Timing matters. The strongest evidence supports starting HRT within 10 years of your last period or before age 60, the "window of opportunity." Outside that window, benefits and risks shift, and we'll have a different conversation.
✓You are likely a fit if
Most peri- and postmenopausal women without contraindications benefit from HRT.
- Perimenopausal symptoms: hot flashes, night sweats, sleep disruption, mood changes, brain fog, joint pain, vaginal dryness, decreased libido.
- You are within 10 years of menopause or under age 60.
- Surgical menopause (oophorectomy) at any age, HRT is strongly recommended unless contraindicated.
- Premature ovarian insufficiency (under 40), HRT is recommended at least until average age of menopause.
- Bone density concerns, family history of osteoporosis, T-score declining.
- You have an intact uterus and can take progesterone with estrogen (or a hysterectomy and don't need it).
×Hard contraindications, we will not prescribe
If any of these apply, systemic HRT is off the table at OPTML. Vaginal estradiol alone may still be appropriate, we'll advise.
- Personal history of breast cancer (any subtype, any time).
- Personal history of estrogen-dependent cancer (endometrial, certain ovarian).
- Active or recent venous thromboembolism (VTE), DVT or PE.
- Known thrombophilia (Factor V Leiden, prothrombin mutation, etc.) without hematology clearance.
- Active liver disease with significant impairment.
- Undiagnosed abnormal vaginal bleeding, needs workup before any prescription.
- Recent (< 6 months) stroke, MI, or unstable cardiovascular disease.
- Pregnancy (rare in this population but disqualifying).
- Known hypersensitivity to estradiol or progesterone.
!Conditions that require extra care
Manageable, but the protocol is adjusted (transdermal preferred over oral, lower starting dose, more frequent monitoring).
- Migraine with aura, transdermal route only; no oral estrogen.
- Family history of breast cancer, not a hard contraindication; risk-benefit conversation.
- Personal history of DVT/PE more than 5 years ago, hematology evaluation; transdermal only.
- High BMI, transdermal preferred; oral estrogen has higher VTE risk.
- Smoking, transdermal only; we'll discuss cessation.
- Gallbladder disease, transdermal preferred over oral.
- Endometriosis or fibroids, HRT is possible but symptoms may flare.
- Started menopause > 10 years ago, age > 60, benefits/risks shift; we'll discuss whether HRT still makes sense.
Pre-start labs we require
Upload labs from the past 6 months or use the OPTML Optimized Health (Female) panel.
| Lab | Why |
|---|
| FSH, LH, estradiol | Confirm menopausal status (especially in perimenopause). |
| Progesterone | Cycle context if still cycling. |
| TSH | Thyroid mimics menopausal symptoms. |
| CMP | Liver and kidney baseline. |
| Lipid panel | Cardiometabolic baseline. |
| HbA1c, fasting glucose | Glycemic baseline. |
| CBC | Anemia and general health. |
| DHEA-S, free & total testosterone | Adrenal and androgen baseline (often low in perimenopause). |
Up-to-date mammogram and Pap are required, we'll ask for the date but won't request the report. If you've had abnormal vaginal bleeding, you'll need a workup with your gynecologist before starting.
What to disclose at intake
All of these change the protocol or the route.
- Personal cancer history of any kind, even decades ago.
- Family history of breast, ovarian, endometrial cancer (first-degree relatives).
- Any personal or family history of blood clots.
- Migraine pattern, with or without aura.
- Smoking status.
- Last menstrual period (if perimenopausal).
- Date of last mammogram and Pap.
- Any prior HRT, brand, route, dose, and how it went.
- All current medications and supplements.