Hormone therapy is safe for most healthy women who start it under 60 or within ten years of menopause, and it is the wrong choice for some. A short list of conditions rules out systemic estrogen. Other conditions change the form or the dose. Women who can't take systemic estrogen can often use low-dose vaginal estrogen for dryness and bladder symptoms or use non-hormonal prescriptions for hot flashes.
Pick what fits to see what the guidelines say.
I've had breast cancer
Local estrogen is still an optionWith the oncologist
Systemic hormone therapy is generally avoided. Low-dose vaginal estrogen for dryness and urinary symptoms is considered reasonable for many survivors, with the oncologist's agreement, particularly those not taking aromatase inhibitors. Non-hormonal options treat the hot flashes.
What you can still useI've had a blood clot
A specialist decisionDepends on the cause
A clot caused by a clear trigger such as surgery or pregnancy doesn't always rule it out. Estrogen through the skin doesn't raise clotting factors the way pills do and may be considered with specialist input. An unprovoked clot or a known clotting disorder usually means no systemic estrogen.
Pill or skinI get migraines with aura
Often yes, through the skinSteady dose
Migraine with aura rules out oral estrogen because of stroke risk, but transdermal estradiol at a steady dose is generally considered acceptable and often helps, since hormone swings trigger migraines. Migraine without aura isn't a barrier.
Conditions that change the formHigh blood pressure or overweight
Often yes, through the skinOnce controlled
Being overweight or having high blood pressure, once controlled: reasons for transdermal, not for no.
Conditions that change the formBreast cancer runs in my family
Not a reason to refuseTalk it through
Not a contraindication in itself. Individual discussion of risk; estrogen-alone and micronised progesterone regimens carry the least breast risk.
Conditions that change the formTold my levels are normal
Not a reason to refuseSymptoms decide
Treatment is decided on symptoms.
Not reasons to refuseI'm over 60
A specialist decisionTransdermal, lowest dose
Not automatically, but the balance changes. Starting within 10 years of menopause or before 60 carries the best balance of benefit and risk, which is what the FDA's updated labelling recommends. Starting later is an individual decision with a clinician, usually with transdermal forms, and local vaginal estrogen is fine at any age.
Conditions that change the formSystemic means estrogen that reaches the whole body: pills, patches, gels, sprays, the systemic ring. These are the situations where guidelines and product labelling advise against it.
For most women with a breast cancer history, systemic estrogen is avoided because of the risk of recurrence. There are exceptions discussed between a woman, her oncologist and a menopause clinician, but the default is no.
Such as endometrial cancer that hasn't been fully treated.
Not a permanent bar, but it must be investigated and explained first; see bleeding in perimenopause and after.
Or active heart disease.
Such as factor V Leiden with a clot history.
Which is still possible in perimenopause; see pregnancy during perimenopause.
Patch vs pill vs gel explains why the skin route is safer for most of these, and heart risk and hormone therapy covers the cardiovascular evidence and the FDA's 2025 labelling change.
These conditions do not always rule out treatment. The form often matters.
Women are still told no for reasons the evidence doesn't support.
"You're too young for menopause."
Not a reasonPerimenopausal symptoms in the 40s are the commonest reason to start treatment, and premature menopause before 40 is a reason to start, not to wait. Weighing birth control against HRT? See birth control or HRT in perimenopause.
"Your hormone levels are normal."
Not a reasonTreatment is decided on symptoms; see hormone testing.
"HRT causes breast cancer."
Not a reasonThe risk picture is more specific than that: a small increase with some combined regimens used for several years, less with estrogen alone and with micronised progesterone, and the FDA began removing its broad boxed warnings in November 2025. See the BHRT guide safety section.
"You've been on it five years, time to stop."
Not a reasonThere's no fixed stopping age; see how long you can stay on HRT.
A family history of breast cancer
Not a reasonOn its own.
Being overweight or having high blood pressure
Not a reasonOnce controlled: reasons for transdermal, not for no.
For dryness, painful sex and urinary symptoms and recurrent infections, low-dose vaginal estrogen acts on the tissue it touches and very little reaches the bloodstream. Guidelines regard it as acceptable for most women in the groups above, including many breast cancer survivors with their oncologist's agreement, particularly those not on aromatase inhibitors. Vaginal DHEA and oral ospemifene are alternatives for painful sex.
What would you like to treat?
FDA-approved in 2023, blocks the brain signal behind flashes; not a hormone; needs liver-enzyme tests in the first months.
FDA-approved for flashes; venlafaxine and other SSRIs/SNRIs used off-label with similar effect, and they help mood. Some SSRIs interact with tamoxifen, so the choice matters after breast cancer.
Especially for night-time flashes and sleep.
Which reduces flashes and sweating.
Both recommended by The Menopause Society for hot flashes; see CBT for menopause.
CBT for insomnia, treatment of depression and anxiety, strength training, vitamin D and sometimes bone medication for bone density, along with lifestyle changes that help regardless of hormones.
The first visit reviews these options against your history. If systemic hormone therapy isn't right for you, the clinician says so and builds a plan from the alternatives above. Those options can also be prescribed by video. If you've been refused hormone therapy elsewhere for one of the reasons in the "not reasons" section, bring the details.
Talk.
A one-on-one video visit about your symptoms, your history and what you want to feel like again. Your first visit is $99, refunded if you cancel at least 24 hours ahead.
Test.
If your provider thinks it will help, a hormone blood panel adds lab results to what you’ve told them. Not everyone needs this step.
Treat.
If treatment is right for you, your plan can include hormone prescriptions, non-hormonal options, lifestyle changes and optional supplements. Then two to three follow-up visits with a doctor and text check-ins through HIPAA-compliant messaging, included in membership at $49 a month, which begins one month after your first visit. Prescriptions and labs are priced separately.
Women with current or past breast cancer or another estrogen-sensitive cancer, unexplained vaginal bleeding, a recent blood clot, stroke or heart attack, active liver disease, or a known clotting disorder are generally advised against systemic hormone therapy. Low-dose vaginal estrogen is still an option for many of them, and there are effective non-hormonal treatments.
A clot caused by a clear trigger such as surgery or pregnancy doesn't always rule it out. Estrogen through the skin doesn't raise clotting factors the way pills do and may be considered with specialist input. An unprovoked clot or a known clotting disorder usually means no systemic estrogen.
Usually yes. Migraine with aura rules out oral estrogen because of stroke risk, but transdermal estradiol at a steady dose is generally considered acceptable and often helps, since hormone swings trigger migraines. Migraine without aura isn't a barrier.
Systemic hormone therapy is generally avoided. Low-dose vaginal estrogen for dryness and urinary symptoms is considered reasonable for many survivors, with the oncologist's agreement, particularly those not taking aromatase inhibitors. Non-hormonal options treat the hot flashes.
Not automatically, but the balance changes. Starting within 10 years of menopause or before 60 carries the best balance of benefit and risk, which is what the FDA's updated labelling recommends. Starting later is an individual decision with a clinician, usually with transdermal forms, and local vaginal estrogen is fine at any age.
A video visit with a clinician who treats perimenopause and menopause, in 33 states.
