Starting Hormone Therapy After 65: New Study Signals Higher Risk and the Need for Individualized Care

For years, many women have been told some version of: By 65, menopause symptoms should be over. If they aren’t, you just have to live with them. But real life keeps disagreeing.

A February 2026 analysis highlighted by The Menopause Society reinforces two truths at the same time: starting systemic hormone therapy after 65 can carry higher risks, and some women still benefit when decisions are made carefully, with close monitoring and a clear reason for treatment. 

That tension is exactly where your over-50 audience lives: the gap between what’s written in broad guidance and what happens in bodies, bedrooms, and 3 a.m. wake-ups.

This article breaks down (1) what the new data suggests, (2) why symptoms can persist well past 65, and (3) what “individualized decision-making” should mean in a real clinic visit.

What the new analysis found, in plain language

The study, published in Menopause (journal of The Menopause Society), examined health outcomes in 83,147 women age 50+ over 22 years using records from a large health system in Israel. Women were grouped by when they started hormone therapy, including those who initiated hormone therapy at 65 or older. 

Key takeaway: Initiating hormone therapy at age 65+ was associated with higher hazards of adverse outcomes in adjusted analyses, including:

• Any cancer
• Cerebrovascular accident (stroke)
• Ischemic heart disease or myocardial infarction (heart attack)

The press release also notes an important pattern: longer duration of hormone therapy was associated with higher morbidity, reinforcing that risk often accumulates with age and time on treatment. 

And the authors emphasize limitations that matter when readers see headlines:

• Observational design (associations, not proof of cause)
• Limited detail on formulation, dose, and route in the dataset 

So the point isn’t “never.” The point is “not automatically, and not casually.”

---

Why so many women are still symptomatic after 65

If menopause were a neat, predictable timeline, “one-size-fits-all” might work. But the symptom story is messy for good reasons.

1) Hot flashes can last longer than most people were taught

In the SWAN study published in JAMA Internal Medicine, frequent vasomotor symptoms (hot flashes/night sweats) lasted a median of 7.4 years, and persisted a median of 4.5 years after the final menstrual period. Some groups experienced longer duration, and factors like stress, anxiety, and depressive symptoms were linked with longer persistence. 

The Menopause Society has also summarized population-level estimates that are especially relevant to older readers: up to 40% of women in their 60s and 10%–15% in their 70s may still experience hot flashes. 

2) The “type” of menopause symptoms shifts with age

By the late 60s and 70s, a lot of women aren’t only dealing with hot flashes. They’re dealing with:

• Genitourinary syndrome of menopause (GSM): vaginal dryness, burning, pain with sex, urinary urgency, recurrent UTIs
• Sleep fragmentation that isn’t just “stress”
• Joint pain and stiffness that can feel inflammatory
• Mood symptoms that can be amplified by poor sleep and caregiving burden

This matters because not all symptoms require systemic hormone therapy. Many GSM symptoms respond to local, low-dose vaginal estrogen or other targeted treatments, which have a different risk profile than systemic pills or patches. 

3) Some women try to stop treatment and symptoms rebound hard

A Menopause Society review of women over 65 using hormone therapy found that many who attempted stopping restarted because symptoms returned, especially hot flashes. 

That rebound experience shapes decision-making: it’s not theoretical. It’s “I can’t sleep, my quality of life fell apart, and I need options.”

4) Vascular and cancer risk profiles change with age

This is the part that’s hard to hold emotionally: symptoms may persist, while baseline risk for stroke, clots, and some cancers rises with age.

The Menopause Society’s 2022 Hormone Therapy Position Statement makes the timing issue explicit: for women who initiate hormone therapy more than 10 years from menopause or after age 60, the benefit-risk ratio is generally less favorable because absolute risks of coronary heart disease, stroke, venous thromboembolism, and dementia are higher. 

So if a woman is 67 and miserable, the clinical question becomes: Can we relieve symptoms while minimizing added risk, and are there safer alternatives that fit her goals?

---

What “individualized decision-making” should actually mean (not just a vague phrase)

“Individualized” is often used like a polite exit ramp: Talk to your doctor.
But women deserve to know what a high-quality, individualized visit includes.

Here’s what it should look like.

