In short
- A decision making appointment, not a prescription visit.
- Usually no hormone test needed. Over 45 the diagnosis is clinical, and levels swing too much to be reliable.
- Your history picks the route. Migraine, clot history, surgery and family history decide patch versus tablet and which progestogen.
- You get the absolute numbers, not a newspaper headline about breast cancer.
- Including no. Where hormone therapy is not appropriate, you hear what is.
Treatment Overview
What this appointment decides
Three things, in order.
- Whether your symptoms are hormonal.
- Whether hormone therapy suits your medical history.
- Which preparation, route and dose make sense for you.
None of those are answered by a hormone panel, which is why one is usually not ordered.
Why blood tests are mostly unhelpful here
In women over 45, perimenopause is diagnosed from the pattern of your cycle and your symptoms. Oestradiol and FSH fluctuate widely from week to week during the transition, so a normal result can be reassuring and completely wrong.
The tests that do add something are thyroid function, a full blood count with ferritin, and a pregnancy consideration where relevant. Those are ordered because they change management.
What decides which preparation you get
| Factor | What it changes |
|---|---|
| Migraine, particularly with aura | Favours transdermal oestrogen over tablets |
| Personal or family history of blood clots | Transdermal, since it showed no excess clot risk even with a clotting mutation |
| Raised body mass index | Also favours transdermal |
| Whether you still have a uterus | Decides whether progesterone is needed at all |
| Heavy or irregular bleeding | A hormonal coil can provide the progestogen and manage the bleeding |
| Family history of breast cancer | Raises the baseline, which changes the absolute numbers you are given |
| Dryness as the main symptom | Local vaginal oestrogen may be all you need |
The numbers you should be given
Per 1000 women over five years, starting between 50 and 59, on combined oestrogen and progestogen: about 3 more breast cancers, 2.5 more coronary events, 2.5 more strokes, 3 more pulmonary emboli, 1.5 fewer hip fractures, and 5 fewer deaths from any cause.
On oestrogen alone the picture is different again, with fewer coronary events, fewer breast cancers and fewer deaths.
You should have those figures before deciding, adjusted for your own baseline risk. That is what this appointment provides.
When the answer is no, or not yet
- Breast cancer or another oestrogen dependent cancer.
- Unexplained vaginal bleeding that has not been investigated.
- Active liver disease.
- Untreated clot or stroke history.
- Age 65 or older having never taken it, where starting is advised against.
In each of those cases you get the alternatives rather than a shrug: local vaginal treatment, non hormonal medicines with trial evidence, and treatment aimed at sleep and mood.
Who Is a Good Candidate?
- You have menopausal or perimenopausal symptoms and want to know whether hormone therapy fits your case.
- You want the actual risk figures rather than a headline.
- You have been told to just wait it out and are not satisfied with that.
- You have a complicating factor such as migraine, a clot history or a family history of breast cancer and need it factored in properly.
- You are already on HRT and want the choice of preparation reviewed.
- You have unexplained vaginal bleeding. That is investigated before any hormone decision.
- You want compounded bioidentical hormones or saliva hormone testing. Neither is used here.
- You need contraception or fertility advice, which belongs with a gynaecologist.
What Happens During the Consultation
-
1
Symptoms and cycle
What has changed and when, how your cycle has behaved, and which symptoms cost you most. Flushes, sleep, mood, concentration, dryness and libido, ranked by impact rather than listed.
-
2
The history that decides the route
Medication, surgery, migraine pattern, clotting history, and family history of breast cancer and heart disease. Blood pressure, weight and smoking. Screening status for breast and cervix.
-
3
Targeted tests only
Thyroid function, full blood count with ferritin, and a pregnancy consideration where relevant. Oestradiol and FSH are generally not ordered, because they do not decide anything.
-
4
A recommendation with numbers
Which route and preparation, why, and the absolute risks and benefits at your age and with your history. Or a clear no with the alternatives set out.
