In the past, many women may not have sought a prescription for menopausal hormone therapy (MHT) out of fear, or even just because they felt their symptoms weren’t “bad enough” to warrant treatment. However, as menopause hits the mainstream, things are changing.

These days, many postmenopausal women may find themselves newly interested in exploring MHT, whether it’s to tackle a new onset of menopause symptoms, to address symptoms they previously expected would resolve themselves by now, or because they’ve become privy to new safety information. Others may be entertaining MHT for the potential long-term health benefits, which may include protection against cardiovascular disease, osteoporosis, metabolic disease, cognitive decline, and genitourinary syndrome of menopause.

That said, it’s not uncommon for postmenopausal women who are over 60 years-old or 10+ years into postmenopause to hear they’ve missed the window of opportunity for using MHT from a provider. The risks and benefits of menopausal hormone therapy are different from early perimenopause to postmenopause. And while it’s still possible to benefit from hormone therapy after menopause, the longer you’re in menopause, the higher potential for risk.

This window of opportunity, referred to as the timing hypothesis, doesn’t exist to make anyone feel bad about “missing the boat,” but instead posits that the effects of hormone therapy on cardiovascular health and other health issues depend on when MHT is initiated. The timing hypothesis suggests that initiating hormone therapy during perimenopause or in early menopause provides more significant benefits and fewer risks compared to starting MHT later.

If you’re curious about MHT, it’s important to review your specific health risks (and benefits) with a provider who’s well-versed in hormone therapy. In the meantime, here’s some info to help you wrap your head around whether (and when) MHT could be right for you.

The truth is there’s very little research on women over 60 using MHT for the first time. Most of the current research shows that starting MHT early in perimenopause or within ten years of menopause decreases cardiovascular risk, lowers all-cause mortality, reduces bone loss, and reduces the risk of developing dementia. The associated risks, which include breast cancer, blood clots, and stroke, are rare, but must be assessed on an individual basis.

For women who initiate hormone therapy more than 10 years after menopause or who are older than 60 years, the benefit-risk ratio appears less favorable concerning cardiovascular protection and cognitive function. For these women, there’s an increased risk of a cardiac event during the first year on MHT.

If you’ve lived for a decade or more without the cardioprotective benefits of estrogen, your blood vessels may become stiff, sticky, and inflamed, which can lead to plaque buildup. In a healthy artery, taking estrogen may have little or no consequences, whereas in a stiffer one, estrogen is associated with an increased risk of plaque rupture during the first year on MHT. Your provider may recommend additional cardiac testing to assess your risk before initiating MHT.

Studies on timing of MHT as it relates to cognitive function, however, are mixed, and it isn’t yet clear whether MHT plays a role in dementia prevention post-menopause.

For women over age 65, a recent large-scale study confirms that the implications of MHT use varies by type, route, and dose. In making decisions about whether, when, and how to use MHT, risks and goals should weighed. For instance, many women who are outside of the so-called window opportunity may still benefit from MHT if they’re in good cardiovascular health but experience persistent vasomotor symptoms, quality-of-life issues, or high risk of osteoporosis.

Notably, unless there’s a specific contraindication, vaginal estrogen, specifically, may be started at any age to improve genitourinary symptoms without many of the risks associated with systemic therapy (more on this in Week 4).

According to The Menopause Society, MHT doesn’t need to be discontinued in women older than 60 or 65 years. After appropriate evaluation and counseling, it can be considered for continuation beyond age 65.

• Reasons for continuation include persistent vasomotor symptoms (such as hot flashes), quality-of-life issues, or prevention of osteoporosis.
• Patients should be appropriately evaluated and counseled on the benefits and risks of long-term hormone therapy, and the decision to continue MHT should be based on individual health status and preferences.

Keep in mind, the risks of MHT shift as you age and are very specific to your health, so the discussion between you and your provider should be ongoing.

There’s no one-size-fits-all prescription when it comes to MHT post-menopause. The decision to use MHT or not should be shared between you and your provider based on a thorough discussion of benefits and risks to you and you alone.

Your provider will review your medical history, family history, and lifestyle factors to assess your risk. For example, if you have a high risk of osteoporosis and a low risk of cardiovascular disease, you might be a good candidate, but if the opposite is true, MHT is less likely to benefit you.

Remember whatever the reason MHT may or may not be the right fit, there’s no “missing out.” Instead of comparing yourself to others or writing rigid rules, keep an open mind, ask questions, and always advocate for yourself.