Smoking Weed and Using HRT: Does Cannabis Change the Menopause Hormone Therapy Conversation?

“I used to smoke cigarettes, but now I mostly smoke weed. Does that matter if I want to use hormone therapy?”

A patient recently raised a question that I suspect many women have but may not think to ask.

It is a good question because discussions around menopausal hormone therapy often focus on whether someone has a history of blood clots, breast cancer, cardiovascular disease, or abnormal bleeding. But smoking history matters too. And today, that history may include more than cigarettes.

Cannabis use has become increasingly common among women in perimenopause and menopause, particularly for sleep, anxiety, mood, and pain. Yet we have far more evidence about cigarette smoking and hormone therapy than we do about cannabis. So the answer requires some nuance.

The Case

Consider a woman in her early 50s experiencing significant menopausal symptoms: hot flashes, disrupted sleep, mood changes, brain fog, vaginal dryness, and declining quality of life.

She is interested in menopausal hormone therapy. She previously smoked cigarettes but quit several years ago. She does, however, smoke cannabis regularly, primarily for sleep and stress.

Her question is simple: Does smoking cannabis mean she cannot use estrogen?

The answer is not automatically no. But it does change the questions I want to ask.

First: Smoking Is Not an Automatic Contraindication to Hormone Therapy

Cigarette smoking alone does not automatically prohibit menopausal hormone therapy. However, current smoking is an important modifier of the overall risk-benefit calculation because smoking independently raises cardiovascular risk.

The route of estrogen also becomes especially important. Oral estrogen passes through the liver before reaching the systemic circulation. Smoking can increase hepatic estrogen metabolism and may reduce some of the therapeutic effects of oral estrogen.

Transdermal estrogen, such as an estrogen patch, bypasses much of this first-pass liver metabolism. That is one reason transdermal estrogen is often preferred in women with smoking-related risk factors who are otherwise appropriate candidates for hormone therapy.

Why the Route of Estrogen Matters

Not all estrogen therapy behaves the same way. This distinction is one of the most important parts of individualized menopause care.

Oral Estrogen

Oral estrogen is absorbed through the gastrointestinal tract and passes through the liver. That first-pass effect influences several liver-produced proteins involved in coagulation and hormone metabolism. Oral menopausal hormone therapy is associated with a higher risk of venous thromboembolism compared with no hormone therapy.

Transdermal Estrogen

Transdermal estrogen is absorbed through the skin and enters the systemic circulation more directly. Because it avoids first-pass hepatic metabolism, it generally has less impact on coagulation pathways.

A 2026 Danish nationwide analysis cited in the clinical evidence reviewed for this case found that oral hormone therapy was associated with higher risks of venous thromboembolism, ischemic stroke, and myocardial infarction. Transdermal hormone therapy was not associated with increased thrombotic risk overall in that analysis, although individual formulations and regimens still matter.

That does not mean an estrogen patch is risk-free. It means route is part of the clinical decision.

What If You Used to Smoke Cigarettes?

A former smoking history does not automatically mean hormone therapy is inappropriate. But I still want to know how long the patient smoked, how much she smoked, when she stopped, whether she has hypertension, diabetes or insulin resistance, her lipid profile, family cardiovascular history, any clotting history, and her current age and time since menopause.

The goal is not to label someone as “high risk” simply because she smoked years ago. The goal is to understand her overall cardiovascular and thrombotic risk profile before choosing a treatment.

In appropriate candidates, especially symptomatic women under age 60 or within about 10 years of menopause onset, the benefit-risk balance of hormone therapy may still be favorable.

Then Comes the Modern Question: What About Weed?

This is where the evidence becomes much thinner.

Cannabis smoke is not identical to cigarette smoke. Cannabis contains THC, CBD, and other cannabinoids, while cigarettes contain nicotine and thousands of other compounds.

But the act of burning plant material produces many overlapping combustion products. Cannabis smoke can contain carbon monoxide, polycyclic aromatic hydrocarbons, airway irritants, and carcinogenic and mutagenic combustion products.

Studies also suggest that smoking cannabis can affect CYP1A enzymes involved in drug metabolism. Some data suggest cannabis smoking may produce substantial carbon monoxide and tar exposure because users often inhale more deeply and hold the smoke longer than cigarette smokers.

Could Cannabis Smoke Affect Estrogen Metabolism?

Possibly. But this is where we need to separate biologic plausibility from actual clinical evidence.

Both tobacco smoke and cannabis smoke can induce CYP1A enzyme activity. These enzymes participate in the metabolism of many medications and hormones. There are also laboratory data suggesting marijuana smoke condensate can influence estrogen metabolism.

So mechanistically, there is a plausible reason to wonder whether smoking cannabis could alter estrogen exposure.

But here is the important distinction: No clinical study has directly established that smoking cannabis changes the effectiveness, cardiovascular risk, blood-clot risk, or dosing requirements of menopausal hormone therapy.

At this point, claiming that cannabis affects HRT exactly the same way cigarettes do would go beyond the available evidence.

Cannabis Use During Menopause Is Common, But the Research Is Early

Cannabis use among women going through menopause is not rare.

In one U.S. survey of 258 women who used cannabis, 79% reported using it for menopause-related symptoms. The most common reasons included sleep, mood, and anxiety.

Another Canadian survey of 1,485 women found that about one-third were current cannabis users, and many reported using cannabis for sleep, anxiety, and joint discomfort.

But surveys tell us what women are doing, not necessarily whether those treatments are effective or safe. At this point, controlled trials have not demonstrated that cannabis effectively treats vasomotor symptoms such as hot flashes, and there are no studies directly evaluating how cannabis use interacts with menopausal hormone therapy.

