Who should not do hormone therapy? A comprehensive guide to risks and contraindications

September 24, 2025 •

5 min read

According to the American College of Obstetricians and Gynecologists, systemic hormone therapy is generally not recommended for individuals with a history of certain serious medical conditions. This critical guide details precisely who should not do hormone therapy due to underlying health risks that could be worsened by treatment.

Quick Summary

Individuals with a history of certain cancers, such as breast or endometrial cancer, and those with a past or current history of blood clots, heart attacks, strokes, or active liver disease, should generally avoid hormone therapy. These contraindications are crucial for patient safety, and a thorough medical evaluation is necessary to determine eligibility for treatment. Some transgender individuals also have specific health considerations that can impact hormone therapy decisions.

Key Points

History of Cancer: Individuals with a history of certain cancers, particularly hormone-sensitive breast or endometrial cancers, should typically not use hormone therapy.
Blood Clots & Cardiovascular Events: A personal history of blood clots (DVT/PE), heart attack, or stroke are strong contraindications for hormone therapy due to increased risk.
Liver Disease: Active liver disease is a contraindication because the liver processes hormones, and HT can exacerbate liver issues.
Informed Consent: Transgender individuals considering gender-affirming hormone therapy with a history of certain conditions like cancer or blood clots should discuss these risks with their healthcare team.
Older Age: For menopausal women over 60 or more than 10 years post-menopause, the risks of HRT, including cardiovascular events, generally outweigh the benefits.
Thorough Evaluation: Anyone considering hormone therapy must undergo a comprehensive medical evaluation to review personal and family history of serious illnesses.

Understanding the Risks of Hormone Therapy

Hormone therapy (HT), including hormone replacement therapy (HRT) for menopause and gender-affirming hormone therapy, can offer significant benefits for many people. However, it is not a suitable option for everyone. Before starting any hormone-based treatment, a careful review of an individual’s personal and family medical history is essential. Certain pre-existing health conditions can increase the risks associated with HT, potentially leading to serious or life-threatening complications. Understanding these contraindications is a crucial step for informed decision-making and patient safety.

Absolute Contraindications: Conditions That Prohibit Hormone Therapy

For some individuals, the risks of hormone therapy definitively outweigh any potential benefits. These absolute contraindications mean that HT should not be started under most circumstances. Conditions in this category include:

History of Certain Cancers: Many cancers, especially breast, endometrial, and some ovarian cancers, are hormone-sensitive. Introducing external hormones can stimulate the growth or recurrence of these cancer cells. For those with a history of estrogen-receptor positive breast cancer, systemic hormone therapy is typically avoided.
History of Blood Clots: Hormonal treatments, particularly estrogen taken orally, can increase the risk of venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE). Individuals with a history of these conditions or certain clotting disorders (thrombophilia) should avoid HT.
History of Heart Attack or Stroke: Estrogen-based therapies have been linked to an increased risk of cardiovascular events, especially in older women or those starting HT more than 10 years after menopause. Anyone with a past history of heart attack or stroke is at a higher risk of recurrence and is typically advised against HT.
Active Liver Disease: The liver is responsible for metabolizing hormones. Active liver disease or impaired liver function can prevent the body from processing hormones correctly, leading to potentially dangerous side effects and worsening liver damage.
Undiagnosed Vaginal Bleeding: Unexplained or undiagnosed vaginal bleeding is a contraindication as it could be a sign of a serious underlying condition, such as cancer, that needs to be properly evaluated before starting HT.
Pregnancy: Hormonal therapy is strictly contraindicated for anyone who is pregnant or suspects they might be.

Relative Contraindications: When Extra Caution Is Needed

Some conditions may not be absolute contraindications but require careful consideration, specialized monitoring, or alternative treatment approaches. These include:

Older Age and Time Since Menopause: For women who are older than 60 or more than 10 years past menopause, the risks of cardiovascular disease and dementia associated with HRT are higher. In these cases, transdermal (patch) formulations may be preferred as they carry a lower risk of blood clots than oral pills.
Uncontrolled High Blood Pressure: While not an absolute contraindication, HT should not be started until blood pressure is under control to minimize cardiovascular risks.
Obesity: Increased body mass index (BMI) is an independent risk factor for blood clots. This risk is compounded by oral hormone therapy, making it another factor for careful evaluation.
Gallbladder Disease: Estrogen-only therapy, particularly oral formulations, is associated with a small increased risk of gallbladder disease.
Gender-Affirming Hormone Therapy: Individuals transitioning with estrogen therapy face similar risks regarding blood clots and cardiovascular issues. Similarly, masculinizing therapy with testosterone can carry risks, such as an increase in red blood cells that requires careful monitoring.

Forms of Hormone Therapy and Their Risks

Different forms of HT carry varying levels of risk. Understanding the delivery method can help mitigate certain issues, especially regarding blood clots.

