Hormone replacement therapy: essential medical records to gather
Hormone replacement therapy is not a supplement regimen you walk into a clinic and request after a 15-minute telehealth call.
It is a prescription intervention with documented effects on cardiovascular, thromboembolic, oncologic, and bone physiology, and the prescribing clinician needs a specific dataset before a single milligram of estradiol is dispensed. Roughly 1 in 4 women in the perimenopausal-to-postmenopausal transition will be considered for systemic MHT, yet most arrive at the consultation with incomplete records, forcing the clinician to either delay initiation or order the missing workup after the visit. The waste of time is avoidable. This is the medical record set you should have assembled, organized, and physically (or digitally) on hand before the appointment.
A hormone prescription without a documented cardiovascular, cancer, and thromboembolic risk profile is a clinical liability, not a shortcut.
Reproductive and Surgical History
The first cluster of questions your clinician will run through has nothing to do with hormones and everything to do with your anatomy and prior surgical decisions. MHT dosing and formulation depend almost entirely on whether you still have a uterus, whether you still have ovaries, and how long it has been since your last spontaneous menstrual period.
Document the following before the visit:
- Date of last menstrual period (or approximate duration of amenorrhea if postmenopausal).
- Surgical history, with particular attention to hysterectomy (total vs. supracervical) and oophorectomy (unilateral vs. bilateral).
- Current uterine status. An intact uterus on systemic estrogen requires co-prescription of a progestogen for endometrial protection. Estrogen-only therapy in a woman with a uterus is contraindicated due to the established risk of endometrial hyperplasia and carcinoma.
- History of endometriosis, fibroids, or any estrogen-sensitive gynecologic condition.
- Pregnancy history and any complications (preeclampsia, gestational diabetes, hypertensive disorders) — these are relevant late-life cardiovascular risk markers.
- Prior hormone therapy use, including oral contraceptives, fertility treatments, or any previous menopausal hormone therapy, with approximate dates and formulations if known.
If a previous oophorectomy was performed before age 45, this is a distinct clinical scenario. Premature ovarian insufficiency carries its own risk-benefit calculation and is not managed identically to natural menopause at age 52.
Baseline Physical Metrics and Laboratory Panel
Vital signs and a baseline metabolic panel are not optional. They establish the starting point against which all follow-up data will be compared and flag contraindications that may be clinically silent.
| Parameter | Required value/format | Clinical purpose |
|---|---|---|
| Blood pressure (mmHg) | Systolic/diastolic, both arms if previously abnormal | Hypertension is a relative contraindication and affects oral vs. transdermal route selection |
| Height and weight | Metric preferred; calculate BMI (kg/m²) | Obesity modifies VTE and breast cancer risk; affects dosing decisions |
| BMI | kg/m², calculated | BMI >30 kg/m² increases baseline VTE risk on oral estrogen |
| Liver function tests (ALT, AST, GGT) | Serum values with reference ranges | Oral estrogen undergoes first-pass hepatic metabolism; hepatic impairment is a contraindication |
| Renal function (creatinine, eGFR) | Serum creatinine, estimated GFR | Required for clearance-based dose adjustment |
| Fasting glucose and HbA1c | Fasting plasma glucose, HbA1c % | Metabolic baseline; diabetes is a CV risk modifier |
| Lipid panel | Total cholesterol, LDL, HDL, triglycerides | Establishes cardiovascular risk profile; oral estrogen raises triglycerides |
| Hemoglobin / CBC | g/dL or g/L with reference range | Rules out anemia from abnormal uterine bleeding patterns |
Blood pressure, BMI, and a lipid panel are the three non-negotiable data points. Without them, route of administration cannot be safely selected.
Cardiovascular and Thromboembolic Risk Assessment
This is where the most consequential prescribing decisions are made. Oral estrogen carries a documented increase in venous thromboembolism risk; transdermal estradiol, which bypasses hepatic first-pass metabolism, has a substantially lower VTE signal in head-to-head observational data. The route of administration is therefore not a patient preference question — it is a risk-stratified clinical decision.
Required documentation:
- Personal history of deep vein thrombosis (DVT) or pulmonary embolism (PE), with dates and treatment details.
