Asking, “When should I start hormone replacement therapy?” seems like it risks slipping into tautology, or at the very least redundancy. After all, isn’t the answer, “When you need more hormones.” But the real answer is more complicated.
Every woman ages differently. Every woman goes through hormonal changes differently. And every woman approaches menopause differently. However, there are broad guidelines that can help you decide if and when hormone replacement therapy (HRT) is the best choice. Significantly, knowing when to start HRT can help you maximize its impact while minimizing any risks. By strategically considering the timing of treatment, you may not only prevent unnecessary suffering, but protect your health for years to come.
The Critical Window Theory of When to Start HRT
Menopause comes at different times for different people. While the average age of menopause in the United States is 51, many factors can impact when menopause occurs, including racial and ethnic differences and overall health. But regardless of when menopause starts, the hormonal changes that lead to the end of your reproductive cycle actually begin years earlier.
So when should you start hormone therapy? In part, it depends on your symptoms. For many women, perimenopause—which can begin as many as 10 years before menopause (in a woman’s late 30s or early 40s)—can be an uncomfortable and distressing experience. The symptoms of perimenopause can include irregular periods, mood disturbances, sleep disturbances, increased anxiety, and vasomotor symptoms like hot flashes, any of which benefit from HRT treatment. However, some women worry that their symptoms are not severe enough to warrant hormone therapy, particularly if they are relatively young. Others erroneously believe that they are too young for HRT even while experiencing severe perimenopause symptoms.
While it’s common to assume that it’s too early to start hormone replacement therapy, research suggests that there may be meaningful benefits to starting HRT earlier rather than later. In fact, a growing body of evidence indicates that there is a critical window of opportunity for HRT to confer significant long-term health benefits.
The critical window theory is based on a plethora of studies showing that the younger women start HRT, the greater its benefits, not just in terms of symptom reduction, but in reducing the risk of multiple health conditions that become more prevalent with age. More specifically, earlier initiation of hormone therapy may provide superior protection from osteoporosis, cognitive decline (including dementia and Alzheimer’s), and diabetes, among others.
Indeed, according to a major study on HRT and coronary heart disease (CHD) found that HRT can significantly reduce the risk of CHD, but “appears to exert its greatest benefit when initiated in women before 60 years of age and/or within 10 years of menopause.” Meanwhile, a 2009 metareview by Barbara Sherwin, Professor Emerita in the Department of Psychology at McGill University found that “the vast majority of the reviewed studies support the idea that early but not late initiation of estrogen therapy might prevent or delay cognitive decline in aging women”—findings that have subsequently been supported by more recent research. In fact, studies indicate that “women who initiate hormone therapy before their final menstrual period show increased blood flow to the hippocampus and better verbal memory compared to nonusers.” What’s more, these neuroprotective effects could increase the longer you take HRT. When it comes to diabetes, researchers have found that HRT may reduce the risk of type 2 diabetes in menopausal women and improves insulin sensitivity in young women already diagnosed with type 2 diabetes more effectively than in older women.
Interestingly, while HRT has long been known to lower the risk of osteoporosis, particularly in younger women, the true benefits may lie in early initiation coupled with duration of therapy. “In order to accrue significant skeletal benefits from HRT, therapy must be administered for at least 5 to 10 years,” explains Dr. Margo R. Fluker, clinical professor at the University of British Columbia. “However, long-term adherence to HRT is relatively low, and bone loss resumes after discontinuation of HRT. Catch-up bone loss is believed to occur, so that 10 or more years after stopping estrogen, bone mass appears similar in treated women and untreated controls.” To fully realize the protective potential of HRT, it may therefore be prudent to not only start HRT early, but stay on it for years to come.
Of course, each woman’s experience of perimenopause is unique and each individual must determine what kind of interventions they are comfortable with. But the evidence for the critical window therapy is compelling, and there is little reason to avoid initiating HRT earlier rather than later.
Starting Hormone Therapy Later In Life
If you are reading this later in life, and particularly over the age of 65, you may assume that it is too late to start HRT. You may fear that you have missed your window not only to derive the greatest benefits of HRT, but to receive treatment at all. But being older doesn’t mean the possibility of HRT is closed.