Oral (Pills): Pills must be processed by the liver, which can affect clotting factors and increase the risk of VTE. This is a primary concern for individuals with pre-existing clotting risks. Oral HT can also impact liver function and gallbladder health.
Transdermal (Patches, Gels, Sprays): Applied directly to the skin, these methods avoid the "first-pass" liver metabolism associated with oral intake. This significantly reduces the risk of blood clots and is often recommended for individuals who are otherwise at risk.
Intrauterine Devices (IUDs) and Injections: These methods, especially those containing progestin, may offer a safer hormonal option for individuals with certain contraindications to estrogen-based therapy, such as those with a history of blood clots.
Vaginal Estrogen: Low-dose vaginal estrogen is used for localized symptoms like vaginal dryness. It is generally considered safe as very little hormone is absorbed into the systemic circulation, and it can sometimes be an option even for breast cancer survivors.

Who Should Not Do Hormone Therapy? A Comparison Table


Condition	Menopausal HT with Estrogen	Gender-Affirming HT with Estrogen	Gender-Affirming HT with Testosterone
History of Breast Cancer	Yes, typically contraindicated due to cancer recurrence risk.	Yes, typically contraindicated, especially for estrogen-receptor positive cases.	Yes, typically contraindicated, though some studies on safety exist.
History of Blood Clots (DVT/PE)	Yes, due to increased risk of recurrence, especially with oral formulations.	Yes, due to significantly increased risk, especially with oral formulations.	Yes, due to potential increased risk, especially with certain pre-existing conditions.
History of Stroke or Heart Attack	Yes, due to increased cardiovascular risk, particularly in older individuals.	Yes, due to heightened risk factors, particularly after age 50.	Yes, risk is a concern, though data may vary depending on individual factors.
Active Liver Disease	Yes, risk of worsening liver function.	Yes, potential for liver damage with high doses.	Yes, requires monitoring due to potential liver impact.
Undiagnosed Vaginal Bleeding	Yes, requires investigation to rule out serious conditions before treatment.	N/A	N/A
Pregnancy	Yes, hormone therapy is not for pregnant individuals.	Yes, strictly contraindicated.	Yes, strictly contraindicated.

The Critical Importance of Medical Evaluation

Before ever starting hormone therapy, a thorough evaluation by a qualified healthcare provider is non-negotiable. This process includes a detailed review of your personal and family medical history, as well as a discussion of your specific health goals and symptoms. It is vital to disclose any history of cancer, cardiovascular events, blood clots, or liver issues. Your doctor can help you weigh the benefits and risks based on your unique health profile.

For those who are not candidates for HT, or for whom the risks are too high, there are many alternative therapies available. For menopausal symptoms, options include non-hormonal medications, lifestyle changes, and herbal remedies. For transgender individuals, alternative approaches can also be discussed with a specialist. Open and honest communication with your medical team is the best way to ensure your treatment plan is both safe and effective.

For more information on menopause and hormonal health, you can consult the official North American Menopause Society website for evidence-based resources: The Menopause Society.

Conclusion: Prioritizing Safety in Hormone Therapy

The decision to pursue hormone therapy is highly personal and must be made in collaboration with a healthcare provider. While HT can offer immense relief for a range of symptoms, it is not a universally safe option. Serious pre-existing conditions, including a history of certain cancers, blood clots, heart attack, stroke, or liver disease, generally serve as contraindications. For many, alternative therapies and lifestyle adjustments can provide effective relief without the associated risks. By prioritizing a thorough medical evaluation, you can ensure that you receive the safest and most appropriate care for your health needs.

Frequently Asked Questions

A family history of breast cancer does not automatically exclude you from hormone therapy, but it does require a careful risk-benefit analysis with your doctor. If you have a known genetic predisposition, such as a BRCA mutation, your risk may be higher. Your doctor will weigh your risk factors before making a recommendation.

Yes, the delivery method can significantly affect your risk. Oral estrogen pills are associated with a higher risk of blood clots than transdermal methods like patches, gels, or sprays, which bypass the liver's first-pass metabolism.

Absolutely. Non-hormonal options include lifestyle changes, such as diet and exercise, as well as prescription medications like certain antidepressants that can reduce hot flashes. Vaginal moisturizers can also help with dryness. Your doctor can help you explore these options.

No, transgender individuals with a history of blood clots are at increased risk for recurrence, especially with estrogen therapy. A doctor may recommend a lower-risk delivery method, alternative medications, or continued anticoagulation, depending on the individual case.

For individuals with severe symptoms who cannot take HRT due to contraindications, a healthcare provider can discuss alternative therapies, including medications specifically approved for hot flashes and other symptoms. Behavioral changes and psychological support can also be beneficial.

Anyone with hormone-sensitive cancer, a history of blood clots, or active liver disease is typically advised against hormone therapy for gender transition, much like the contraindications for menopause therapy. Close medical supervision and a thorough risk assessment are necessary.

Guidelines from medical organizations suggest that starting hormone therapy before age 60 or within 10 years of menopause is associated with a more favorable risk-benefit profile. Starting later or after a decade of menopause may increase cardiovascular risks.