Decreasing or stopping HRT after 55?

[Wafffly]

I've recently changed GP and had a review of my HRT today. I've been happily using a 75mcg oestradiol patch for nearly 10 years after hysterectomy and removal of my ovaries.

To my horror the new GP wanted to discuss either reducing or stopping my HRT as "the risks of taking HRT increase after 55 particularly breast cancer and dvt / stroke".

I've never been told this before and I said I don't want to reduce or stop at present, so she sent me some resources to read...but they don't appear to highlight any increased risks for transdermal oestrogen-only HRT!

This won't raise its head again until my next review but I dont want to keep having to justify my decision to stay at the same dose.

Could I be missing something in terms of where she was coming from? Is the "over 55" thing current guidelines?

Not an expert but in a similar position - had a hysterectomy but kept my ovaries, using oestrogen only patches. GP supportive and has said that patches don't raise the risk and has never mentioned stopped or tapering.

A quick google brings up this GP guidance which says: "There is no definitive age cut off for HRT use as this should be determined by individual with risks versus benefits. Persistent symptoms on cessation of HRT or the need for bone protection are indicators for on-going treatment."

Did you get the impression that the GP knew their stuff or is she just one of those poorly-trained and misinformed GPs that so many of us have to go into battle with?

https://www.chelwest.nhs.uk/professionals/gp-hrt-advice-guidance

I stopped at 58. I’ve adjusted my lifestyle to help with bone density (weight bearing exercise), and I take collagen and a multivitamin. I’m not noticing many changes, and I have lost a bit of weight.

I had a premature menopause. My GP changed, and a new one wanted me to come off HRT, explaining much the same thing. I pointed out to them that all the HRT was doing in my case was replacing the hormones that should still have been there in the first place naturally, had I not had an early menopause. Since you had a hysterectomy your menopause was premature too, for different reasons.

If they keep going on about it, ask to be referred to gynaecology or the menopause clinic at your local hospital.

I recently went to a Peri / Menopause group presentation put on by my GP practice.

The Drs said a lot of the old cancer / HRT link has been disproven and is only really applicable if you start HRT after 60 (?)

I only started hrt at age 59. My hysterectomy/oophorectomy was about 8 years ago. Your GP is out of date I think. I'm pretty sure that transdermal oestrogen is the least likely to have negative effects. My mother took hrt until she was 83.

Having watched my mother suffer the consequences of osteoporosis in her later years after she was taken off her oestrogen only HRT, I intend to stay on HRT as long as possible and accept the risk involved in that. My understanding was that you can stay on it for as long as you like but I must admit I haven't checked to see if that still stands. If you can bear to get past the "people with a uterus" bullshit on this, it might be helpful, it's been recently updated
www.nice.org.uk/guidance/ng23/chapter/Recommendations#starting-and-stopping-hormone-replacement-therapy-for-anyone

I hope we can post images again…please see link for comparison of risks of HRT regarding breast cancer. As a hospice worker, it’s gets my goat how over focussed they are on HRT and cancer risk….how often do they highlight the increased risks of various cancers ( as well as cardio vascular risk) to obese women or those who drink more than 14 unit’s a week? If you are on HRT and doing all the healthy things diet/ exercise wise that any woman should be doing at this stage of life ( for me that’s far easier to do now I’m on HRT which has improved my pain levels) then I would just smile and reach for any resources form the menopause specialist dr’s and organisation out there! https://thebms.org.uk/wp-content/uploads/2023/01/WHC-Infographics-JANUARY-2023-BreastCancerRisks.pdf

It's shocking that your GP doesn't know the facts @Wafffly

The breast cancer risks for women on estrogen only HRT are lower than for women not using ANY HRT.

https://www.womens-health-concern.org/wp-content/uploads/2019/10/WHC-UnderstandingRisksofBreastCancer-MARCH2017.pdf

See the table here.

4 fewer cases per 1000 women, over 5 years for women on estrogen only compared to women NOT on HRT.

Maybe print and take this in to show them?

There is no additional risk of stroke or DVT - it stays the same as your baseline risk (and there is some evidence it protects against heart disease.)

The Women's Health Concern is the 'patient' information website of the British Menopause Society and written by meno specialists.

It seems your GP doesn’t know her menopause onions. Maybe she’s in need of training?

Or maybe she only remembers from flicking through her books in medical school, the now thoroughly debunked Women’s health Initiative (deeply flawed) research.

If she’s bolshy and decides unilaterally and top down that HRT is ‘not suitable’ for you, please insist to be referred see a qualified menopause specialist.
Stick to your guns and don’t leave her office without the referral.

Thank you so much everyone. Really helpful resources.