Many women continue to experience a plethora of disruptive symptoms in their postmenopausal years, compromising overall health, functionality, and quality of life. Meanwhile, you are facing an ever-increasing risk of bone density loss and osteoporosis. Until relatively recently, however, HRT was not recommended to address these concerns after a certain age; doctors have long been reluctant to prescribe HRT to women over the age of 65—or even 60—due to both a lack of appreciation for the impact of women’s symptoms and, sometimes, a belief that it carried too many risks for too few benefits. But, now, that is changing.
It is true that many of the protective benefits of HRT appear to diminish or disappear with age. It is also true that older women may be more likely to have risk factors that make them less than ideal candidates for HRT. However, for many women, HRT can be a truly transformative, positive intervention even after the age of 65.
Growing understanding of the benefits of hormone therapy for older women recently led the North American Menopause Society to update its position on HRT after 65. According to their 2017 position statement:
[HRT] treatment should be individualized using the best available evidence to maximize benefits and minimize risks, with periodic reevaluation of the benefits and risks of continuing HRT. Hormone therapy does not need to be routinely discontinued in women aged older than 60 or 65 years and can be considered for continuation beyond age 65 years for persistent [vasomotor], [quality of life] issues, or prevention of osteoporosis after appropriate evaluation and counseling of benefits and risks.
With this new understanding, more women can realize the benefits of HRT and preserve their quality of life as they age. However, research suggests that older women should try to stick to particular types of hormones and administration methods to reduce health risks.
HRT After Premature, Early, and Surgical Menopause
While most women experience natural menopause around the age of 50, some women reach menopause much earlier or after surgery. In these cases, HRT should typically be started immediately.
Menopause that happens before the age of 40 is known as premature menopause, while between 40 and 45 it is known as early menopause. Women who experience premature or early menopause can have the same symptoms as women who experience typical menopause, but may also be at greater risk for psychological distress and a number of serious physiological health conditions. Meanwhile, women who undergo oophorectomy—surgical removal of one or both ovaries—prior to natural menopause can experience even more severe symptoms due to the extreme and sudden drop in hormones as well as significant long-term health risks. For all women who experience premature, early, or surgical menopause these risks include cardiovascular disease, osteoporosis, neurological disease, mood disorders, and premature death.
Due to these risks, it is typically recommended that women who experience premature, early, and surgical menopause start hormone replacement therapy as soon as possible. As the American Society For Reproductive Medicine, mincing no words, said of bilateral oophorectomy patients:
Without hormone replacement therapy most of these women develop severe symptoms of estrogen deficiency and are at increased risk for osteoporosis, cardiovascular disease, cognitive decline, dementia, and the associated increases in morbidity and mortality.
In these cases, there is little doubt that HRT is the right choice and should be initiated immediately.
Seeking Expert Guidance
No matter what your stage of life, deciding whether and when to start HRT is a serious decision—and it’s not one you have to make alone. By seeking out a practitioner who specializes in hormone replacement therapy, you can ensure that you get expert guidance as you weigh your options. If you do decide to initiate treatment, they can develop a treatment plan customized to your needs, taking into account your symptoms, preferences, and overall health to optimize efficacy and minimize risk.
Listen to your body. Talk to your health care practitioner. And take care of yourself, now and in the future.
If you want to know more about when to start HRT, BodyLogicMD can help. The BodyLogicMD network is comprised of top medical professionals specializing in hormone health, HRT, and integrative medicine. BodyLogicMD-affiliated practitioners are dedicated to helping women address perimenopause and menopause symptoms through personalized treatment plans that enhance quality of life. Contact a local practitioner to schedule your first appointment, or take the BodyLogicMD Hormone Balance Quiz today.
Disclaimer: These statements have not been evaluated by the Food and Drug Administration. All content on this website is for informational purposes only. The content is not intended to diagnose, treat, cure or prevent diseases.
Charlotte is a patient care coordinator specializing in bioidentical hormone replacement therapy. She is committed to helping patients who struggle with the symptoms of hormonal change and imbalance explore their treatment options and develop effective strategies to optimize wellness.