--- title: "Like, Forever?" entity: "blog" canonical_url: "https://www.drsmithnd.com/blog/likeforevermenopausehormonetherapy" markdown_url: "https://www.drsmithnd.com/llms/blog/likeforevermenopausehormonetherapy" lastmod: "2026-02-23T23:39:00.000Z" --- Many women remain uneasy about what appears to be a reversal in messaging about menopausal hormone therapy. After the initial 2002 publication of the Women’s Health Initiative, headlines suggested hormone therapy was broadly dangerous. Two decades later, major menopause societies do support individualized, potentially long-term use. This is not an arbitrary flip in science, it reflects refinement of interpretation and the emergence of evolving data. In the original WHI study, the average participant was 63 years old. Many had already been in menopause for over a decade before starting hormones. When researchers later separated the data by age and followed women for more than 20 years, a clearer pattern emerged. Women who begin hormone therapy before age 60, or within 10 years of menopause, tend to have more benefit and lower overall risk. The earlier headlines did not account for how strongly timing of initiating use of MHT and age influences outcomes.¹ This evolution reflects better analysis, not contradiction. Is There a Mandatory Stop Age? There is no fixed age at which MHT must be discontinued. The most recent Position Statement from The Menopause Society (2022) states that therapy may continue as long as benefits outweigh risks, with annual reassessment.² There is no evidence-based five-year expiration rule or that everyone after 60 must stop. Professional societies including The Menopause Society, the Australian Menopause Society, and the British Menopause Society explicitly reject arbitrary age cutoffs. Continuation beyond age 65 is appropriate for persistent menopause symptoms or bone protection in well-screened women, using the lowest effective dose, (topical estrogen not oral) and reassessing yearly.³ In clinical practice, shared decision-making guides continuation, prioritizing quality of life alongside quantified risk.⁴ What Changed Since the Early Cancer and Stroke Concerns? Early concerns focused on breast cancer, stroke, and thromboembolism (clot). Longer-term data clarify several points: - Risks are smaller than originally reported when age stratified - Cardiovascular risk is strongly dependent on timing of initiation - Transdermal routes are associated with lower clot risk than oral estrogen - Lower modern dosing improves safety profiles Women initiating MHT before age 60 generally demonstrate neutral or favourable cardiovascular outcomes, while initiation after 60 carries approximately a 20 to 30 percent relative increase in stroke and clot risk, particularly with oral formulations .⁵ All-cause mortality has not been shown to increase with appropriately timed initiation.⁵ Key Benefits of Ongoing Therapy MHT remains one of the most effective interventions for: - Reduction of vasomotor symptoms - Prevention of bone loss - Reduction in osteoporotic fracture risk - Treatment of genitourinary syndrome of menopause Estrogen therapy reduces fracture risk and slows bone density decline. Early use may improve lipid profiles and has neutral to mildly favourable metabolic effects.⁶ These benefits are clinically significant and must be weighed alongside risk. When Should MHT Be Discontinued? Clear contraindications include: - Active or recent breast cancer - Estrogen-dependent malignancy - Active thromboembolic disease - Prior stroke - Unexplained vaginal bleeding - Significant liver disease These remain consistent across endocrine and primary care guidelines.⁷ Annual review of personal and family history is standard. What about Vaginal Estrogen though? Major menopause society guidelines support the continued use of low-dose vaginal estrogen for genitourinary syndrome of menopause, even in women with contraindications to systemic hormone therapy, given its minimal systemic absorption; in cases of estrogen-dependent breast cancer, management should be coordinated with oncology.* What Happens After Stopping MHT? Between 44 and 82 percent of women experience recurrence of vasomotor (hot flashes) and other symptoms after discontinuation, regardless of age, including women in their seventies. Gradual tapering may reduce symptom rebound.