Starting hormone replacement therapy (HRT) involves a medical evaluation, blood work, a conversation about your goals and health history, and then choosing a delivery method that fits your life. Whether you’re seeking relief from menopause symptoms or pursuing gender-affirming hormone therapy, the process follows a similar path: get assessed, get prescribed, and follow up regularly to fine-tune your dosage.
The First Step: Medical Evaluation
HRT begins with a thorough consultation. Your provider will review your personal and family medical history, current symptoms, lifestyle factors, and what you’re hoping to get from treatment. For menopause-related HRT, the severity of symptoms like hot flashes, sleep disruption, and vaginal dryness plays a major role in whether hormones are the right fit. For gender-affirming care, the conversation centers on your transition goals and overall health.
During this visit, expect a physical exam. For people with a uterus, that typically includes a pelvic exam and possibly a Pap smear or pelvic ultrasound to check for any issues with the uterus, ovaries, or cervix. Your provider will also check your blood pressure, weight, and general cardiovascular health. If you’re over 40, a recent mammogram is usually part of the baseline workup.
Blood Work You’ll Need Before Starting
Before writing a prescription, your provider orders a set of baseline labs. These aren’t just checking hormone levels. They’re making sure your body can safely process the hormones you’ll be taking. A typical panel includes:
- Hormone levels: Estrogen, progesterone, and testosterone, depending on your situation. These establish your starting point.
- Liver and kidney function: Your liver and kidneys metabolize and clear hormones from your body, so they need to be working well.
- Lipid profile: HDL, LDL, and triglycerides. Hormone therapy can shift cholesterol levels, so your provider needs a baseline to track changes.
- Blood glucose and A1C: These screen for insulin resistance or diabetes, which can affect how your body responds to hormones.
- Complete blood count (CBC): Checks red and white blood cells and platelets to rule out anemia or other blood abnormalities.
- Thyroid function: Thyroid hormones interact with your broader hormonal balance, so T3, T4, and TSH are often included.
For men starting testosterone therapy, a prostate-specific antigen (PSA) test screens for prostate issues before treatment begins. Some providers also order a bone density scan, particularly for postmenopausal women at risk for osteoporosis. Not every test on this list is required for every patient. Your provider will tailor the panel to your age, sex, and risk factors.
Conditions That May Rule Out Standard HRT
Certain health conditions make standard estrogen-based HRT too risky. These include a history of estrogen-sensitive breast cancer, a history of uterine cancer (unless you’ve had a hysterectomy with no remaining disease), active or past deep vein thrombosis or pulmonary embolism, a known blood clotting disorder like Factor V Leiden, and a history of stroke. If you have a clotting disorder, transdermal estrogen (patches or gel) may still be an option since it bypasses the liver and carries a lower clot risk than pills. Your provider will weigh the specifics of your history before making a decision.
Choosing a Delivery Method
Once you’re cleared, you and your provider choose how you’ll take your hormones. There’s no single best method. It comes down to your symptoms, medical history, and personal preference.
Tablets are the most common form. You take them once a day, and they’re straightforward. The downside is that oral estrogen passes through the liver first, which slightly raises the risk of blood clots compared to other routes.
Skin patches stick to the lower body and release hormones gradually. You change them every few days, depending on the brand. Patches deliver a steady dose and avoid the liver-first-pass issue, making them a better choice for people with elevated clot risk or liver concerns.
Gels and sprays are increasingly popular. Estrogen gel is smoothed onto the skin once a day, and sprays are applied to the inner arm or thigh. Both are absorbed through the skin and offer the same liver-bypassing advantage as patches. Testosterone for any patient group is also typically prescribed as a gel.
For menopause-related vaginal dryness specifically, low-dose vaginal estrogen (creams, rings, or tablets applied locally) treats the symptom directly without significantly raising hormone levels throughout the body.
Bioidentical vs. Traditional Formulations
“Bioidentical” means the hormones are chemically identical to what your body produces naturally. Many FDA-approved HRT medications already contain bioidentical hormones, so the term doesn’t automatically mean a specialty product. Some compounding pharmacies market custom-mixed bioidentical hormones based on saliva testing, but research from the Mayo Clinic shows that saliva hormone levels don’t reliably reflect blood levels or correspond to symptoms.
Compounded hormones also aren’t held to the same quality standards as commercially manufactured medications, meaning dose and purity can vary between batches. There’s no evidence that compounded bioidentical hormones work better or are safer than standard FDA-approved options. If “bioidentical” matters to you, know that many mainstream prescriptions already fit the definition.
What Happens in the First Few Months
Your body needs time to adjust. Common early side effects of estrogen-based HRT include breast tenderness, bloating, headaches, and irregular bleeding or spotting. These typically settle within the first three months as your body adapts to the new hormone levels. If side effects persist or become bothersome, your provider can adjust the dose or switch the delivery method.
For gender-affirming hormone therapy, changes unfold on a more specific timeline. On feminizing HRT (estrogen-based), decreased libido and softer skin typically appear within one to three months. Breast growth and body fat redistribution begin around three to six months. Thinning of body and facial hair takes longer, usually six to twelve months. On masculinizing HRT (testosterone-based), increased skin oiliness and the cessation of menstrual periods often happen within one to six months. Voice deepening, facial hair growth, and body fat redistribution start between three and six months. Increased muscle mass builds over six to twelve months. These are averages, and individual experiences vary widely based on genetics, age, and dosage.
Follow-Up Appointments and Monitoring
Your first follow-up is typically scheduled about three months after starting HRT or after any dosage change. This visit checks whether your symptoms are improving, whether side effects are manageable, and whether your blood work looks healthy on the new regimen. Your provider will recheck hormone levels along with liver function and lipid panels to make sure everything is tracking in the right direction.
After that initial three-month check, most people move to annual reviews. Each yearly visit includes a blood pressure and weight check, a review of side effects, updated blood work, and a conversation about whether continuing HRT still makes sense for you. You’ll also be encouraged to stay current on screening mammograms and cervical screening if appropriate for your age. The risk-benefit balance of HRT can shift over time, so these annual reviews aren’t just routine. They’re how you and your provider decide together whether to continue, adjust, or eventually stop treatment.
Getting Started: Practical Next Steps
If you’re experiencing menopause symptoms that interfere with daily life, or you’re seeking gender-affirming care, the starting point is the same: book an appointment with a provider who prescribes HRT. For menopause, that’s typically a gynecologist or your primary care provider. For gender-affirming care, look for an endocrinologist or a clinic that specializes in transgender health. Many informed-consent clinics allow you to begin the process without a therapist’s referral, though requirements vary by location.
Come prepared with a list of your current medications, your family’s health history (particularly any history of breast cancer, blood clots, or heart disease), and a clear sense of the symptoms you want to address. The more specific you can be about what you’re experiencing and what you hope to achieve, the easier it is for your provider to match you with the right formulation and dose from the start.