Step 1: Name the symptoms precisely (because the treatment depends on what you’re treating)

A strong clinician doesn’t treat “menopause” as one blob. They separate:

• Vasomotor symptoms (VMS): hot flashes/night sweats
• GSM: vaginal/urinary symptoms
• Sleep: trouble falling asleep vs waking with sweats vs early waking
• Sexual pain vs libido vs arousal issues
• Mood symptoms that may be primary or secondary to sleep disruption

This matters because a woman with mainly GSM may not need systemic hormone therapy at all.

Step 2: Distinguish systemic hormone therapy from local vaginal estrogen

This distinction has become even more visible in recent U.S. policy discussions about labeling.

ACOG has emphasized that low-dose vaginal estrogen and systemic estrogen (oral/transdermal) have different safety profiles, and that low-dose vaginal estrogen labeling has historically created barriers for people with significant vaginal and urinary symptoms. 

Specialty guidelines also note that local low-dose vaginal estrogen generally results in negligible serum estradiol levels and is not associated with increased risks the way systemic therapy can be. 

Translation for readers: If your main problem is vaginal dryness, urinary urgency, or recurrent UTIs, your conversation may be about local therapy, not “HRT forever.”

Step 3: Clarify the goal of treatment (symptom relief vs disease prevention)

This is where misinformation can sneak in.

Major preventive guidance from the USPSTF recommends against using systemic hormone therapy for the primary prevention of chronic conditions in postmenopausal people. That recommendation is about prevention in asymptomatic people, not symptom treatment. 

A good clinic visit makes it explicit:

• “We’re treating symptoms that are harming your quality of life.”
• “We are not using this as a general anti-aging strategy.”

Step 4: Map personal risk factors that change the decision at 65+

A meaningful risk assessment typically includes:

• Personal history of breast cancer, endometrial cancer, blood clots, stroke, heart disease
• Migraine with aura, uncontrolled hypertension, smoking status
• Family history patterns (not just one relative, but clustering)
• Uterus status (because estrogen alone vs estrogen + progestogen decisions differ)
• Current meds and interactions
• Baseline screening status (mammography; evaluation of any postmenopausal bleeding)

The 2026 Menopause study is essentially a reminder that when initiation happens after 65, those risks deserve extra attention and ongoing reassessment. 

Step 5: Choose the lowest-risk path that can still work

Sometimes that means:

• Trying nonhormonal options for hot flashes first (especially if risks are higher)
• Using local vaginal therapies for GSM instead of systemic therapy
• If systemic therapy is used, using careful dosing, route, and follow-up consistent with menopause society guidance emphasizing individualized regimens and periodic reevaluation 

Nonhormonal options have advanced. For example, fezolinetant (Veozah) is FDA-approved for moderate-to-severe hot flashes, but it comes with liver monitoring recommendations and an FDA warning about rare serious liver injury. 

Translation for readers: “Alternative” doesn’t mean “herbs on the internet.” It can mean modern prescription options with specific monitoring.

Step 6: Monitoring should be planned, not improvised

If a woman is using any therapy with meaningful risk tradeoffs, individualized care includes:

• A timeline for reassessment (often at 6–12 weeks for symptom response, then at least annually for risk-benefit review)
• Clear “stop and call” triggers (new vaginal bleeding, chest pain, neurologic symptoms, severe headaches, jaundice symptoms if on certain nonhormonal meds)
• A plan for tapering vs continuing, revisited over time as health status changes

---

A short “clinic visit script” your readers can bring with them

Here are questions that turn “individualized” into something real:

1. “Which symptom are we treating: hot flashes, sleep disruption, or vaginal/urinary symptoms?”
2. “Do I need systemic treatment, or would local vaginal therapy address most of this?”
3. “Given my age and health history, what are my biggest risks with starting systemic hormone therapy now?”
4. “What are my nonhormonal options, and what monitoring do they require?”
5. “If we try something, what does success look like in 8–12 weeks, and when do we reassess?”

---

Menopause care after 65 is a quality-of-life issue, not a moral test

The most important shift in this new Menopause Society–highlighted analysis is not a simple yes or no. It’s the recognition that:

• Symptoms can persist well past 65
• Initiating systemic hormone therapy after 65 can be riskier
• Some women still benefit when care is careful, specific, and regularly re-evaluated 

Suffering isn’t a requirement for being “responsible.” Menopause care isn’t about enduring symptoms as a test of will. It’s about making a thoughtful plan with a clinician who takes symptoms seriously while protecting long-term health.