What laboratory assessments are recommended prior to initiating hormone replacement therapy (HRT)?

Laboratory Assessments Required Prior to Initiating Hormone Replacement Therapy

Prior to initiating hormone replacement therapy (HRT), a comprehensive laboratory assessment should include complete blood count, urinalysis, serum electrolytes (including calcium and magnesium), blood urea nitrogen, serum creatinine, glucose, lipid profile, liver function tests, iron studies, and thyroid-stimulating hormone. 1

Core Laboratory Tests

Essential Baseline Tests

• Complete blood count (CBC) - To assess for anemia or polycythemia
• Comprehensive metabolic panel:
  • Serum electrolytes (sodium, potassium, calcium, magnesium)
  • Blood urea nitrogen (BUN)
  • Serum creatinine
  • Glucose
  • Liver function tests (AST, ALT, bilirubin)
• Lipid profile - Total cholesterol, LDL, HDL, triglycerides
• Thyroid-stimulating hormone (TSH) - To rule out thyroid dysfunction
• Iron studies - Serum iron, ferritin, transferrin saturation

Hormone-Specific Tests

• Baseline hormone levels relevant to the specific HRT being considered:
  • For testosterone replacement: Serum testosterone level 1
  • For estrogen/progesterone: Follicle-stimulating hormone (FSH) and estradiol (E2) to confirm menopausal status 2

Additional Assessments Based on HRT Type

For Testosterone Replacement

• Prostate-specific antigen (PSA) - Mandatory before initiating testosterone therapy 1
• Digital rectal examination - To assess prostate health 1
• Hematocrit or hemoglobin - To monitor for polycythemia 1

For Estrogen/Progesterone Replacement

• Mammography - To exclude breast malignancy 2
• Pap smear - Based on standard screening guidelines

Cardiovascular Risk Assessment

• Blood pressure measurement including orthostatic changes 3
• Assessment of cardiovascular risk factors - Particularly important as HRT may impact cardiovascular health 4

Monitoring Schedule After Initiating HRT

For Testosterone Replacement

1. First follow-up: 1-2 months after initiation
2. Subsequent monitoring: Every 3-6 months for the first year, then yearly
3. Each visit should include:
   • Assessment of symptomatic response
   • Monitoring for side effects (sleep apnea, voiding symptoms)
   • Digital rectal examination
   • Blood tests: Serum testosterone, PSA, hematocrit/hemoglobin 1

For All HRT Types

• Regular monitoring of the specific parameters that were assessed at baseline
• Adjustment of therapy based on clinical response and laboratory values

Important Considerations and Pitfalls

• Timing matters: The risk-benefit profile of HRT differs markedly based on age, time since menopause, and comorbidity status 5
• Cancer history: HRT may be contraindicated in certain cancer types (e.g., breast cancer, endometrial stromal sarcoma) 6
• Fluid retention: Use HRT cautiously in patients with congestive heart failure or renal insufficiency 1
• Polycythemia risk: Monitor hematocrit/hemoglobin closely with testosterone therapy as levels may increase significantly 1
• Prostate health: Regular monitoring of PSA and prostate examination is essential with testosterone therapy 1

By following this structured laboratory assessment approach before initiating HRT, clinicians can identify contraindications, establish baseline values for monitoring, and optimize the safety profile of hormone replacement therapy.