What baseline laboratory and screening studies should be obtained before initiating hormone replacement therapy in a menopausal woman?

Baseline Laboratory and Screening Studies Before Initiating HRT

No routine laboratory testing is required before starting hormone replacement therapy in most menopausal women—the decision is based on clinical assessment, not lab values. 1, 2

Essential Clinical Assessment (Not Laboratory)

Before ordering any tests, you must first screen for absolute contraindications through history and physical examination: 1, 3

• Personal history of breast cancer (absolute contraindication) 1, 2
• History of venous thromboembolism or pulmonary embolism (absolute contraindication) 1, 3
• History of stroke or coronary heart disease/myocardial infarction (absolute contraindication) 1, 3
• Active liver disease (absolute contraindication) 1, 2
• Known or suspected estrogen-dependent neoplasia (absolute contraindication) 3
• Antiphospholipid syndrome or positive antiphospholipid antibodies (absolute contraindication) 1, 2
• Thrombophilic disorders (absolute contraindication) 3

Required Screening Studies

1. Mammography

• Current age-appropriate mammography per standard screening guidelines is the only universally required test before HRT initiation 3, 4
• This screens for occult breast cancer, which is an absolute contraindication 3

2. Blood Pressure Measurement

• Measure baseline blood pressure because menopause elevates BP and hypertension worsens the HRT risk-benefit ratio 3
• Hypertension is a relative contraindication requiring careful consideration 2

3. Uterine Status Confirmation

• Determine whether the patient has an intact uterus (by history or imaging if uncertain) 1, 2
• Women with an intact uterus must receive combined estrogen-progestogen therapy to prevent endometrial cancer 1, 2
• Women post-hysterectomy can use estrogen-alone therapy, which does not increase breast cancer risk 1

Optional/Conditional Laboratory Tests

FSH and Estradiol: Only When Menopausal Status Is Uncertain

• Do NOT routinely measure FSH or estradiol in women with clear clinical menopause (age ≥45 with ≥12 months amenorrhea) 1, 2
• Measure FSH/estradiol only when menopausal status is uncertain: 1, 2
  • Women <60 years with ≤12 months of amenorrhea
  • After chemotherapy-induced amenorrhea
  • When switching from tamoxifen to an aromatase inhibitor 1
• Menopause is a clinical diagnosis based on age and amenorrhea pattern, not laboratory confirmation 3

Lipid Panel: Reasonable in High-Risk Patients

• Consider baseline lipid panel to assess cardiovascular risk, particularly in smokers or women with other cardiovascular risk factors 3
• This helps with risk stratification but does not determine HRT eligibility 3

Liver Function Tests: Only If Clinical Suspicion

• Order liver function tests only if clinical suspicion of liver disease exists (not routinely) 3
• Active liver disease is an absolute contraindication 1, 2

Tests That Are NOT Indicated

• Pelvic ultrasound: Cannot reliably exclude malignancy and is not required 4
• Pap smear: Not specifically required for HRT initiation (follow standard cervical cancer screening guidelines) 4
• Routine endometrial assessment: Not needed before starting HRT in asymptomatic women 1
• Coagulation studies: Not routinely indicated unless personal/family history suggests thrombophilia 2
• Bone density testing: Not required before HRT initiation (HRT is not indicated solely for osteoporosis prevention) 5, 1

Common Pitfalls to Avoid

• Do not delay HRT while waiting for "confirmatory" FSH levels in a clearly menopausal woman—this wastes time and money 1, 3
• Do not order extensive laboratory panels (thyroid, comprehensive metabolic panel, etc.) unless clinically indicated for other reasons 1, 3
• Do not initiate HRT solely for chronic disease prevention (osteoporosis, cardiovascular disease) in asymptomatic women—this carries a USPSTF Grade D recommendation (recommend against) 5, 1
• Never prescribe estrogen-alone therapy to women with an intact uterus—this dramatically increases endometrial cancer risk 1

Practical Algorithm for Pre-HRT Assessment

1. Confirm clinical menopause (age ≥45 + ≥12 months amenorrhea) or surgical menopause 1, 3
2. Screen for absolute contraindications through history (breast cancer, VTE, stroke, CAD, liver disease, thrombophilia) 1, 3
3. Measure blood pressure 3
4. Verify current mammography is up to date 3, 4
5. Confirm uterine status (intact vs. hysterectomy) 1, 2
6. Consider lipid panel if cardiovascular risk factors present 3
7. Measure FSH/estradiol only if menopausal status uncertain 1, 2
8. Proceed with HRT if no contraindications identified 1, 3