“Can I Take Hormones for Menopause?”: Understanding Risks and Alternatives for Menopause Relief
Menopause can bring a range of symptoms — from hot flashes and night sweats to mood changes, sleep problems, and vaginal dryness. For many women, menopause hormone therapy (MHT), also called hormone replacement therapy (HRT), can be life-changing. But it’s not the best or safest choice for everyone.
As your healthcare provider, I want to help you understand when hormone therapy should be avoided, when it might still be possible with careful consideration, and what nonhormonal options are available to help you feel better.
🚫 When Hormone Therapy Is Not Safe: Absolute Contraindications
There are certain medical conditions where hormone therapy should not be used because the risks clearly outweigh any potential benefit. These are known as absolute contraindications.
1. Current or Past Breast Cancer
If you’ve had breast cancer, estrogen therapy can stimulate cancer cell growth. For this reason, MHT is generally not recommended unless under very specific, closely supervised circumstances.
2. Estrogen-Dependent Cancers (Like Endometrial Cancer)
Estrogen can promote the growth of certain cancers, such as cancer of the uterine lining. Until these conditions are fully treated and cleared, hormone therapy isn’t safe.
3. Unexplained Vaginal Bleeding
Any bleeding after menopause should always be evaluated first. While often benign, it can sometimes signal something serious like endometrial cancer. Hormone therapy shouldn’t be started until a clear cause is identified.
4. Active or Recent Blood Clots
If you’ve had a deep vein thrombosis (DVT) or pulmonary embolism (PE), or have a known clotting disorder, oral estrogen can increase the risk of another clot forming. That makes MHT unsafe.
5. Recent Heart Attack or Stroke
Estrogen can slightly increase the risk of stroke or heart attack. Women with recent or active cardiovascular disease should avoid hormone therapy.
6. Severe Liver Disease (cirrhosis)
Because estrogen is metabolized in the liver, significant liver problems can worsen with hormone therapy. Until liver function normalizes, it’s best avoided.
⚖️ When We Need to Be Careful: Relative Contraindications
Sometimes, the risks aren’t absolute, but we still need to be cautious. These are called relative contraindications — situations where therapy might still be possible with individualized risk assessment and monitoring.
1. Migraine with Aura
Estrogen can trigger or worsen migraine auras in some women. For patients with this history, we often use transdermal estrogen (patch, gel, or spray) instead of oral tablets, as it carries less risk.
2. High Blood Pressure
If your blood pressure is well controlled, MHT can still be considered. We’ll just monitor it closely to ensure it stays in a safe range.
3. Gallbladder Disease
Estrogen can increase the risk of gallstones. If you’ve had gallbladder issues, a non-oral route like a skin patch may be safer.
4. Blood Clotting Risk Factors
Women with a family history of clots, obesity, smoking, or certain genetic mutations need individualized care.
Major guidelines — including those from the American Society of Hematology (ASH) — recommend that women with factor V Leiden, a common inherited clotting disorder, undergo a personalized risk assessment.
Oral estrogen therapy is generally contraindicated in women with factor V Leiden.
However, transdermal MHT may be considered in carefully selected women who are asymptomatic heterozygotes (carry one copy of the mutation).
Transdermal Estrogen: A Safer Choice for Many
One of the most important findings from recent research is that transdermal estrogen (patch, gel, or spray) does not significantly increase the risk of blood clots (VTE), unlike oral estrogen.
Studies such as the Estrogen and Thromboembolism Risk Study (Scarabin et al., 2003) and more recent analyses (Vinogradova et al., 2019) found no increased risk of clots with transdermal estrogen compared to women not on hormones.
This is why most experts—including ACOG, 2019—recommend transdermal formulations for women with higher VTE risk, metabolic syndrome, or obesity.
🌿 When Hormones Aren’t an Option: Nonhormonal Ways to Find Relief
For women who cannot take hormone therapy — such as those with a history of breast cancer, blood clots, or heart disease — there are excellent nonhormonal therapies to help manage menopause symptoms.
