After the WHI (Women's Health Initiative) Study, Menopausal Hormone Therapy (MHT, which is also sometimes called HRT) got a bad rep and was rarely prescribed. We now know many of those initial findings aren't true for all women, and for young women close to menopause (<60 years old or <10 years from their final period), the benefits of hormones typically outweigh any risks. However, there is still a lot of misinformation floating out there, even among healthcare professions. So, you may have been told that you can't take MHT for whatever reason. But, is that really true? There are some reasons you absolutely should not use MHT....
Absolute Contraindications for Hormone Therapy (if you have these, you really shouldn't 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 reasons that women have been given for not being prescribed MHT, though, aren't actually contraindications to hormones. So, let's break these down....
Family History of Breast Cancer or BRCA gene mutation carrier
Estrogen alone therapy does not increase the risk of breast cancer at all. Estrogen + progesterone therapy (which is needed if you haven't had a hysterectomy) can SLIGHTLY increase the risk of breast cancer after 5-7 years of use. The risk is still very small, and studies show the risk of dying from breast cancer is NOT increased. The additional risk of breast cancer with estrogen + progesterone MHT is 9 extra cases diagnosed per 10,000 women every year on MHT compared to those who are not. As all women have a 1 in 8 (or 13%) lifetime risk of being diagnosed with breast cancer, this is really not clinically significant. Per the Menopause Society, women who are at higher risk of breast cancer due to genes or family history can still take MHT as it does not significantly increase their risk of breast cancer over their baseline risk.
Migraine with aura
Women who have migraine with aura should not use combination birth control pills, patches, or rings because it can increase the risk of stroke. However, the doses of estrogen in MHT are 10-20x lower than what is in hormonal birth control (it is a different type of estrogen, so you can't just look at the mcg or mg and compare those). For this reason, MHT is considered safe for women who have migraine with aura. Using transdermal estradiol as a part of MHT further reduces the risk of stroke and is VERY safe for women with this condition.
Family History of Cardiovascular Disease or Heart Attack
For young women <60 years old and <10 years from menopause, MHT does not increase the risk of cardiovascular disease and likely decreases the risk. It has also been shown to decrease the risk of dying early from any cause. So, regardless of family history of heart disease, as long as you do not personally have heart disease, you can still take MHT!
Family History of Stroke
While oral estrogens can increase the risk of stroke, many recent studies show that using non-oral routes of estradiol such as transdermal patches, sprays, gels, or the Femring (vaginal ring for systemic estrogen) has a much lower or possibly no increased risk of blood clots or stroke. So, as long as you have not personally had a stroke or TIA ("mini-stroke"), MHT is still considered safe regardless of this family history if you are otherwise a candidate.
Previous blood clot or genetic risk factor for blood clot
For women with a prior blood clot in the leg or lungs or those with a genetic mutation that increases clotting risks (such as Factor V Leiden), combination hormonal birth control is not recommended as it can increase the risk of blood clots to an unacceptable level. However, menopausal hormone therapy may still be appropriate. MHT has a much lower dose of hormones than birth control pills. Additionally, transdermal estradiol is much safer with a lower risk of blood clots than oral estrogen. Many newer studies show that the risk may not be increased at all. Several studies have shown that women with a previous clot or those who are at higher risk of clots due to genetic factors likely have no increased risk of blood clots when placed on transdermal estrogen therapy for menopause. Risks and benefits of any hormone therapy should always be discussed with your doctors.
Obesity
While women with obesity sometimes have other health issues, obesity itself is not a reason to avoid MHT. Obesity can increase the risk of blood clots, but using non-oral estrogens like a patch or gel can decrease or eliminate the increased risk of blood clots that comes with MHT.
Diabetes
Type 2 diabetes without complications is not typically a reason that you cannot use hormone therapy. MHT can actually help improve glycemic control in women without diabetes. In women <60 years old or <10 years from the onset of menopause, MHT can lower the risk of cardiovascular disease as well and can be beneficial. If you are older than this or >10 years from menopause or have other health conditions, the risk to benefit ratio is not as clear and needs to be discussed with your doctor.
Older Age
We do not see the same health benefits from MHT when it is started or restarted in women >60 and >10 years from menopause. However, this doesn't necessarily mean that you can't start MHT at this point if you are otherwise healthy. If you are having bothersome menopausal symptoms that are interfering with your life, have a discussion with your doctor (who knows about menopause) to discuss the risks versus benefits for you. Risks are generally low.
Menopausal Hormone Therapy is safe and effective for most women. Even if you have been told in the past that you are not a candidate, if you are interested in starting MHT for bothersome menopausal symptoms, it may be worth another discussion!
Best,
Jackie Stone, MD
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