How would you approach hormone replacement therapy for perimenopause in a patient with increased risk factors for VTE?

Like many medical choices, this decision involves weighing trade-offs—specifically, the risk of venous thromboembolism (VTE) versus the burden of severe menopausal symptoms. If we focus only on VTE risk (and set aside the trade-offs related to menopausal symptoms and the controversial issue of breast cancer risk), the ASH thrombophilia guidelines provide the following recommendations:

1. Women with a family history of VTE and low-risk thrombophilia (factor V Leiden or prothrombin G mutation) considering hormone replacement therapy (HRT).

• • Recommendation: offer HRT (estrogen only or combined estrogen + progestin therapy).
  • Decision model (Thrombophilia Calculator): Agrees with this recommendation. The model is not meaningfully altered by pati...

In addition to Dr. @Dr. First Last answer, the lowest effective dose via the transdermal route is generally felt to be safest. I would highly recommend the 2024 ASH Education Program articles in the category "Sex Hormones, Contraceptives, and Thrombotic Risk: Where Are We Now?"