💊 Why Do People Worry About the Liver and HRT?

It’s understandable that patients and clinicians may be cautious when it comes to hormone therapy and liver health — especially in the context of historical guidance or past diagnoses (e.g., breast cancer, endometriosis, thrombosis). 

Here’s what contributes to the concern:

• Oral estrogen is processed by the liver. When taken by mouth, estrogen undergoes first-pass metabolism, meaning it is absorbed through the gut and filtered through the liver before entering the bloodstream. This can slightly elevate liver enzymes and increase production of clotting factors, which historically raised safety concerns.
• Early hormone therapy formulations (especially higher-dose oral options) had less favorable safety profiles and may still influence current perceptions.
• People with a history of liver disease or hormone-sensitive cancers are often advised to avoid oral estrogen, leading to confusion or fear around any HRT use.  There aren't clear guidelines about transdermal estrogen, however it isn't metabolised by the liver!

The liver plays a key role in detoxification, hormone clearance, and cholesterol regulation — so even small changes in liver tests during HRT use can feel like a red flag.

🧘🏽‍♀️ What We Now Understand — Reassurance & Clarity

Transdermal (patch, gel, spray) estrogen bypasses the liver entirely. It delivers hormones directly into the bloodstream without stimulating liver enzyme production or affecting clotting pathways. This makes it the preferred route for:

• Women with raised LFTs
• A history of liver or clotting disorders
• Slight elevations in liver enzymes while on HRT — particularly if using oral formulations — are not uncommon and are often not harmful. The key is monitoring and adjusting the route or dose as needed.

The benefits of HRT, including symptom relief, metabolic support, and improved quality of life, often outweigh minor, non-progressive changes in liver markers — especially with individualised care.

🧬 Why Slightly Raised Liver Function Tests Matter — Without Causing Alarm

Slight elevations in liver function tests (typically less than twice the upper limit of normal) are common, often benign, and not necessarily a sign of serious liver disease. That said, they can serve as an early signal — a gentle prompt to pause, check in, and consider factors that may be influencing liver health over time.

🌿 What Could Be Behind Mild LFT Elevations?

• Hormonal changes: In perimenopause or postmenopause, shifts in metabolism and inflammatory tone can subtly affect liver markersMetabolic health: Slightly raised LFTs are sometimes associated with non-alcoholic fatty liver (NAFLD), especially in the presence of insulin resistance, central weight gain, or PCOS.
• Medications or supplements: Even commonly used treatments — such as oral estrogen (HRT), certain antidepressants, or herbal remedies — can nudge liver enzymes upward. Transdermal estrogen is typically liver-neutral.
• Transient stressors: Viral illness, alcohol, or even strenuous exercise can cause temporary shifts that normalize on follow-up.

🔍 Why We Take Note (But Don't Panic)

While these small elevations are rarely urgent, they’re worth noticing because they:

Provide an opportunity to support long-term liver wellbeing.

Help identify modifiable risks (like metabolic factors or medication sensitivities).

Allow us to tailor care — especially when hormones, mood, or energy are in flux.

In essence, slightly raised LFTs can be seen as the liver waving a small flag, not sounding an alarm. It’s not about worrying — it’s about listening early, supporting gently, and avoiding future strain.

✅ A Calm, Thoughtful First Step

If LFTs are mildly elevated:

• Repeat the test in 1–3 months — they often settle.
• Review medications and supplements (including HRT type).
• Check alcohol intake and overall metabolic health (e.g., glucose, lipids, iron studies).
• Consider abdominal ultrasound if levels persist or clinical features suggest fatty liver or biliary concerns.

❤️ Reassurance and Recovery

The liver is remarkably resilient. With awareness and small changes — such as optimizing hormones, improving metabolic markers, or adjusting medications — liver enzymes often return to normal. And even if they don’t immediately, many people with mild, stable LFT changes live well without progression to liver disease.