So What Do I Ask My Patients?

I no longer think the question should simply be: “Do you smoke?”

I want to know more:

• Do you currently smoke cigarettes?
• Did you smoke in the past?
• Do you smoke cannabis?
• Do you vape cannabis or nicotine?
• How frequently do you use these products?
• Are you using edibles instead of inhaled cannabis?
• What symptoms are you trying to treat with cannabis?

Those details matter. For example, inhaled cannabis introduces combustion-related respiratory and cardiovascular considerations that an oral edible would not introduce in the same way.

That does not automatically make edibles harmless. Cannabinoids have their own pharmacologic effects, but the exposure is different.

What Would I Consider Before Prescribing HRT?

For a woman with a current or previous smoking history who is considering menopausal hormone therapy, I would look at the whole picture rather than making the decision based on one risk factor alone.

Cardiovascular Risk

Blood pressure, lipids, insulin resistance, diabetes risk, family history, smoking history, and other cardiovascular factors.

Thrombotic Risk

Personal or family history of blood clots, thrombophilia, obesity, immobilization, and other risk factors.

Cancer History

Particularly breast and endometrial cancer history.

Liver Health

Active liver disease may change whether systemic hormone therapy is appropriate.

Uterine Status

A woman with an intact uterus generally needs endometrial protection with progesterone or another appropriate progestogen when using systemic estrogen.

Type of Symptoms

If symptoms are primarily vaginal or urinary, local vaginal estrogen and other targeted treatment options may be more appropriate than systemic therapy, depending on the individual situation.

Route of Estrogen

When systemic estrogen is appropriate and cardiovascular or thrombotic risk is a concern, transdermal estrogen may be preferable to oral estrogen.

The Bigger Lesson

The question is rarely simply: “Can I take estrogen?”

A better question is: What is the safest and most appropriate way for this particular woman to use estrogen, if she is a candidate at all?

That means considering her age, time since menopause, symptoms, uterine status, cardiovascular risk, clotting risk, cancer history, cigarette-smoking history, current cannabis use, and the route and dose of estrogen.

Medicine gets much more useful when we move away from blanket statements. “Smoking means you can never take hormones” is too simplistic. So is: “Weed is natural, so it doesn’t matter.”

The truth is somewhere in the middle. Cannabis smoke and cigarette smoke are not identical. But inhaling burned cannabis exposes the body to many of the same types of combustion products found in tobacco smoke.

We also do not yet have enough clinical research to tell women exactly how smoked cannabis interacts with menopausal hormone therapy. Until we do, cannabis use belongs in the conversation.

Bottom Line

Smoking cannabis does not automatically mean a woman cannot use menopausal hormone therapy. Neither does a remote history of cigarette smoking. But both are clinically relevant.

For women who are appropriate candidates for systemic hormone therapy and who have smoking-related cardiovascular considerations, the route of estrogen may matter significantly, with transdermal estrogen often favored over oral therapy.

And if you use cannabis, tell your clinician, not because you should expect judgment, but because the more complete the clinical picture, the better your care can be individualized.

For more information about Dr. Sadi’s approach to personalized care, visit the Meet Dr. Sadi page or explore the Hormone Replacement Therapy page.

Dr. Sadi Jimenez, ND
Dr. Sadi’s Wellness
Integrative Women’s Health & Metabolic Medicine
Los Angeles + Telehealth

Educational Disclaimer

This article is for educational purposes only and is based on a de-identified/composite clinical scenario. Details have been changed to protect patient privacy. It does not replace individualized medical evaluation or treatment. Menopausal hormone therapy decisions should be made with a qualified healthcare professional after reviewing individual risks, benefits, medical history, and treatment goals.

Selected Clinical References

1. Ruan X, Mueck AO. Impact of Smoking on Estrogenic Efficacy. Climacteric. 2015.
2. Shifren JL, Crandall CJ, Manson JE. Menopausal Hormone Therapy. JAMA. 2019.
3. Blondon M, Wiggins KL, Van Hylckama Vlieg A, et al. Smoking, postmenopausal hormone therapy and the risk of venous thrombosis: a population-based, case-control study. British Journal of Haematology. 2013.
4. Cho L, Kaunitz AM, Faubion SS, et al. Rethinking Menopausal Hormone Therapy: For Whom, What, When and How Long? Circulation. 2023.
5. Berggreen J, Pourhadi N, Wood-Kurland H, et al. Contemporary Menopausal Hormone Therapy and Thrombotic Disease: Nationwide Nested Case-Control Study. BMJ. 2026.
6. Page RL, Allen LA, Kloner RA, et al. Medical Marijuana, Recreational Cannabis, and Cardiovascular Health: A Scientific Statement From the American Heart Association. Circulation. 2020.
7. Anderson GD, Chan LN. Pharmacokinetic Drug Interactions with Tobacco, Cannabinoids and Smoking Cessation Products. Clinical Pharmacokinetics. 2016.
8. Mejia-Gomez J, Phung N, Philippopoulos E, Murphy KE, Wolfman W. The Impact of Cannabis Use on Vasomotor Symptoms, Mood, Insomnia and Sexuality in Perimenopausal and Postmenopausal Women: A Systematic Review. Climacteric. 2021.
9. Babyn K, Ross S, Makowsky M, Kiang T, Yuksel N. Cannabis Use for Menopause in Women Aged 35 and Over: A Cross-Sectional Survey on Usage Patterns and Perceptions in Alberta, Canada. BMJ Open. 2023.