A generation of women was told they "can't take HRT" based on the initial 2002 Women's Health Initiative results and a cautious post-WHI clinical culture. Two decades of re-analysis and new evidence have meaningfully shifted the eligibility picture. Most women with moderate-to-severe perimenopausal symptoms are candidates; the exclusions are narrower than commonly assumed.
Absolute contraindications
These are situations where HRT should not be started until the underlying issue is addressed: (1) unevaluated vaginal bleeding — must be worked up first to rule out endometrial pathology; (2) active or recent breast cancer; (3) active venous thromboembolism (DVT or PE) within the past year; (4) active liver disease or significant liver dysfunction; (5) known coronary heart disease in late postmenopause (the timing-hypothesis context matters here); (6) untreated severe hypertension; (7) pregnancy.
Relative contraindications — discuss, don't exclude
These require shared decision-making rather than automatic exclusion. (1) Family history of breast cancer — most non-BRCA family history does not preclude HRT; the absolute risk increase is modest. (2) Migraine with aura — historically taught as a strong contraindication; current evidence supports transdermal estradiol as acceptable. (3) Gallbladder disease — oral estrogen increases risk; transdermal does not. (4) Endometriosis or fibroids — manageable with appropriate progesterone strategy. (5) BRCA mutation carriers — careful conversation, not automatic exclusion, particularly for women who've had risk-reducing oophorectomy.
Workup before starting
A typical pre-HRT workup includes: thorough medical history with attention to VTE risk factors, breast cancer family history, and migraine pattern; baseline blood pressure; mammogram per age guidelines; pelvic exam if not recent; endometrial assessment if there's any abnormal bleeding history; baseline lipid panel; thyroid testing if symptoms overlap. Labs to confirm "menopausal status" (FSH) are generally not required if symptoms and cycle history are typical.
Timing — the most important factor
The strongest evidence supports HRT initiation within 10 years of the FMP or before age 60. In this window, cardiovascular outcomes are neutral-to-favorable, stroke risk is low with transdermal preparations, and symptom benefit is largest. Starting HRT for the first time more than 10 years after FMP carries higher cardiovascular risk and is generally not recommended unless symptoms are severe and other options have failed.
Form choice
For women with VTE risk factors (obesity, smoking, family history, migraine), transdermal estradiol (patch, gel, spray) is generally preferred over oral because it bypasses first-pass liver metabolism — VTE risk is much lower. Progesterone is still required if the uterus is present (micronized progesterone is well-tolerated; synthetic progestins are an alternative). Vaginal estrogen (low-dose tablets, rings, creams) for genitourinary symptoms has virtually no systemic absorption and few contraindications.
When to revisit eligibility
HRT eligibility is not a once-and-done decision. Review annually with your clinician, especially around milestones — new diagnoses, age 60 or 65, changes to risk factors. The duration question is also nuanced: there's no hard cutoff at 5 or 10 years on HRT. Continue as long as benefits outweigh risks for your individual situation.
Informational only — eligibility is a clinical decision requiring evaluation by a clinician trained in menopause care.