Who should not take HRT

HRT suits most women with menopausal symptoms, but not everyone. Some conditions make it unsafe, some call for specialist involvement first, and in some cases the form of HRT changes whether it is appropriate. Knowing where you stand is part of an assessment, and being honest about it protects you.

This article sets out the main situations. It is a guide to the conversation, not a substitute for an individual assessment.

When HRT is generally not advised

• A current or recent oestrogen-receptor-positive breast cancer, in most circumstances.

• Other current hormone-sensitive cancers, unless cleared by the specialist managing them.

• Active liver disease where liver function is abnormal.

• Unexplained vaginal bleeding that has not yet been investigated.

• An untreated blood clot in the leg or lung, or a recent one.

• Untreated high blood pressure, until it is controlled.

Some of these are absolute and some are temporary. Unexplained bleeding, for instance, needs investigating first; it does not necessarily rule out HRT once a cause is known. Uncontrolled blood pressure means treating the pressure first, not avoiding HRT forever.

When it needs care, not a refusal

Many situations call for a more careful choice rather than a flat no. A personal or strong family history of blood clots, migraine with aura, a higher body weight, gallbladder disease, or a family history of breast cancer all make the conversation more detailed. Often the answer is to use the safer route, transdermal oestrogen through the skin, which avoids the clot risk of tablets, rather than to avoid HRT altogether.

Why the route changes the answer

It is worth understanding that oral and transdermal oestrogen are not equivalent on safety. Oestrogen taken as a tablet passes through the liver and raises the risk of blood clots; oestrogen through the skin as a gel, patch or spray does not carry that increased clot risk. So a woman for whom tablets would be unwise can often safely use the transdermal form. This is why a blanket no to HRT is often the wrong answer, and a tailored yes is the right one.

A history of cancer is not always a no

Cancer histories vary. A past oestrogen-receptor-positive breast cancer usually means systemic HRT is avoided, but even then, low-dose vaginal oestrogen for genitourinary symptoms may be possible after discussion with the oncology team, because so little reaches the bloodstream. Other cancers may not affect the decision at all. The point is that it is individual, and worth assessing rather than assuming the door is closed.

What to do if HRT is not for you

If systemic HRT is not advisable, you still have options. Non-hormonal prescription medicines can reduce flushes, CBT helps the impact of symptoms and sleep, lifestyle measures help, and local vaginal oestrogen can usually treat genitourinary symptoms. Being unable to take systemic HRT does not mean being left without a plan; it means a different plan, which we cover in our article on non-hormonal options.

Red flags to act on while taking HRT

Once you are on HRT, a few symptoms warrant prompt attention rather than waiting for your next review:

• Any unexplained or persistent vaginal bleeding, especially if it starts after six months of settled treatment.

• A new breast lump or a change in the look or feel of a breast.

• Signs of a blood clot: swelling or pain in one leg, chest pain, or sudden breathlessness, which need urgent assessment.

• A new migraine with aura, meaning visual or sensory disturbance before the headache.

These are uncommon, and most are not serious when checked, but they are the situations where it is right to contact a clinician rather than assume. Knowing them in advance means you can act quickly if they ever happen.

The honest summary

A few conditions genuinely rule HRT out, at least for now. Many more simply call for the right form and a careful discussion rather than avoidance. And where systemic HRT is off the table, effective alternatives remain. The job of an assessment is to work out exactly which of these applies to you.

Ready to start?

If you want to move from reading to acting, the next step is a short assessment with a doctor on the GMC GP Register. It takes about ten minutes and tells you whether HRT is right for you.

Begin your assessment at this link. Online or in person at Westfield London.