Contraindications for Estrogen Therapy
Estrogen therapy is absolutely contraindicated in patients with a history of hormone-dependent cancers, undiagnosed abnormal genital bleeding, active thromboembolic disorders, and certain specific cancer types including low-grade serous epithelial ovarian cancer, granulosa cell tumors, and certain sarcomas. 1, 2
Absolute Contraindications
Cardiovascular and Thromboembolic Conditions
- Thrombophlebitis or active thromboembolic disorders
- Past history of deep vein thrombophlebitis or thromboembolic disorders
- Cerebral vascular or coronary artery disease (current or history)
- Valvular heart disease with complications
- Severe hypertension 1
Cancer-Related Contraindications
- Known or suspected breast cancer or personal history of breast cancer
- Carcinoma of the endometrium or other known or suspected estrogen-dependent neoplasia
- Low-grade serous epithelial ovarian cancer
- Granulosa cell tumors
- Certain types of sarcoma (leiomyosarcoma and stromal sarcoma)
- Advanced endometrioid uterine adenocarcinoma 1, 2
Other Absolute Contraindications
- Undiagnosed abnormal genital bleeding
- Cholestatic jaundice of pregnancy or jaundice with prior pill use
- Hepatic adenomas or carcinomas
- Known or suspected pregnancy
- Hypersensitivity to any component of estrogen products 1
- Major surgery with prolonged immobilization 1
Special Considerations
Cancer Survivors
- Estrogen therapy is generally contraindicated in breast cancer survivors 2
- For women with endometriosis who required oophorectomy, combined estrogen/progestogen therapy can be effective for vasomotor symptoms but must be carefully considered 2
- For gynecologic cancers that are not hormone-dependent (cervical, vaginal, vulvar), systemic or topical hormone therapy is not contraindicated 2
Migraine and Hypertension
- Migraine with focal neurological symptoms is a contraindication 1
- For women with POI (premature ovarian insufficiency) and migraine without focal symptoms, estrogen is not contraindicated but requires monitoring 2
- Hypertension without vascular involvement is not a contraindication for women with POI, but transdermal estradiol is preferred in hypertensive women 2
Route-Specific Considerations
Topical/Vaginal Estrogen
- Topical estrogen has minimal systemic absorption and may be safer in some cases where systemic therapy is contraindicated 3
- However, local estrogen treatments (rings, suppositories, creams) are still contraindicated in hormone-sensitive tissues/cancers 2
- For women with a history of endometrial, ovarian, or cervical cancer who are disease-free, vaginal estrogen may be considered with appropriate specialist consultation 4
Monitoring and Management
For patients using estrogen therapy who don't have contraindications:
- Annual clinical review with attention to compliance
- Monitor for abnormal vaginal bleeding in women with intact uterus
- Consider changing dose, route of administration or regimen if migraine worsens during therapy
- For women with an intact uterus, progestogen should be given in combination with estrogen therapy to protect the endometrium 2
Alternative Options When Estrogen is Contraindicated
- Non-hormonal pharmacologic treatments (antidepressants, anticonvulsants, neuronal inhibitors)
- Vaginal moisturizers and water-based lubricants
- Pelvic floor physical therapy
- Cognitive behavioral therapy for psychological aspects of menopausal symptoms 2, 3
When managing menopausal symptoms in patients with contraindications to estrogen therapy, a careful assessment of risks versus benefits must be made, with referral to appropriate specialists for complex cases.