Who Is — and Is Not — a Good Candidate for Hormone Replacement Therapy (HRT)?

For many women, hormone therapy can be a safe and effective way to manage symptoms of perimenopause and menopause — particularly when started relatively early in the transition. But clinicians emphasize that it isn’t appropriate for everyone.

“Safe doesn’t mean risk-free,” says Sara Szal, MD, author of Women, Food, and Hormones. “Every therapy has a context, and women deserve counseling about their specific risks.”

In general, many healthy women under age 60 — or within about 10 years after their last ­menstrual period — may be good candidates for hormone therapy if they need help with symptoms like hot flashes, sleep disruption, mood changes, or vaginal dryness.

Yet it’s still important to consider your medical history and risk factors. “The conversation is always individualized,” Szal says. “Personal and family history, genetic risk, and metabolic health all matter.”

Some women may be advised to avoid systemic hormone therapy altogether (this includes any hormone treatments that enter the bloodstream). According to guidelines from major medical organizations, systemic hormone therapy is generally not recommended for women with certain conditions:

• a personal history of breast cancer or other estrogen-sensitive cancers
• unexplained vaginal bleeding
• active liver disease
• prior blood clots, stroke, or heart attack
• certain inherited clotting disorders

In these cases, nonhormonal therapies or lifestyle strategies may be safer options. Karen Kaufman, MD, a board-certified obstetrician and gynecologist, and the medical director of MIORA in Colorado, does note that those with a history of breast cancer may still be able to pursue some forms of HRT with careful guidance from an attentive provider.

Topical hormone therapies like vaginal suppositories are another option for symptom relief. Rather than raising hormone levels throughout the body, they act on the tissues of the vagina and pelvic floor to help with vaginal dryness, pain with sex, urinary urgency, and recurrent UTIs. Because they’re more targeted, they can be an option even for women who are not good candidates for full-body HRT.