Menopausal hormone therapy begins not with deciding on a medication, but with sorting out, beforehand, “whether this treatment suits you right now.” In the clinic, the more someone comes having resolved on treatment because their symptoms are hard, the more they ask, “Can’t I just get the medication right away without testing?”—but the pre-start evaluation is half of safe and effective treatment. Even for the same menopausal symptoms, the recommended approach changes depending on medical history and physical condition, and for some, treatment may be postponed or another approach recommended. In this article, I’ll explain step by step which items are examined before starting after deciding on hormone therapy, and why those tests are needed.
Before medication, history-taking builds the framework of treatment
The start of hormone therapy is not a testing machine but a conversation. By hearing the recent menstrual pattern, the timing of the last period, and which menopausal symptoms are most distressing, the administration method, cycle, and direction of diagnosis are determined. Because whether to use estrogen alone or progestogen together depends on whether the uterus is present, past surgical history is always confirmed.
Internal medical conditions and surgical history also change medication choice. For example, if there is a past history of venous thrombosis or liver disease, a route other than oral medication may be considered. So the one thing I emphasize most in the clinic is this.
If you are currently taking any medications and supplements, please tell me all of them without omission. A single medication that seems trivial can change the method and safety of hormone therapy.
If you’re curious about the mechanism of menopausal symptoms itself, reading along with an article explaining the causes and mechanisms of menopausal body changes makes it easier to understand why the history-taking items are structured this way.
We first sort out indications and contraindications
The core of pre-start evaluation is simultaneously weighing “whether treatment is permissible” and “whether treatment is helpful.” The North American Menopause Society position statement (2022) and the Korean Society of Menopause clinical guideline (2019) commonly recommend that hormone therapy be approached with a tailored strategy after confirming the individual’s indications and contraindications.
Generally, in the following cases, systemic estrogen therapy is carefully reconsidered or avoided.
- A past history of breast cancer or estrogen-dependent tumors
- Vaginal bleeding of unknown cause
- Venous thrombosis, pulmonary embolism, or recent stroke·coronary artery disease
- Active liver disease
- Possibility of pregnancy
Here, a contraindication is closer to a signal of “this route and dose may be risky, so let’s find another method” than to “absolutely not allowed.” Family history—especially family history related to breast cancer and thrombosis—is also evaluated together to individualize the risk. If you want to know more about whether hormone therapy is needed in your situation, a Q&A explaining when hormone therapy is needed is also a helpful reference.
Bone health evaluation: bone density and bone metabolism markers
Because bones weaken rapidly when estrogen decreases after menopause, confirming bone status before starting is an important axis of hormone therapy evaluation. As emphasized in the original article, for underweight women, women who have undergone oophorectomy, and women with early menopause, a bone density test is an item that especially must not be omitted. This is because their period of estrogen deficiency is long or deep, so the risk of bone loss is relatively greater.
Bone density is usually measured by dual-energy X-ray absorptiometry (DXA), and it creates a baseline that tracks both current osteoporosis·osteopenia status and treatment effect. In addition, using bone metabolism marker tests helps gauge the speed at which bone is made and resorbed, aiding in assessing changes before and after treatment.
If you’re curious about how osteoporosis itself is diagnosed, you can see more detail in an article organizing how osteoporosis is diagnosed and an article on the diagnosis·prevention of menopause and osteoporotic fractures. Hormone therapy is reported to help slow menopausal bone loss, and the starting point of that is precisely the pre-start bone evaluation.
Breast and gynecological basic evaluation
Breast and uterine evaluation is a basic check to safely start hormone therapy. Because estrogen and progestogen act on the breast and uterine lining, before starting we confirm breast status and recommend a check-up including mammography at an appropriate time. This is not a procedure to block you from getting treatment, but a process to create a baseline to compare subsequent changes.
For women who have a uterus, we always make sure to address whether there is vaginal bleeding of unknown cause. This is because post-menopausal bleeding is not a period and is a signal that needs separate evaluation. If you’re curious about this part, I recommend reading the article that post-menopausal bleeding is not a period.
Blood pressure measurement and basic metabolic status confirmation are also done together. In cases of uncontrolled hypertension or high cardiovascular risk, the treatment route and timing are decided more carefully. You can check which items are bundled in menopausal screening in the care guide organizing menopausal screening items.
If menopausal symptoms are affecting your daily life, don’t delay evaluation and consultation.
Consult about pre-hormone-therapy testsWe also examine the mind and sleep together
Something that cannot be left out of pre-hormone-therapy evaluation is psychiatric·psychological·neurological assessment. During menopause, depressed mood, anxiety, insomnia, and neurological symptoms commonly appear together, and distinguishing whether these symptoms are due to hormonal change or a separate problem governs the direction of treatment.
In the clinic, we differentiate depressive symptoms with depression scales (such as BDI) and insomnia and neurological symptoms through history-taking. In my clinical experience, it is not uncommon for depression·insomnia that was dismissed as “it’s just menopause” to actually be a state needing active treatment. If necessary, I may also recommend a collaborative consultation with psychiatry.
| Evaluation area | What is examined | Why it’s examined before starting |
|---|---|---|
| History·medical history | Menstrual pattern, menopausal symptoms, surgical history, medications | To decide administration method and cycle |
| Indications·contraindications | Breast cancer·thrombosis·liver disease·bleeding of unknown cause | To select treatment feasibility and route |
| Bone health | Bone density (DXA), bone metabolism markers | To assess bone loss risk and set a baseline |
| Breast·gynecology | Mammography, endometrial·bleeding evaluation | Safe start and a basis for later comparison |
| Mind·sleep | Depression scale, insomnia·neurological symptoms | To differentiate accompanying symptoms and decide treatment scope |
The reason for examining areas this way separately is that menopausal symptoms do not come from only one cause.
The “tailored treatment” that test results create
The purpose of pre-start evaluation is ultimately to design a treatment that fits one person. Even for the same hot flashes, the method and route recommended differ for someone with weak bones, someone with thrombosis risk, and someone with accompanying depression. The North American Menopause Society (2022) reports that the benefits and risks of hormone therapy vary depending on age and the time elapsed since menopause, which is why before starting we confirm “at what age, how long since menopause, and what risks one carries.”
As noted in the original article, even among those who think they don’t need treatment because they exercise, live regularly, and moderate their eating habits, there are in fact many cases where evaluation and treatment are helpful. This is because lifestyle management does not reverse hormonal deficiency itself. So I recommend confirming the self-judgment of “I don’t need treatment” once through a check-up.
If you’re worried about the safety of treatment, a Q&A on the risks and safety of hormone therapy, and if you’re curious about the overall treatment process, the menopausal hormone care guide, are good to review together.
In closing
The tests performed before post-menopausal hormone therapy encompass basic physical health diagnosis and psychiatric·psychological·neurological analysis, and through these an individually tailored treatment is created. Testing is not a procedure that delays treatment, but a guide to start more safely and accurately. If you have symptoms, rather than judging alone, I hope you receive proper treatment after sufficiently consulting with an obstetrics-gynecology specialist.
Written by: Lee Dong-hee, Director · Obstetrics and Gynecology Specialist · View medical staff profile
First published November 7, 2023 · Last reviewed May 30, 2026
References: The North American Menopause Society, 2022 Hormone Therapy Position Statement (2022), American College of Obstetricians and Gynecologists, Management of Menopausal Symptoms (2014), Korean Society of Menopause Clinical Guideline for Menopausal Hormone Therapy (2019)
This article is intended to provide general health information and does not replace individual diagnosis or treatment. If you have symptoms, please consult through a medical visit.