oral formulations. Start with the lowest possible dose of estrogen; this may help avoid mastalgia, particularly in individuals who have been estrogen-deficient for a long time. See c_srg2-c24-s7.html#srg2-c24-s7__tsrg2-c24-tbl3 for available formulations of low-dose estrogen. The lowest available options in the low-dose range should be considered when starting MHT. A low-dose patch can be cut in half to reduce the dose further. If oral medication is used in older individuals, alternate daily dosing is appropriate for some preparations. Review response after 2 to 4 weeks. If tolerated, increase the dose if required, but keep the dose within the low-dose range.

Addition of a progestogen is required for individuals with endometrial tissue. This may include those who have had a total hysterectomy, but who have significant endometriosis, to prevent stimulation of endometrial deposits and malignant transformation; seek specialist advice. See also Systemic MHT in individuals with endometriosis. If a progestogen is required, limited evidence suggests micronised progesterone may be associated with a lower risk of VTE and cardiovascular disease. Also address other cardiovascular risk factors.