Why not hormone replacement therapy for elderly patients?

The new guidelines for menopauseby NAMS, emphasize personalized care, moving away from strict age/time limits, focusing on shared decisions between patient and doctor, and recognizing benefits like cardiovascular and bone health when started earlier (within 10 years/age 60) but allowing for individual risk/benefit assessment at any age
So there are no age limitations anymore for any BHRT or HRT .
A hormone supplement that is tied to better sleep is pregnenolone with several research studies showing deeper sleep. Pregnenolone does pull some major body levers so it may have some good and less desirable consequences; it just depends on how your body decides to use the supplement. The hormone most tied to better sleep is Progesterone; in fact the side effect of too high a dose of progesterone is sleepiness.
Progesterone would be a good hormone to consider adding to your daily schedule; it is very safe and could have an immediate benefit of sleep for you.
Something to bear in mind is that most hormones may convert one to the other; estriol is the exception. So when taking progesterone, estradiol and testosterone you may end up having higher levels of other hormones etc. So good testing and a good doctor is necessary.
I would suggest having a hormone specialist check your hormone levels; your local compounder will be knowledgeable about which ones use tests like salvia, dutch, serum, spot tests and who uses the safer BHRT, bioidentical hormone therapy.
Something else to consider, check your iron levels. Seems that the iron levels need to be at a particular amount in order to produce all the products that allow us to sleep, just low normal levels don't seem to be enough. Check out with a good google search; I forget the levels needed right now but I found it easily in the past.

Yes, most of us have come to the point where we balance quantity of life vs quality of life
Mini strokes/strokes and HRT and BHRT
Bioidentical Hormone Replacement Therapy (BHRT), especially when using transdermal (skin-applied) estradiol, appears to have a lower stroke risk than traditional oral HRT, which is linked to increased clotting; transdermal routes bypass the liver, reducing clotting factors, while bioidentical progesterone may also be safer than synthetic progestins, making the delivery method and type of hormone crucial factors in stroke risk.
It seems that the safest way to administer any hormone therapy is via topical, bypassing the liver and bioidentical which the body recognizes since it is well , bioidentical, ha.
https://www.epicresearch.org/articles/blood-clot-risk-influenced-by-hormone-therapy-administration-route-in-women-50-and-older
https://www.ahajournals.org/doi/10.1161/strokeaha.117.017132.
Conclusions—
In a national setting, we found an increased risk of stroke, based on ischemic stroke, with oral hormone therapies that was comparable to findings from randomized studies. We found no risk of stroke with transdermal application and a reduced risk with vaginal estrogen.

I'm almost 50 and am three months post-hysterectomy. Prior to hysterectomy, I was wearing a low-dose Estradiol patch for hot flashes, headaches and joint pain. After hysterectomy, the patch was not enough for my symptoms, especially the joint pain and genitourinary symptoms so my gynecologist switched me to an Estradiol gel at a 1.25mg dose. I rub it behind my knees and on my wrists everyday as it works more slowly and the patch more quickly. It's still not enough for my vaginal symptoms so I use other things for that and if you want to discuss it I can.

For something natural prior to hysterectomy, I did take a break from Estradiol and find hot flash relief using a bottle of Soy Isoflavone capsules purchased at Sprouts or Amazon. I tried Estroven as well that you can buy in a grocery store. It contains Rhapontic Rhubarb and Isoflavones. But because I was having so many terrible symptoms I reverted to Estradiol but this time to a gel with my gynecologist's help.

I see a NP at a separate practice who runs bloodwork every 2-3 months to monitor my hormone and other levels.

I hope this helps and am happy to discuss further.

@blueskies1530
Thank you for these alternatives. I have tried vaginal estradiol, but found it to cumbersome. It's good to know a gell can go elsewhere.

@jlam1950

There are different forms of vaginal Estradiol that aren't messy. They would be Vagifem and Imvexxy suppositories. There's vaginal DHEA suppositories called Intrarosa that converts to estrogen and testosterone.

Yeah, so far the Estradiol gel is helping. Compounding pharmacies can give you alternatives like a wrist roll-on device or a spray.

@blueskies1530

There are also pellets which are inserted just below the skin. Also, estradiol patches and compounded testosterone cream that is applied to the skin