WHEN I WAS ASKED the question “Who can’t take HRT?”, I thought the answer would be simple. Hormone Replacement Treatment (HRT) is a well-recognised UK term, although the international expert community refers to it as MHT or Menopausal Hormone Treatment. Does the above question really mean “who can’t” or “who shouldn’t” take HRT?

This article was included in issue 108 (Spring 2026) of The Menopause Exchange newsletter.

An individualised approach

An individualised decision-making process involves weighing the benefit(s) against the risk(s) for the woman concerned. It’s subtle and nuanced and ideally conducted in consultation with an appropriately trained healthcare professional. It’s only after this discussion that a few women might be advised not to take HRT.

Any type of medicine or intervention should only be used when needed – if it’s not needed, it shouldn’t be used. Therefore, women who are premenopausal with no symptoms of hormone deficiency shouldn’t use HRT (because they don’t need it). At a later stage in their lives, they may have menopausal symptoms and/or need bone protection and decide at that stage that they do want to take HRT. The question should therefore be “when” should women not have HRT?

Other women pass through the menopause with few or no symptoms and decide they don’t need any intervention. If they live healthy lives, eat a good diet and their periods stop at a typical age, they may very reasonably determine that they don’t need HRT.

Some women will have taken HRT for their symptoms in the perimenopausal stage, converted to a continuous regime as bleeding settled and then gradually reduced the dose. If a woman is otherwise well and any risk factors for long-term health problems are controlled, she may very reasonably stop HRT and see what happens. If her quality of life deteriorates, she can always revise her decision later on.

Healthcare professionals are aiming for a situation in which HRT benefit(s) outweighs HRT risk(s), that a woman makes an informed decision about her health, and she’s being prescribed the lowest, effective dose of HRT. Certain health risks and other factors may affect this balance.

Cardiovascular diseases

Cardiovascular diseases affect the heart and blood vessels and, when grouped together, are the cause of death for more than 50% of women. Although NICE didn’t position it in this way, most international authorities believe that if oestrogen is started within 10 years of the menopause, it will reduce the risk of coronary artery disease and probably other arterial diseases as well. This is due to oestrogen’s role in reducing atheroma (a build-up of fatty material) and other changes in blood vessel walls.

Oral oestrogen increases the risk of blood clots and is best avoided by women with higher risks of blood clots, including surgery with immobilisation. If women have had previous heart/circulatory disease or associated medical events, they should be assessed by a menopause specialist and discuss the assessment results with their vascular/cardiology/haematology specialist. The answer to whether they should take HRT may not be “no” – instead, a suitable HRT regime may be proposed.

Breast cancer

Breast cancer is an emotionally charged issue and not well understood. The approach is usually to consider a woman’s baseline risk, including the impact of her menopausal symptoms and her bone health, and start the balancing act. Having a family history of breast cancer isn’t a contraindication, but it’s important to take into account who the family members were, how old they were at diagnosis, and how many of them had breast cancer. Women with proven susceptibility genes will be offered a risk-reducing mastectomy (breast removal) and usually removal of both ovaries. This is drastic but justifiable. These women will immediately feel the effects of a surgical menopause, but can be offered HRT with no loss of benefit. The NICE guidance that applies to this situation suggests that HRT should be continued to the average age of the menopause. As always, the importance of annual reviews and evaluations should apply.

Women who have already been diagnosed with a gynaecological cancer or breast cancer need careful specialist evaluation, as many of these tumours are sensitive to hormones. This group is most likely to be advised not to take HRT. However, after an individual estimate of the risk of the cancer coming back, very few will decide that (for them) the risks of HRT are outweighed by the potential benefits. If this decision is truly evidence-based and informed, they’ll be prescribed HRT.

Other considerations

Women with inflammatory bowel disease, who have had gut surgery or are taking GLP-1 medicines (weight loss jabs) may have reduced gut absorption. This means they would be best having their HRT delivered by other routes. They may, however, have particularly good reasons to use HRT, as poor gut absorption raises the risks of bone loss and broken bones.

Allergy to HRT is exceedingly rare, but an intolerance of other HRT ingredients (e.g. excipients or adhesive/glue) is much less rare. Trial and error may be needed to identify an HRT regime that’s effective and tolerated in these cases.

Summary

In summary, HRT use should be determined by the individual woman, following good evidence-based information and a discussion with her healthcare provider. Her wellbeing, cardiovascular profile, bone health, breast risk, mental health, bleeding and many other factors need to be taken into consideration – and this needs to be a balanced decision. Who can’t take HRT is, in the end, the woman who doesn’t want it, or the woman for whom the risks are untenable.

About the author
Dr Sarah Gray is a GP specialist in women’s health based at St Erme Medical in Truro, Cornwall.

Created Spring 2026
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