The importance of persistent climacteric vasomotor symptoms (VMS) is largely underestimated. Although median total VMS duration is 7 years, VMS often last up to the age of 80-90 years. At the age of 65 years, about 25% of all women suffer still from hot flushes. In a recent study, among a group of women aged 85 years, 16 % still complained about VMS during day and /or night time, 10 % were severely or moderately disturbed by their VMS, and 6.5% used regularly oestrogens at the age of 85 years. Furthermore, women suffering from VMS have a higher risk for cardiovascular diseases, fractures and depression than women without. MHT is the most effective therapy for VMS and urogenital atrophy. There are no reasons to place mandatory limitations on the duration of oestrogen administration if MHT is individualized and tailored according to symptoms and the need for prevention, as well as personal and family history, results of relevant investigations and the woman’s preferences and expectations. Other menopause-related complaints, such as joint and muscle pains, mood swings, sleep disturbances, sexual dysfunction (including reduced libido) and quality of life may improve during MHT. VMS may last far into the ages of 80-90 years. Furthermore, MHT has been shown to significantly lower the risk of hip, vertebral and other osteoporosis-related fractures in post-menopausal women independent of age. For the continuation of MHT after the age of 65, a documented indication such as persistent climacteric symptoms or bone loss is needed, with shared decision-making and periodic re-evaluation. If systemic MHT is needed, low-dose and ultralow-dose oestrogens are sufficient in most elderly women for a significant amelioration of climacteric symptoms, allowing to maintain the benefits and to lower the risks. Transdermal administration should be chosen to minimize the risks of VTE and stroke. Healthy women having started MHT before the age of 60 years and/or less than 10 years from menopause and continuing MHT after 65 should not be unduly concerned about the safety profile of a correctly indicated MHT. Although the evidence is small, it can be assumed that in elderly healthy symptomatic women without MHT-specific risk factors in whom MHT has been started below the age of 60 years or within 10 years of menopause onset and then continued into the old age, benefits will outweigh the risks. This is not the case if MHT has been initiated only after this “window of opportunity”.