Starting hormone therapy at 60 or over: when it is reconsidered and what the alternatives are

Starting menopausal hormone therapy at 60 or over is not ruled out, but the balance changes. For women who start it after 60, or more than 10 years after their last period, The Menopause Society considers the benefit-risk ratio less favourable, because of the greater absolute risk of coronary heart disease, stroke, venous thrombosis and dementia. That is why it is reconsidered case by case, especially when hot flushes persist and weigh on daily life, and there are local and hormone-free alternatives worth knowing about.

Why 60 years of age and 10 years since menopause mark a line

The 2022 position statement of The Menopause Society, formerly The North American Menopause Society, sums it up like this: in women under 60 or within 10 years of menopause, and without contraindications, the balance is favourable for treating bothersome hot flushes and preventing bone loss. Beyond that point, the same treatment starts from different ground. The risks, it adds, depend on the type of hormone, the dose, the duration, the route of administration, the timing of initiation and whether a progestogen is used. For the general background, see what hormone therapy is, who it is for and its real risks.

The underlying reason is arithmetic. The summary of product characteristics of an estradiol patch authorised in Spain explains it using stroke: hormone therapy is associated with up to a 1.5-fold relative risk of ischaemic stroke, and that relative risk does not change with age; but because the baseline risk of stroke rises with the years, the number of additional cases grows in older women. The same document notes that coronary risk is slightly higher in users of combined therapy over 60.

In Spain, a consortium of scientific societies coordinated by the Spanish Menopause Society (AEEM) published eligibility criteria for hormone therapy in 2022, based on 14 systematic reviews and 32 meta-analyses. Age and timing of menopause are among the areas analysed, and each situation is classified into four categories, from use without restriction to do not use.

What trials show when therapy is started late

Much of what we know comes from the WHI study, in women aged 50 to 79. Its analysis by time since menopause (Rossouw, JAMA 2007) found a gradient in coronary risk: a hazard ratio of 0.76 in women less than 10 years past menopause, 1.10 at 10 to 19 years and 1.28 at 20 years or more. In absolute terms, this went from 6 fewer cases to 17 more cases per 10,000 women per year. Stroke, by contrast, increased with no clear differences by age.

The 2015 Cochrane review, with 19 trials and 40,410 women, reached a similar conclusion. Those who started within 10 years of menopause had lower mortality (relative risk 0.70) and less coronary heart disease (0.52). Those who started later saw no appreciable effect on mortality or the heart, but did have more strokes (1.21) and more venous thrombosis (1.96).

Something similar happens with memory. In the WHIMS study, in women aged 65 or over, the combination of oestrogen and progestogen doubled the risk of probable dementia (hazard ratio 2.05), around 23 additional cases per 10,000 women per year. The Spanish summaries of product characteristics reflect this: hormone therapy does not improve cognitive function and there is some evidence of a higher risk of probable dementia in women who start it after 65.

An important nuance: the WHI used oral conjugated equine oestrogens and medroxyprogesterone acetate, and not all formulations behave in the same way. In a large British study of women aged 40 to 79 (BMJ 2019), oral therapy was associated with more venous thrombosis (odds ratio 1.58) and transdermal therapy was not (0.93). This is observational data and it concerns thrombosis, not heart attack or memory.

And breast cancer: does anything change with age?

The meta-analysis by the Collaborative Group on Hormonal Factors in Breast Cancer (The Lancet, 2019), with 108,647 women with breast cancer, found that every type of hormone therapy except vaginal oestrogens was associated with an excess risk that grew with duration and was greater with oestrogen plus progestogen. By its estimate, 5 years of treatment from the age of 50 meant one extra case for every 50 users of oestrogen with daily progestogen, one for every 70 with intermittent progestogen and one for every 200 with oestrogen alone. That relative excess was attenuated when starting after 60. In the WHI, oestrogen alone did not increase breast cancer (cumulative hazard ratio of 0.79).

When it is considered again after 60

A less favourable balance does not mean the door is closed. Hot flushes do not always end soon: in the SWAN study, the median duration of frequent hot flushes was 7.4 years, and an Australian survey of 2,020 women found moderate to severe vasomotor symptoms in 6.5% of postmenopausal women aged 60 to 65. The Menopause Society accepts longer treatment when there is a documented indication, such as persistent hot flushes, with shared decision-making and periodic review.

