After the WHI (Women's Health Initiative) study, Menopausal Hormone Therapy (MHT, sometimes called HRT) got a bad reputation and was rarely prescribed. We now know many of those initial findings aren't true for all women — and for younger women close to menopause (under 60, or within 10 years of their final period), the benefits of hormones typically outweigh any risks.

Still, a lot of misinformation persists, even among healthcare professionals. So you may have been told that you can't take MHT for one reason or another. But is that really true?

When you really shouldn't use MHT

There are some absolute contraindications. If you have any of these, you should not use MHT:

  • Personal history of breast cancer
  • Personal history of endometrial cancer (high grade, or stage 3/4)
  • Previous stroke or TIA ("mini-stroke")
  • Previous heart attack or heart disease (coronary artery disease)
  • Uncontrolled high blood pressure
  • Active liver disease

Many other reasons women are told they "can't" take MHT aren't actually contraindications. Let's break those down.

Reasons that are often not a dealbreaker

Family history of breast cancer or a BRCA gene mutation. Estrogen-alone therapy does not increase breast cancer risk at all. Estrogen + progesterone therapy (needed if you still have your uterus) can slightly increase risk after 5–7 years of use — but the risk is very small, and studies show the risk of dying from breast cancer is not increased. The added risk works out to about 9 extra cases per 10,000 women per year. Since all women have roughly a 1-in-8 (13%) lifetime risk of breast cancer, this is not clinically significant. Per The Menopause Society, women at higher risk due to genes or family history can still take MHT.

Migraine with aura. Women with migraine with aura shouldn't use combination birth control pills, patches, or rings, because they can raise stroke risk. But the estrogen dose in MHT is 10–20x lower than in hormonal birth control (and a different type of estrogen), so MHT is considered safe here. Using transdermal estradiol reduces the stroke risk even further.

Family history of cardiovascular disease or heart attack. For women under 60 and within 10 years of menopause, MHT does not increase cardiovascular risk and likely decreases it — and it's been shown to lower the risk of dying early from any cause. As long as you don't personally have heart disease, family history alone doesn't rule you out.

Family history of stroke. While oral estrogens can raise stroke risk, non-oral estradiol (transdermal patches, sprays, gels, or the Femring) carries much lower or possibly no increased risk. As long as you haven't personally had a stroke or TIA, MHT is still considered safe if you're otherwise a candidate.

Previous blood clot or a genetic clotting risk. For women with a prior clot or a mutation like Factor V Leiden, combination birth control isn't recommended. But MHT uses a much lower hormone dose, and transdermal estradiol is far safer than oral estrogen for clotting — many newer studies suggest the risk may not be increased at all. Risks and benefits should always be discussed with your doctor.

Obesity. Obesity itself is not a reason to avoid MHT. It can raise clotting risk, but using non-oral estrogens like a patch or gel can reduce or eliminate that added risk.

Diabetes. Type 2 diabetes without complications typically isn't a reason to avoid hormone therapy. MHT can actually improve glycemic control, and in women under 60 or within 10 years of menopause it can lower cardiovascular risk. If you're older than that or have other conditions, the risk-benefit balance is less clear and should be discussed with your doctor.

Older age. We don't see the same health benefits when MHT is started or restarted in women over 60 and more than 10 years past menopause. But that doesn't automatically mean you can't start it if you're otherwise healthy and having bothersome symptoms — have a discussion with a doctor who knows menopause. Risks are generally low.

The takeaway

Menopausal hormone therapy is safe and effective for most women. Even if you've been told in the past that you're not a candidate, if you're interested in starting MHT for bothersome menopausal symptoms, it may be worth another conversation.