Too Late for HRT? What Women Over 60 Should Know

Many women in their 60s are told they have "missed the window" for hormone replacement therapy (HRT). For some women that is the right call. For many others, it is a conversation worth reopening. Menopause doctors including Dr Louise Newson, Dr Mary Claire Haver and Dr Shauna Watts, and neuroscientist Dr Lisa Mosconi, have helped change how we think about HRT later in life. Here is a plain-English summary of what has changed.

Where the fear came from

In 2002, early results from a large American study called the Women's Health Initiative (WHI) linked HRT to heart disease, stroke, blood clots and breast cancer. The headlines went around the world and HRT use dropped sharply almost overnight.

Looking back, the study had some big limitations:

• The average participant was in her early 60s, and many started HRT more than 10 years after menopause.

• Most women in the study did not have menopause symptoms, so it was not testing the women who usually seek HRT.

• It used older hormone types: oral oestrogen made from horse urine, plus a synthetic progestin (MPA).

Later analysis told a different story. Women who started HRT closer to menopause generally did better. Women without a uterus who took oestrogen alone actually had fewer breast cancers over long-term follow-up. In late 2025, the US FDA removed the old "black box" warnings from HRT labels, saying they overstated the risks for most women.

What is different now

Today, HRT usually means body-identical hormones. These are made from plants and are the same shape as the hormones your ovaries used to make:

• Oestradiol as a patch, gel or spray through the skin (transdermal).

• Micronised progesterone as a capsule, to protect the lining of the uterus if you still have one.

These are TGA-approved, regulated medicines. They are not the same as compounded "bioidentical" creams, which are not tested or regulated in the same way and are not recommended by the Australasian Menopause Society.

The route matters. Oestrogen tablets pass through the liver first, which can raise clotting factors and triglycerides (a blood fat). Oestrogen through the skin skips that step. Research shows transdermal oestrogen carries a lower risk of blood clots and stroke than tablets, and it does not raise triglycerides. That makes it the preferred choice for many women over 60.

Is 60 really too late?

This is the honest answer. Timing does matter.

• Starting before 60, or within 10 years of menopause: for most healthy women, the benefits outweigh the risks. Oestrogen helps keep healthy blood vessels flexible.

• Starting after 60, or more than 10 years after menopause: the risks are higher, mainly for heart attack and stroke, because some women have already developed plaque in their arteries.

Higher risk is not the same as an automatic no. Major menopause guidelines do not set a hard age cut-off. The decision should rest on your health, symptoms and risk factors, not your birth year alone. Roughly, women fall into three groups:

• Lower risk: healthy weight and blood pressure, active, low heart risk. HRT may be a reasonable option.

• Moderate risk: high blood pressure, high cholesterol, diabetes, smoking or carrying extra weight. HRT may still be possible, and through-the-skin oestrogen is strongly preferred.

• Higher risk: previous heart attack, stroke, blood clot or some breast cancers. Systemic HRT is usually not advised, but local vaginal treatment often still is.

Your brain and your bones

Dr Mosconi describes menopause as a brain transition as much as an ovarian one. Brain scans show that falling oestrogen changes how the brain uses energy, which helps explain brain fog, poor sleep and word-finding trouble. Some research suggests that starting HRT closer to menopause may be linked with a lower risk of dementia later on. Starting much later has not shown the same benefit, so HRT is not currently recommended purely to prevent dementia.

Bones are a stronger case. Oestrogen helps protect bone density, and broken hips are serious: around 1 in 5 older women die within a year of a hip fracture. For some women, bone protection is a big part of the HRT conversation.

Vaginal oestrogen: an option at almost any age

Hot flushes often settle with time. Vaginal dryness, painful sex, bladder urgency and repeat urinary tract infections (UTIs) usually get worse with age. This is called genitourinary syndrome of menopause.

Low-dose vaginal oestrogen (a cream, pessary or ring) works directly where it is needed, with very little reaching the bloodstream. It is suitable for most women, including many who cannot take systemic HRT. If you have had breast cancer, talk to your specialist first.

Testosterone is also TGA-approved for women in Australia to treat low libido. Other benefits are still being researched.

Before your GP appointment

These checks give you and your doctor a clear picture:

• Blood pressure

• Cholesterol and triglycerides

• Fasting blood sugar or HbA1c (diabetes screen)

• Thyroid function

• Iron and vitamin B12

• A heart risk calculation (your GP can use the Australian CVD risk calculator)

• Bone density scan, if not done recently

• Breast screening up to date

Questions you could ask:

• "Given my own risk factors, is HRT an option for me, and which type?"

• "If I am on older HRT tablets, could I switch to a patch or gel with micronised progesterone?"

• "Is there a reason I need to stop HRT at a set age, or can we review it each year?"

• "Could low-dose vaginal oestrogen help my bladder or vaginal symptoms?"

• "Can you refer me to a menopause specialist if you are not sure?"

If you would like a second opinion, the Australasian Menopause Society has a "Find an AMS Doctor" directory on its website.

The bottom line

Being over 60 does not automatically rule out HRT, but it does mean a careful, individual assessment. Ask the questions, get the right tests, and make the decision with a doctor who looks at the whole picture.

In clinic, I often see women navigating this decision. Acupuncture and Chinese medicine can sit alongside your medical care, and I am always happy to work with your GP.

Further reading

• Australasian Menopause Society. Information sheets and Find an AMS Doctor. menopause.org.au

• The Menopause Society (formerly NAMS). 2022 Hormone Therapy Position Statement. Menopause 2022;29(7):767-794.

• Manson JE et al. Menopausal hormone therapy and long-term all-cause and cause-specific mortality: the WHI randomised trials. JAMA 2017;318(10):927-938.

• US Food and Drug Administration. Removal of boxed warnings from menopausal hormone therapy labelling, November 2025.

• Mosconi L. The Menopause Brain. Avery, 2024.

• Newson L. The Definitive Guide to the Perimenopause and Menopause. Yellow Kite, 2023.

• Haver MC. The New Menopause. Rodale, 2024.

This article is general information only and is not medical advice. HRT is prescribed by a medical doctor. Please speak with your GP or a menopause specialist about your own health and treatment options.