@CrotchetyQuaver sorry to hear about your mum's experience. I've never had a bone scan but have had previous courses of treatment with GnRH-a for endometriosis which I know can affect bone density, so actually that's a very good reason for me to continue i would have thought.

@Yayayaboo I do exercise regularly and completely agree that without HRT I'd probably not make it to the gym at all. I dont drink either!

I'll make sure I'm armed with appropriate resources next time it's raised.

This thread is timely for me. I'm 60, have only been on HRT for two and a half years, and I feel great on it.

My GP thinks I should be coming off it now, or at least cutting down. I'm only on two pumps of oestrogen gel plus the Mirena coil. The Mirena has only been in situ for a year, and my gynaecologist is perfectly happy for me to stay on HRT as long as I want.

If my GP gets stubborn, what I've learned from this thread is to insist on a referral to a menopause specialist - so thank you for that.

@DramaAlpaca i see similar issues ahead with my gp practise…hopefully as time goes on there will be more research . The women in my family tend to live into their 90’s but with significant musculo-skeletal problems that have caused them a lot of pain and mobility loss in later years which is what drives my wish to stay on it longer.

@DramaAlpaca If your gynaecologist is happy, can't they take over the prescribing instead of your GP? They'd write to your GP with their 'recommendations' that it's prescribed.

I'm 61 and my 5 years is up re the mirena coil. GP has talked about it not being replaced and switching to gel hrt instead of oestrogen pills. Does this mean we don't need the progesterone as we age or have you a mirena for different reasons? I've wondered why she doesn't want it replaced now.

On a different note, does cream/gel work just as well as pills?

I've just had this discussion as well. I'm 53 and on 100mcg patches and provera with testosterone as well. I trialled a lower patch, tried the spray but none suited me as well. The only change I have made is upping the provera to 10mg a day as per new bed guidelines because higher oestrogen requires higher progesterone or something. There is an increased risk with this of course as well, but on balance I'm happy to accept it

https://thebms.org.uk/wp-content/uploads/2023/04/14-BMS-TfC-Progestogens-and-endometrial-protection-APR2023-A.pdf

@viralviv is there a reason why you are on oestrogen pills rather than transdermal patches/ gel/ spray? The risk profile is different hence why transdermal methods are far preferred these days to pills….has your GP not had that discussion about switching with you before? As long as you have your womb you will always need some form of progesterone if taking oestrogen.

But that is still the GP prescribing and taking the responsibility legally. A consultant telling us to prescribe doesn't remove our legal liability for prescribing. (I'm talking generally here not just this thread)

However I agree with the thread that some GPs don't know the changes in HRT recommendations. I qualified in 1992 as a GP so a very long time ago but did go on updates over the years and in fact had a very good book that the last course I went on produced with loads of up to date info. I left it when I retired for my replacement.

I'm 61 obese and drink too much and on HRT. I think the HRT is the least of my worries.

Yes, that's true but surely GPs don't disagree with a consultant's recommendations for something quite basic and also within the guidance of NICE and the BMS - unless it's off-licence or out of their budget.

@JinglingSpringbells in our area they have tightened up massively on HRT prescribing, and people have had medicines withdrawn that were previously supplied, there is always a postcode lottery on what the local formularies decide to allow because they take economics into account not just guidelines.

No, GP only raised it at the last review. So if my mirena is removed in April, can I get a combined gel to also supply the progestin?

@viralviv the gel is only oestrogen so you have the option of moving to either a combined HRT patch to give both or gel plus urtogestan tablets for the progesterone. However I haven’t found any rationale why someone should not be able to have another mirena inserted ( other than orthodoxy)seeing as it suits some people very well. Personally I would suggest you speak to your GP now about switching to gel .I’m attaching a graphic that illustrates the different risks of oral oestrogen compared to transdermal. https://balance-menopause.com/uploads/2023/10/Risks-of-HRT-visual-aid.pdf

@Wafffly I found the graphic which expands on the British meno society pdf and illustrates risks of cardio- vascular events as well as breast cancer https://balance-menopause.com/uploads/2023/10/Risks-of-HRT-visual-aid.pdf as ,again, it shows no evidence for additional risk of DVT/ stroke in those who are on transdermal oestrogen…..again, dr’s should be understanding the difference between oral and transdermal methods and should not be prescribing oral oestrogen as first line treatment unless there’s a v.good reason.

Thanks that's really helpful

That sounds ridiculous as HRT is cheap. (mine's on a private prescription so I pay RRP.)

Are you a dr or is this what you've been told?
No women should have medication withheld because of cost.

I've only just started at 56! Specialist HRT nurse at GP surgery said that a lot of the old 'advice' has been disproven now.