The short answer
You can, but the math changes. The Menopause Society says starting systemic hormone therapy after 60, or more than 10 years after your last period, carries greater absolute risks of heart disease, stroke, clots and dementia. Vaginal estrogen can be used at any age.
What guidance says, by when you start
| When you start | What the guidance says |
|---|---|
| Under 60, or within 10 years of your last period | Benefit-risk is favorable for bothersome hot flashes, with no reason to avoid hormones [1]. The FDA’s revised labels say starting can be considered in this window [2]. |
| 60 or older, or more than 10 years after | Benefit-risk appears less favorable because of greater absolute risks of heart disease, stroke, clots and dementia [1]. NICE notes that stroke risk with oral estrogen alone is higher when it is started after 60 [3]. |
| 65 or older, starting fresh | The American Geriatrics Society advises against starting oral or patch estrogen; low-dose vaginal estrogen remains acceptable [4]. |
| Any age, vaginal symptoms only | Low-dose vaginal estrogen may be used at any age and for as long as needed [1]. |
Why timing changes the numbers
The Women’s Health Initiative counted every major outcome together, a “global index,” by age. On estrogen alone it meant 19 fewer events per 10,000 women a year at ages 50 to 59 and 51 more at ages 70 to 79. On estrogen with a progestin it meant 12 more events at 50 to 59 and 38 more at 70 to 79 [5]. Over 18 years, deaths from any cause were about the same with hormones or placebo (27.1% vs 27.6%), and the comparison favored younger women over older ones [6].
The ELITE trial tested the timing idea directly in 643 women. Oral estradiol slowed the thickening of the neck arteries in women under 6 years past menopause, but not in women 10 or more years past it [7]. Arteries seem to respond to estrogen differently once years have passed.
What a physician looks at first
- How many years since your last period, not just your age.
- Your heart and stroke risk: blood pressure, cholesterol, diabetes and smoking, which the estrogen leaflet lists as raising the chances of heart disease [8].
- Any past clot, stroke, heart attack or breast cancer, each a reason not to take estrogen [8].
- Your bones. In the Women’s Health Initiative, estrogen with a progestin meant 5 fewer hip fractures per 10,000 women a year [9], which matters more as fracture risk climbs with age.
- Whether the symptom is local. Dryness or pain with sex alone points to vaginal estrogen rather than a patch or pill [4].
Already on HRT and turning 60 or 65?
That is a different question from starting late. The Menopause Society says hormone therapy does not need to be routinely stopped at 60 or 65, and that an age-based stopping rule is not appropriate [1]. The FDA’s revised labels also drop the old advice to use the lowest dose for the shortest time [2]. Your physician reviews the plan with you each year instead; the full record of that change is in the FDA label change tracker.
If dryness or pain with sex is the main problem
Vaginal symptoms often start or worsen years after the last period. Low-dose vaginal estrogen treats them locally with very little reaching the blood, and both the Menopause Society and the geriatrics society consider it appropriate at older ages [1] [4]. See the vaginal estrogen page.
- Hot flashes still strong after 60? A physician may still prescribe estradiol, often through the skin at a low dose, after weighing your heart and clot history; details on the estradiol page.
- High blood pressure or other heart risks? Read HRT with high blood pressure.
- Still having periods, or just stopped? Read starting HRT in perimenopause.
VevaMD’s menopause program is for women 35 to 80; every option, including non-hormonal ones, is on the menopause care page.
VevaMD is a technology company, not a medical provider. Educational content only, not medical advice. A US-licensed physician decides whether any treatment fits you, and a prescription is not guaranteed.
Sources
- The North American Menopause Society. The 2022 hormone therapy position statement. Menopause. 2022;29(7):767-794. Checked October 23, 2026.
- FDA. FDA requests labeling changes related to safety information to clarify benefit/risk considerations (menopausal hormone therapy). November 10, 2025; updated February 12, 2026. Checked October 23, 2026.
- National Institute for Health and Care Excellence (NICE). Menopause: identification and management (NG23). Recommendations, updated April 2026. Checked October 23, 2026.
- American Geriatrics Society 2023 Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-2081. Checked October 23, 2026.
- Manson JE, Chlebowski RT, Stefanick ML, et al. Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women’s Health Initiative randomized trials. JAMA. 2013;310(13):1353-1368. Checked October 23, 2026.
- Manson JE, Aragaki AK, Rossouw JE, et al. Menopausal hormone therapy and long-term all-cause and cause-specific mortality: the Women’s Health Initiative randomized trials. JAMA. 2017;318(10):927-938. Checked October 23, 2026.
- Hodis HN, Mack WJ, Henderson VW, et al. Vascular effects of early versus late postmenopausal treatment with estradiol (ELITE). N Engl J Med. 2016;374(13):1221-1231. Checked October 23, 2026.
- Divigel® (estradiol gel) prescribing information, revised February 2026. DailyMed. Checked October 23, 2026.
- Writing Group for the Women’s Health Initiative Investigators (Rossouw JE, et al.). Risks and benefits of estrogen plus progestin in healthy postmenopausal women. JAMA. 2002;288(3):321-333. Checked October 23, 2026.