Hormone therapy is a prescription-only medicine. The summary of product characteristics of an estradiol patch does not list age among the contraindications, but it warns that experience in women over 65 is limited, that therapy should only be started when symptoms adversely affect quality of life and that the benefit-risk balance should be reviewed at least once a year. Before starting, it requires a complete personal and family medical history. Broadly, what is assessed:

• How many years have passed since the last period and how much the symptoms affect daily life.
• A history of thrombosis, recent heart attack or angina, and clotting disorders, which are among the contraindications in the summary of product characteristics.
• A personal history of breast cancer or other oestrogen-dependent tumours, also contraindications.
• The dose, the transdermal or oral route and the need for a progestogen, factors that according to The Menopause Society change the risk.

It is worth separating two situations that are often confused: starting at 60 or over, which is what this article is about, and continuing a treatment begun earlier, which is decided with periodic reviews according to the same guidelines. If you are wondering how that assessment is done remotely, we explain it in how menopause treatment via telemedicine works in Spain.

If the symptom is vaginal dryness, age weighs differently

Many complaints after 60 are not hot flushes but dryness, stinging or pain during sex, known as the genitourinary syndrome of menopause. Here the conversation is different. When over-the-counter products are not enough, The Menopause Society recommends low-dose vaginal oestrogen, vaginal prasterone or oral ospemifene. And vaginal oestrogens were the only type of hormone therapy with no excess breast cancer risk in The Lancet meta-analysis.

In Spain, the following are authorised on prescription: vaginal oestrogens such as estradiol vaginal tablets (Vagifem) or estriol gel (Blissel), prasterone pessaries (Intrarosa) and ospemifene tablets (Senshio). There are nuances here too: the Vagifem summary of product characteristics states that experience in women over 65 is limited. We cover this in vaginal dryness and pain during sex in menopause.

Hormone-free alternatives for hot flushes

The 2023 Menopause Society position statement on non-hormonal treatments recommends, with the highest level of evidence, cognitive behavioural therapy, clinical hypnosis, SSRI and SNRI antidepressants, gabapentin and fezolinetant; with somewhat weaker evidence, oxybutynin; and with limited evidence, weight loss and stellate ganglion block. It does not recommend, on the other hand, supplements and herbal remedies, soy, acupuncture or paced breathing.

Fezolinetant (Veoza) is authorised and marketed in Spain, on prescription, for moderate to severe menopausal hot flushes. Its summary of product characteristics states that its safety and efficacy have not been studied in women who start it after 65: the trials included women aged 40 to 65, with a mean age of 54. It requires liver function tests before starting and every month for the first three months. There is more detail in fezolinetant, the non-hormonal pill for hot flushes.

Elinzanetant (Lynkuet) is not marketed in Spain: the AEMPS register lists it as authorised but not marketed. It has held European authorisation since November 2025 for moderate to severe hot flushes associated with menopause or caused by adjuvant endocrine therapy for breast cancer.

Paroxetine and gabapentin are among The Menopause Society's options, but in Spain their summaries of product characteristics do not include hot flushes: paroxetine is authorised for depression and anxiety, and gabapentin for epilepsy and neuropathic pain. Using them for hot flushes is off-label use, which Royal Decree 1015/2009 treats as exceptional and to be justified in the medical record. After 60 they have their own precautions: gabapentin may require dose adjustment for kidney function, and hyponatraemia has rarely been reported with paroxetine in older people.

What should not be taken for granted

• «Hormone therapy is forbidden after 60.» No: age is not among the contraindications in the summary of product characteristics, although the balance is less favourable.
• «Starting it late protects the heart or memory.» Data on late initiation show no benefit for mortality or the heart, and in women over 65 probable dementia increased.
• «Supplements are an equivalent alternative.» The Menopause Society does not recommend them for hot flushes.

What to take away

Starting hormone therapy at 60 or over is not impossible, but it calls for a finer assessment than at 50: the absolute risk to the heart, the brain, the circulation and memory is higher, and the route, the dose and the specific symptom change the answer. And for some symptoms there are local or hormone-free options. What does exist in Spain today is menopause treatment with a prior assessment, a prescription when appropriate from a registered doctor and continuous follow-up, starting from your full history and not just your age. You can check in a few minutes whether the treatment fits your case.