- Family history of VTE in first-degree relatives under age 50, which may indicate inherited thrombophilia.
- Personal history of stroke, transient ischemic attack, or known cerebrovascular disease.
- Known thrombophilia (Factor V Leiden, prothrombin gene mutation, antiphospholipid antibody syndrome) — if previously tested.
- Current smoking status, quantified in pack-years where possible. Smoking compounds VTE and cardiovascular risk in an additive, not multiplicative, manner.
- Established coronary artery disease, peripheral arterial disease, or prior myocardial infarction.
- Migraine with aura — a relative contraindication to oral estrogen due to ischemic stroke signal.
If any of the above are positive, the default clinical choice is transdermal 17β-estradiol (patch, gel, or spray) at the lowest effective dose, not oral conjugated equine estrogens or oral estradiol.
Diagnostic Imaging and Cancer Screening Records
Hormone-sensitive tissue responds to exogenous estrogen. The breast and endometrium are the two organs that demand active surveillance before systemic therapy begins and on a defined interval thereafter.
Imaging and screening documentation required:
- Mammogram: within the past 12 months for women age 40 and above, or per local screening protocol. A mammogram older than 24 months is not adequate baseline data. Any prior biopsies, benign proliferative changes, or atypical hyperplasia findings must be reported.
- Cervical cancer screening (Pap smear ± HPV testing): current per national screening interval (typically 3 years for cytology alone, 5 years for co-testing in women age 30+).
- Bone mineral density (DEXA scan): indicated at age 65, or earlier in the presence of risk factors (low body weight, prior fracture, glucocorticoid use, family history of osteoporosis). MHT has a documented fracture-reduction benefit; the DEXA result helps frame whether that benefit is a primary therapeutic target.
- Pelvic ultrasound: not routinely required, but indicated if abnormal uterine bleeding is reported in perimenopause or early postmenopause. Any unexplained bleeding on established MHT requires evaluation, not dose adjustment.
Mammography, cervical screening, and (where indicated) DEXA are the three imaging prerequisites. An abnormal mammogram is an absolute contraindication until cleared by a breast specialist.
Establishing a Timeline for Follow-up and Monitoring
MHT is not a "prescribe and forget" intervention. Clinical guidelines — including the 2023 Menopause Society practice guidelines and the 2025 Korean Society of Menopause updated MHT guidelines — converge on a structured follow-up schedule.
| Time point | Required assessment |
|---|---|
| Baseline (pre-initiation) | Full history, BP, BMI, labs, imaging as above |
| 3 months after initiation or regimen change | Symptom response, side effect review, BP, bleeding pattern assessment |
| 12 months | Annual review: BP, BMI, lipid panel, mammography (if due), symptom reassessment, dose adjustment as needed |
| Every 1–2 years thereafter | Continued benefit-risk re-evaluation; consideration of lowest effective dose |
The first 3-month review is not a courtesy call. It is the window in which side effects (breast tenderness, breakthrough bleeding, headache, mood change) typically manifest, and in which the dose, route, or progestogen component may require modification. The annual review reassesses the original indication: have vasomotor symptoms resolved? Has the patient crossed a new clinical threshold (new diagnosis, new medication, age >60 or >10 years since menopause) that alters the benefit-risk ratio?
After age 60, or after 10 years since the final menstrual period, the cardiovascular and breast cancer risk profile of systemic MHT begins to shift unfavorably. This does not mandate automatic discontinuation, but it mandates a documented re-evaluation of dose, route, and continued indication at every annual review.
The Bottom Line
Initiating hormone replacement therapy on an incomplete record set is a documented safety gap, not a clinical efficiency. The non-negotiable data set before the first prescription includes: full reproductive and surgical history with uterine status confirmed, baseline BP, BMI, and metabolic panel, cardiovascular and VTE risk profile, current mammogram and cervical screening, and (where relevant) DEXA. With this assembled, the prescribing clinician can match the formulation and route to the individual risk profile, select transdermal over oral when the VTE signal warrants it, and schedule the 3-month and annual reviews that catch adverse effects before they become clinical events. Without it, the consultation ends with a lab order sheet, not a prescription — and that is the correct outcome.