The two most common issues we address are:
Vasomotor symptoms (VMS) – hot flashes and night sweats
Genitourinary syndrome of menopause (GSM) – vaginal dryness, irritation, and urinary symptoms
Let’s look at the evidence-based options.
🔥 Managing Hot Flashes and Night Sweats
These “heat surges” can be frustrating, but several medications can help reduce their frequency and intensity.
1. SSRIs and SNRIs (Antidepressants)
Certain antidepressants can calm hot flashes, even at low doses.
Paroxetine (7.5 mg daily) is the only SSRI FDA-approved specifically for hot flashes.
Other helpful options include citalopram, escitalopram, venlafaxine, and desvenlafaxine.
Note: If you take tamoxifen, some SSRIs can interfere with its effectiveness. Your doctor will help choose a safe option.
2. Gabapentin and Pregabalin
Originally used for nerve pain, these can also reduce hot flashes and help with sleep. Some women feel a bit drowsy or dizzy, especially at first.
3. Fezolinetant
A newer, nonhormonal medication that works directly on brain receptors involved in temperature control. It’s FDA-approved and effective for many women, but it requires occasional liver function monitoring to ensure safety.
4. Oxybutynin and Clonidine
These can reduce hot flashes for some women but are less commonly used due to side effects and variable results.
🧘 Mind-Body and Lifestyle Approaches
Beyond medication, several behavioral and lifestyle strategies can make a real difference:
Cognitive behavioral therapy (CBT) and clinical hypnosis can help reduce how distressing hot flashes feel and improve overall quality of life.
Cooling strategies, stress management, mindfulness, and maintaining a healthy weight can also help.
Herbal supplements and phytoestrogens (like soy) are popular but not well-proven — and some carry safety concerns — so they’re generally not recommended.
💧 Vaginal Dryness and Urinary Changes
Vaginal and urinary symptoms are extremely common after menopause and can affect intimacy, comfort, and quality of life. These symptoms fall under genitourinary syndrome of menopause (GSM), and fortunately, there are safe, nonhormonal options available:
Vaginal moisturizers and lubricants can provide effective, over-the-counter relief.
Ospemifene (Osphena) is a prescription medication that improves vaginal dryness and pain with intimacy without using estrogen.
Pelvic floor physical therapy and behavioral techniques can help with urinary leakage and sexual function.
💬 The Bottom Line
Hormone therapy can be incredibly helpful for many women, but it’s not the right choice for everyone. If you have any of the conditions that make it unsafe, or if you simply prefer not to take hormones, there are proven nonhormonal therapies that can help you feel more like yourself again.
Treatment should always be individualized — taking into account your medical history, personal preferences, and any other medications you use. We’ll work together to create a plan that’s both effective and safe.
If you ever feel unsure or overwhelmed by your options, that’s okay — you don’t have to navigate it alone. Your healthcare team is here to guide you every step of the way.
📚 References
Niskanen LM, Kärkkäinen HJ, Tuppurainen MT. Treatment of Menopausal Symptoms When Hormone Therapy Is Contraindicated. Semin Reprod Med. 2025.
Pinkerton JV. Hormone Therapy for Postmenopausal Women. N Engl J Med. 2020;382:446–455.
The North American Menopause Society. The 2023 Nonhormone Therapy Position Statement. Menopause. 2023;30(6):573–590.
Crandall CJ, Mehta JM, Manson JE. Management of Menopausal Symptoms: A Review. JAMA. 2023;329(5):405–420.
Chang JG, Lewis MN, Wertz MC. Managing Menopausal Symptoms: Common Questions and Answers. Am Fam Physician. 2023;108(1):28–39.
Huang AJ, Faubion S, Grady D. Nonhormonal Treatment of Menopausal Vasomotor Symptoms. JAMA Intern Med. 2025;185(7):874–875.
FDA Orange Book.
Steinman MA. Alternative Treatments to Selected Medications in the 2023 American Geriatrics Society Beers Criteria®. J Am Geriatr Soc. 2025;73(9):2657–2677.
This information is for educational purposes only and shouldn’t replace personalized medical advice. Always talk to your healthcare provider about your specific health situation before starting or stopping any treatment.