Does Hormone Replacement Have an Expiration Date?

HRT

Mar 6

Written By Aurelia

Hormone Replacement Therapy (HRT) has long been a cornerstone in managing hormonal symptoms and promoting women's health during midlife and beyond.

Historically, medical guidelines recommended discontinuing HRT after five years, primarily due to findings from the flawed Women's Health Initiative (WHI) study. However, contemporary research and updated guidelines have shifted this perspective, emphasizing a more individualized approach to HRT duration. At Aurelia, we evaluate patients on a case-by-case basis, and we believe that HRT is an effective chronic disease prevention strategy.

Historical Perspective: The Five-Year Discontinuation Guideline

In the early 2000s, the Women's Health Initiative (WHI) study raised concerns about the long-term use of HRT, associating it with increased risks of breast cancer, heart disease, stroke, and pulmonary embolism. These findings led to a widespread recommendation to limit HRT use to a maximum of five years. Consequently, many women discontinued therapy prematurely, often experiencing a resurgence of menopausal symptoms and uncertainty about their long-term health strategies.

Something important to note is that WHI study utilized hormone therapies that we no longer prescribe regularly, and that we don’t employ at all at Aurelia. The primary medication used was Prempro, a conjugated oral equine estrogen tablet. Oral estrogen-like products are the only hormone medications shown to increase clots and thrombo-embolic events.

While the WHI study made significant contributions to understanding HRT, later analyses revealed critical flaws. The study primarily focused on older women (average age 63) who were well past the menopausal transition. This led to misleading conclusions that failed to differentiate between initiating HRT during early menopause versus later in life. Further research has since demonstrated that the timing of HRT initiation plays a significant role in risk profiles, particularly concerning cardiovascular health and cognitive function.

We encourage women to be evaluated for hormone decline early—as soon as symptoms begin.

Evolving Guidelines: The Shift Towards Individualization

Over the past two decades, re-evaluations of the WHI study data and new research have led to a paradigm shift in hormone replacement therapy (HRT) recommendations. The Menopause Society, formerly known as The North American Menopause Society (NAMS), now advocates for a personalized approach to HRT, stating:

"There is no 'right' time to stop Hormone Therapy. Many women try to stop HT after 4 to 5 years because of concerns about a potential increased risk of breast cancer. Other women may lower doses or change to nonpill forms of HT. Hot flashes may or may not return after you stop HT." (The Menopause Society)

At Aurelia, we believe this recommendation does not fully embrace HRT's potential as a health optimization strategy. Emerging research suggests that HRT can be utilized as a preventive measure for long-term health benefits, including cognitive function, bone density, and cardiovascular health. For instance, studies have indicated that initiating HRT in women younger than 60 years and/or near menopause significantly reduces all-cause mortality and cardiovascular disease (CVD). (PubMed)

While the evidence is promising, it is important to acknowledge that HRT is not a universal solution for every woman. The decision to continue HRT should be based on an ongoing assessment of risks versus benefits, taking into account individual health status, family history, and personal preferences.

HRT for Optimal Health and Longevity

Beyond alleviating menopausal symptoms, HRT has been associated with several long-term health benefits, making it a potential tool in longevity and disease prevention.

Bone Health

Estrogen plays a crucial role in maintaining bone density. Postmenopausal women face an increased risk of osteoporosis and fractures due to declining estrogen levels. HRT has been shown to significantly reduce the risk of osteoporotic fractures, especially when started during early menopause or perimenopause. Women who use HRT for at least five years have a lower incidence of hip and vertebral fractures compared to those who do not. (Meta-Analysis on HRT)

Brain Health and Alzheimer’s Prevention

One of the most exciting areas of research in women's health is the impact of estrogen on brain function. Estrogen has neuroprotective properties, supporting synaptic plasticity, reducing inflammation, and promoting cerebral blood flow. Studies by Dr. Lisa Mosconi and others have shown that estrogen decline during menopause correlates with increased Alzheimer’s risk. In fact, women make up nearly two-thirds of Alzheimer’s cases, and the sharp decline in estrogen during midlife is thought to be a key factor.

"Women who start HRT early in menopause show better cognitive performance and brain imaging markers than those who never take it." (Nature)

This suggests that HRT may not only alleviate menopausal symptoms but also serve as a crucial intervention in maintaining brain health and preventing neurodegenerative disease.

Cardiovascular Health

Cardiovascular disease (CVD) remains the leading cause of death in women, and estrogen plays a protective role in heart health. Estrogen helps maintain arterial flexibility, reduces inflammation, and supports cholesterol metabolism. Research has shown that initiating HRT in early menopause can lower the risk of coronary artery disease and stroke.

A systematic review published in Circulation concluded that HRT, when started in women under 60 or within ten years of menopause, significantly reduces CVD risk. Women who take estrogen therapy alone (without progestin) experience an even greater reduction in risk. This is likely due to the fact the progestin studied is synthetic, not bio-identical progesterone, and synthetic progestins are known to be pro-inflammatory.

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Aurelia’s Approach: A Lifetime of Support

At Aurelia, we believe that HRT should not have an arbitrary end date. As long as the benefits continue to outweigh the risks, women should have the option to maintain their HRT regimen for a lifetime. Our approach is centered on:

Regular Check-ins: We prioritize long-term relationships with our patients, ensuring that their therapy remains optimized over time.
Comprehensive Lab Evaluations: We monitor metabolic and inflammatory markers to ensure that HRT is delivering the intended benefits without increasing risks.
Personalized Care Plans: We tailor HRT regimens based on each woman’s unique needs, rather than relying on outdated, one-size-fits-all guidelines.

Aurelia is committed to empowering women with evidence-based, forward-thinking care. Midlife should be a time of strength, vitality, and confidence—not uncertainty about health. With the right strategy, women can Do Midlife Better™, using HRT as a powerful tool for longevity and well-being.

Takeaways for you

The narrative around HRT has evolved dramatically in the past two decades, yet outdated fears and rigid guidelines persist. The five-year discontinuation rule was based on incomplete interpretations of the WHI study, and more recent research highlights the diverse benefits of HRT beyond menopause symptom relief.

Women deserve healthcare that reflects the latest science—not outdated misconceptions. At Aurelia, we advocate for a modern, hormones-first™ approach that empowers women to take control of their long-term health. As long as HRT continues to provide benefits and is safely monitored, there is no compelling reason for women to discontinue therapy based on an arbitrary timeline.

For women navigating menopause and beyond, the question should not be if they can use HRT for prevention—it should be how we can optimize its benefits for a lifetime of health.

Learn more about our programs for perimenopausal and menopausal women.

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