⁸ What do I observe clinically when people stop MHT? I typically see a return of things like poor sleep, fatigue, low mood, worse memory (could be poor sleep, we don’t know), a return/ worsening of body aches, and in some women hot flashes return but are not as strong. In some women this is very, very mild, in some women this is pronounced (the return of some symptoms), but never are they as intense as when they were in perimenopause. What about Bone Density After Discontinuation? Bone density does not collapse immediately after stopping MHT, but loss resumes. Without MHT, spinal bone density may decline 3 - 5% in the first year of menopause, then 1-3% annually thereafter.⁹ After stopping MHT, bone loss typically resumes at approximately 1-2% per year at the hip and spine. Protective gains may persist for two or more years but gradually diminish over 5-10 years.¹⁰ Hip and femoral bone mineral density declines approximately 1% annually after discontinuation. Longer duration of prior therapy may leave a residual density advantage of up to 20% compared with never-users. Gains of 5-10% acquired during therapy fade over 5-10 years.¹¹ Fracture risk correlates directly with bone density. Every 10 percent decline in bone mineral density approximately doubles fracture risk. Some data suggest hip fracture odds increase 20 to 30 percent within five years of discontinuation. Prior MHT use remains associated with a 30 to 50 percent reduction in lifetime fracture risk compared with never use.¹² Breast Cancer Risk Simplified Combined estrogen–progestin therapy is associated with a small increase in breast cancer diagnosis after more than five years of use in women over 60. For perspective, among 1,000 healthy women over age 55 not using MHT, the baseline risk of developing breast cancer over 10 years is 25-35 women. With combined estrogen–progestin therapy, that increases to approximately 30-40 cases per 1,000 over 10 years, representing roughly five additional cases per 1,000 women .¹⁴ Risk declines after discontinuation. Mortality impact remains less clear. For the savvy amongst my readers, yes it is true that much of the historical data reflects synthetic progestins while the modern approach mostly uses micronized progesterone, and so it may well be that emerging data looking at use with micronized progesterone may clarify different risks.¹ ⁴ Key Take Aways There is no mandatory stop age for menopausal hormone therapy. Continuation is appropriate when symptoms persist, bone protection remains necessary, and individualized risk assessment supports ongoing use with annual review. The modern approach to MHT is evidence-based, stratified by age and timing, and is grounded in long-term follow-up data. For many of us, the medically accurate answer to “Like, forever?” is straightforward: as long as the benefits outweigh the risks. This is not about blind reassurance, and it is not a directive to continue MHT indefinitely. It is about understanding the implications of the scientific data we currently have and applying it thoughtfully to our individual risk profiles. As both a primary care provider and a Menopause Society Certified Practitioner, I have pursued the highest level of formal menopause training available. My role is to interpret the evolving literature, guideline statements, and long-term outcome data, and to translate that evidence into individualized medical decision-making. Midlife women’s health has been underrepresented and inconsistently applied in clinical practice which is why we must uplevel your education. Midlife care is evolving and requires clarity, thoughtful reassessment, and partnership. We deserve accurate data and care that reflects current science. As many of you know, I am in this phase of life as well, and that only strengthens my commitment to staying current with the evidence so that the guidance I bring to the table remains clear, rigorous, and relevant. We are all in this together ladies. Dr. Kirsten This content is intended for educational purposes only and does not establish a physician–patient relationship. It is not a substitute for individualized medical advice, diagnosis, or treatment. All decisions regarding menopausal hormone therapy should be made in consultation with a licensed healthcare provider who can evaluate your specific medical history and risk profile. References The Menopause Society. 2022 Hormone Therapy Position Statement. PubMed 35797481. 2022 NAMS Position Statement. British Menopause Society 2020 HRT Recommendations. Cleveland Clinic Journal of Medicine. 2016;83(8):605. PubMed 25962085. PMC10752002. AAFP Guidelines for MHT. PMC4011401. PMC6362761. JCEM 2016;101(12):5004. PMC10721581. PMC12137504. PubMed 34119418. PMC6891893. #### Hi, I'm Dr. Kirsten Smith #### Women’s health warrior and advocate with 15+ years of experience in hormonal health My goal is to support women at all stages of their hormonal journey, through pre-perimenopause, perimenopause and post-menopause.