What are the contraindications to Menopausal Hormone Therapy (MHT) in a peri- or postmenopausal woman?

Contraindications to Menopausal Hormone Therapy (MHT)

MHT is absolutely contraindicated in women with a history of hormone-dependent cancers (breast cancer, estrogen-dependent neoplasia), active or recent cardiovascular events (myocardial infarction, stroke), history of venous thromboembolism or thrombophilic disorders, active liver disease, and unexplained vaginal bleeding. 1

Absolute Contraindications

The following conditions represent absolute contraindications where MHT should not be prescribed:

Malignancy-Related Contraindications

• History of breast cancer - MHT increases breast cancer risk with a relative risk of 1.24 for estrogen plus progestin therapy 2, 3
• Known or suspected estrogen-dependent neoplasia (including endometrial cancer in advanced stages) 1
• Low-grade serous epithelial ovarian cancer 1
• Granulosa cell tumors 1
• Certain sarcomas (leiomyosarcoma and stromal sarcoma) 1
• Advanced endometrioid uterine adenocarcinoma 1

Cardiovascular and Thrombotic Contraindications

• History of myocardial infarction 1
• Active or recent stroke 1
• History of deep vein thrombosis 1
• Thrombophilic disorders (inherited or acquired) 1
• Active cardiovascular disease 1

Hepatic Contraindications

• Active liver disease 1

Other Absolute Contraindications

• Undiagnosed or abnormal vaginal bleeding - requires evaluation to rule out malignancy before any MHT consideration 1, 3
• Known pregnancy 1

Strong Relative Contraindications (High-Risk Situations)

These conditions warrant extreme caution and typically preclude MHT use:

Age and Timing Considerations

• Age ≥60 years - oral estrogen-containing MHT is associated with excess stroke risk and must be weighed against clinical benefits 1
• More than 10 years after natural menopause - significantly increased cardiovascular and stroke risk 1
• Elevated baseline risk for cardiovascular disease or stroke - MHT should not be used for cardiovascular disease prevention 1

Cancer History Requiring Specialist Consultation

• Early-stage endometrial cancer - may be considered with specialist input, but carries recurrence risk particularly in Black American women 1
• History of breast cancer on adjuvant therapy - represents a relative contraindication 4

Important Clinical Caveats

Risk Stratification by Formulation

• Oral estrogen formulations carry higher thrombotic risk than transdermal preparations 2, 5
• Transdermal estradiol may be preferred when MHT is indicated due to lower rates of venous thromboembolism and stroke 2
• Topical/vaginal estrogen is not associated with stroke risk and may be used for genitourinary symptoms even when systemic MHT is contraindicated 1

Conditions Where MHT Is NOT Contraindicated

Despite common misconceptions, the following are NOT absolute contraindications:

• Cervical, vaginal, or vulvar cancers (not hormone-dependent) 1
• Most epithelial ovarian cancers (high-grade, clear cell, mucinous) 1
• Family history of breast cancer (without personal history) 4
• Varicose veins (without thrombosis history) 4

Critical Assessment Before Prescribing

Before initiating MHT, assess for:

• Personal history of cardiovascular events (MI, stroke, TIA) 1
• Thrombotic history (DVT, PE, thrombophilia) 1
• Cancer history (particularly hormone-sensitive malignancies) 1
• Liver function status 1
• Unexplained vaginal bleeding requiring workup 3
• Current age and time since menopause onset 1

Common Pitfalls to Avoid

• Do not prescribe MHT for cardiovascular disease prevention - multiple guidelines explicitly recommend against this practice 1, 2, 3
• Do not use custom-compounded bioidentical hormones - these lack FDA oversight, standardization, and safety data while carrying the same risks as conventional MHT 2
• Do not assume "bioidentical" means safer - all estrogen-based therapies carry similar risks regardless of source 2
• Do not initiate MHT in women with angiopathies (from hypertension, diabetes, lupus) - these represent absolute contraindications 5

Risk Mitigation When MHT Is Considered

If MHT is being considered despite relative contraindications:

• Use transdermal formulations over oral to minimize thrombotic risk 2, 5
• Select micronized progesterone or dydrogesterone over medroxyprogesterone acetate 2, 5
• Prescribe the lowest effective dose for the shortest duration 3, 6
• Ensure patient is within the "window of opportunity" (age <60 or within 10 years of menopause) 7, 5
• Obtain written informed consent and consultation with specialists when prescribing in difficult circumstances 4