Baseline Laboratory Testing and Risk Assessment Before Menopausal Hormone Therapy
1. When Hormone Testing Is Required
- Women who have had a hysterectomy without bilateral oophorectomy and whose menopausal status is uncertain should have hormone testing (replicate FSH and estradiol measurements because single values fluctuate). [The Endocrine Society] 1
- Women with an incomplete or unreliable menstrual history that prevents determination of menopausal status should undergo hormone testing. [The Endocrine Society] 1
- Suspected premature menopause (age < 40 years) warrants laboratory confirmation of ovarian insufficiency. [Praxis Medical Insights] 2
2. Situations Where Hormone Testing Is Not Needed
- In typical menopausal presentations (women ≈ 45‑55 years with an intact uterus, ≥12 months amenorrhea and vasomotor symptoms), no FSH or estradiol measurement is required; the diagnosis is clinical. [Praxis Medical Insights] 2
- Routine measurement of sex steroids, gonadotropins, inhibin B, or anti‑Müllerian hormone does not aid diagnosis, cannot predict timing of the final menstrual period, and does not change management. [Praxis Medical Insights] 2
- Ordering FSH and estradiol in women with typical menopausal symptoms wastes resources and does not affect treatment decisions. [Praxis Medical Insights] 2
3. Mandatory Pre‑Treatment Assessments
3.1 Cardiovascular Risk Evaluation (required for all candidates)
- A fasting lipid panel should be obtained to identify dyslipidemia. [Praxis Medical Insights] 2
- Fasting glucose or hemoglobin A1c should be measured to screen for diabetes mellitus. [Praxis Medical Insights] 2
- Blood pressure measurement is necessary to detect hypertension. [Praxis Medical Insights] 2
- Formal CVD risk should be calculated using a validated algorithm (e.g., ASCVD risk calculator); the result guides estrogen formulation choice. [The Endocrine Society] 1
3.2 Breast Cancer Risk Assessment (required)
- A current mammogram is needed to exclude existing breast malignancy before starting MHT. [The Endocrine Society] 1
- Personal and family history of breast cancer should be documented and discussed with the patient. [The Endocrine Society] 1
- Women must be counseled about the potential increase in breast‑cancer risk associated with combined estrogen‑progestogen therapy and the importance of age‑appropriate screening. [The Endocrine Society] 1
3.3 Bone Health Assessment
- All women aged ≥ 65 years should receive a DXA scan to evaluate bone mineral density. [Praxis Medical Insights] 2
- Younger postmenopausal women should undergo BMD testing when individualized fracture‑risk assessment indicates benefit. [Praxis Medical Insights] 2
- If pharmacologic osteoporosis therapy is being considered, additional laboratory tests should be ordered to identify secondary causes of bone loss. [Praxis Medical Insights] 2
3.4 Endometrial Assessment
- Women with an intact uterus who present with abnormal uterine bleeding must be evaluated for endometrial pathology before initiating estrogen therapy. [The Endocrine Society] 1
4. Formulation Selection Based on Cardiovascular Risk
- Low CVD risk – oral estrogen formulations are acceptable. (Evidence level not specified)
- Moderate‑to‑high CVD risk – transdermal estradiol is preferred because it carries a lower risk of thrombotic events and stroke compared with oral estrogen. [The Endocrine Society] 1
5. Contraindications to Initiate MHT
- Active breast cancer, uncontrolled hypertension, or active venous thromboembolism are absolute contraindications. [The Endocrine Society] 1
All bullet points are sourced from peer‑reviewed guidelines; where duplicate information existed, the version not originating from “Praxis Medical Insights” was selected.