What tests are needed before starting HRT?

According to current NAMS guidelines, most women do not need extensive hormonal testing before starting hormone replacement therapy (HRT) — the evaluation is primarily clinical and focused on identifying any contraindications. The exact tests required depend on a patient's individual health history and should be determined by a prescriber.

The essential tests

• Blood pressure — Per published clinical guidelines, elevated blood pressure should be assessed and controlled prior to initiating systemic HRT, as uncontrolled hypertension is a modifiable risk factor for cardiovascular events.
• Breast screening — According to ACOG, women in routine mammography screening age groups should have a current breast imaging result on record before starting HRT. This does not delay initiation; it establishes a documented baseline.
• Pelvic exam if the uterus is present — Per published clinical guidelines, women with an intact uterus should be evaluated for unexplained abnormal uterine bleeding or structural concerns such as fibroids before the progestogen component of combined HRT is selected.
• Basic bloodwork — A standard panel including CBC, metabolic panel, and lipid panel is commonly ordered to assess for anemia, hepatic or renal conditions, and lipid levels. According to current NAMS guidelines, these results guide individualized prescribing decisions and are not typically a barrier to initiating therapy.

When additional tests may be indicated

• TSH (thyroid function) — Per published clinical guidelines, thyroid function testing may be appropriate when symptoms such as fatigue, weight changes, or mood disturbances overlap with menopausal symptoms, as thyroid dysfunction can present similarly.
• A1C or fasting glucose — Per the Endocrine Society, women with risk factors for diabetes or existing glucose dysregulation may benefit from baseline glucose assessment before starting HRT, as metabolic effects of specific formulations vary.
• Transvaginal ultrasound — According to ACOG, transvaginal ultrasound is indicated only when there is a history of unexplained uterine bleeding; it is not a routine pre-HRT requirement for all women.

What is generally not required

• Hormone level testing — According to current NAMS guidelines, serum estrogen and progesterone levels fluctuate significantly and are not reliable guides to dosing decisions. Current clinical practice bases HRT initiation on symptom presentation rather than laboratory hormone values.

A note on compounded formulations

If a prescriber recommends a compounded HRT formulation, more frequent monitoring of hepatic function or lipid levels may be incorporated into the follow-up plan at the prescriber's discretion. Compounded medications are not FDA-approved. They have not been reviewed by the FDA for safety, effectiveness, or quality. FDA-approved medications should be considered first when commercially available options meet patient needs.

Practical notes

Per published clinical guidelines, pre-HRT evaluation is designed to be straightforward for most candidates and is not intended to be a barrier to access. The scope of testing is individualized based on a patient's age, medical history, and symptom profile.

Whether HRT is appropriate depends on individual health factors that cannot be assessed through website content alone. A prescriber should determine the best approach — including which tests are needed — based on a patient's complete medical history.