Should elderly trans women continue taking HRT?

Disclaimer: I am not a medical professional and this is not medical advice.

One question frequently asked by trans women pertains to whether they will continue to take cross-sex hormones throughout their lifetime, or whether this will be tapered off or discontinued once they reach an age at which most cis women experience menopause. For many trans women, this won’t become relevant to them for several decades, but for others, this is a more immediate question: Gooren & T’Sjoen (2018) note that hundreds of trans women at the VU University gender clinic in Amsterdam are now age 60 or older. Additionally, some trans women may first seek treatment at an age beyond that at which cis women typically experience menopause. The circumstances of aging trans women, who do not possess ovaries and may or may not still possess testes, are clearly different from those of postmenopausal cis women in regards to sex hormones and development. So what approach to HRT is recommended for this group?

UCSF’s Center of Excellence for Transgender Health notes that advanced age is not a barrier to starting hormone therapy for trans women, as long as appropriate precautions are taken:

Older transgender women initiating therapy may have less rapid and a lesser degree of changes. Due to higher levels of co-occurring conditions in older individuals, there may also be higher risk of adverse effects. Nevertheless a large number of women have started hormones at advanced ages and safety and satisfaction have been reported as acceptable.

However, their advice on whether trans women should cease taking hormones upon reaching an age typical of menopause is rather equivocal:

There is no evidence to support continuation or cessation of hormones for older transgender women.

Since the mean age of menopause in the U.S. is 49, it is reasonable in transgender women who have undergone gonadectomy to consider stopping hormone therapy around age 50. Expected effects of this may be similar to non-transgender women experiencing menopause. Transgender women who retain their gonads but withdraw hormone therapy may experience return of virilization. A discussion of the pros and cons of this approach, with individualized and shared decision making is recommended.

Clearly, “consider” is not the same as “should”, and many if not most trans women would consider it unacceptable to resume experiencing masculinization in the absence of HRT. Other sources do not consider discontinuation of HRT to be necessary, and instead recommend that older trans women switch to forms of estrogen that carry a lower risk of cardiovascular side effects, such as transdermal patches (Libby, Lee, & Liu, 2019):

Transdermal preparations are generally recommended after the age of 40 or for individuals at increased risk of venous thromboembolism as they avoid first pass metabolism by the liver. …  It is a general rule that hormone therapy should be continued at the lowest effective dose to achieve feminization and suppress testosterone levels. Hormone therapy is generally continued for life and there have been no recommendations to change doses in older patients. It is important to continue to monitor serum hormone levels.

Gooren & T’Sjoen (2018) partially concur, agreeing that transdermal estrogen may be more appropriate for older trans women, but noting that estrogen dose may need to be reduced and antiandrogens may need to be discontinued:

The dose of estrogens in aging transgender women must probably be lowered, because side effects of estrogen replacement therapy may become more present past the age of 50– 55 years, in particular the cardiovascular side effects of estrogens. Several studies have documented that hormone replacement treatment in post-menopausal women for either primary or secondary prevention of cardiovascular disease events has no benefits while it may produce a rise in the risk of stroke and venous thromboembolic events. The lowest effective dose of estrogens should be given, particularly in women with risk factors for cardiovascular events. Transdermal estradiol is probably to be preferred over oral estrogens. … When transgender women get older, they probably should not be treated for an extended period with anti-androgens such as cyproterone acetate (in combinations with estrogens) which increases the risk of thrombo-embolism.

Additionally, the authors note that in trans women who’ve undergone vaginoplasty or orchiectomy, estrogen may need to be continued in order to avoid bone loss:

In case of surgical menopause bone loss occurs more rapidly during the first years. These findings may be interpreted as to suggest that complete discontinuation of hormones in transgender women above the age of 50 leads to a profound loss of bone strength. Therefore, 17β-estradiol medications in an age-appropriate dose might be advisable after the age of 50 years.

Altogether, the existing literature does not appear to offer any blanket recommendation that HRT must, or even should, be discontinued in elderly trans women; instead, dosages and route of administration may simply need to be adjusted to account for the risk factors associated with advanced age, as well as any individual health considerations. ■