Program Structure & Follow-Up
What happens after this appointment
- If hormone therapy fits, you leave with a prescription, instructions, what to expect in the first weeks including irregular bleeding, and a review booked at three months. Details on the treatment page.
- If local treatment is enough, vaginal oestrogen is started, which many women can use even where systemic therapy is unsuitable.
- If hormones are not appropriate, you get the non hormonal options that have trial evidence behind them rather than a list of supplements.
- If sleep or mood is the dominant problem, that is assessed and treated in its own right.
What you should expect to be told
- Which symptoms hormone therapy treats well, and which it does not.
- Your absolute risk figures, not relative ones.
- That the trial data everyone quotes used older oral preparations, and that modern transdermal oestradiol with micronised progesterone is expected to look better rather than worse.
- That there is no fixed stopping date, and that the decision is reviewed annually.
Benefits, Limits & Safety
What a proper consultation gives you
- A diagnosis based on your cycle and symptoms rather than a misleading blood test.
- A preparation chosen around your specific risks rather than whatever is standard.
- Real numbers, so the decision is yours and informed.
- The treatable imitators excluded, particularly thyroid disease and iron deficiency.
The limits
- No test can confirm or exclude perimenopause, so certainty is not on offer.
- Hormone therapy does not treat everything in midlife. Sleep disorders, depression and thyroid disease need their own treatment.
- It is not used to prevent heart disease.
What is not used here
- Compounded bioidentical hormones, which are not regulated for dose, purity or effectiveness.
- Saliva or blood hormone monitoring to set the dose. Symptom response guides it.
- Testosterone for general wellbeing in women.
What you leave with
A clear recommendation with the absolute numbers for your age and history, or a clear no with the alternatives. Not a prescription issued before the risks were discussed.
Which tests are done
Thyroid function, full blood count with ferritin, and a pregnancy consideration where relevant. Oestradiol and FSH are generally not ordered because they do not decide anything.
When hormone therapy is not started
Breast or other oestrogen dependent cancer, unexplained vaginal bleeding, active liver disease, untreated clot or stroke history, and first starting at 65 or older.
Cost & Program Investment
Cost depends on which tests are needed and whether treatment follows, so a single number on a website would be misleading. You get the full figure in the consultation before anything is arranged, and there are no charges you have not been told about.
Frequently Asked Questions
Usually not. Over 45 the diagnosis is clinical, and oestradiol and FSH swing widely week to week during the transition, so a normal result can be reassuring and completely wrong. Thyroid function, blood count and ferritin are ordered instead, because they change management.
The absolute numbers for your age. Per 1000 women over five years starting at 50 to 59 on combined therapy: about 3 more breast cancers, 2.5 more coronary events, 3 more pulmonary emboli, 1.5 fewer hip fractures and 5 fewer deaths from any cause.
Mostly on your risk factors. Migraine, a clot history or a raised body mass index all favour transdermal, which showed no excess clot risk in meta-analysis even in women with a clotting mutation.
If you still have a uterus, yes, to protect the womb lining. Micronised progesterone is used. Where bleeding is heavy, a hormonal coil can serve as the progestogen and manage the bleeding at the same time.
Local vaginal oestrogen is usually the better answer. It acts where it is applied and many women can use it even when systemic therapy is unsuitable for them.
Often yes, and it is discussed with your actual numbers. Family history raises your baseline risk, which raises the absolute effect, but the relative effect of hormone therapy appears similar across women.
You get the alternatives that have evidence: cognitive behavioural therapy, certain SSRIs and SNRIs, gabapentin, oxybutynin and newer medicines developed specifically for flushes. Not a list of supplements.
No. They are mixed to order and are not regulated for dose, purity or effectiveness. Regulated body identical preparations, transdermal oestradiol with micronised progesterone, are used instead.
No. Dose is guided by symptom response. Hormone levels fluctuate and do not predict who feels better, and saliva testing has no role.
Long enough to take a proper history, examine you where needed, go through your risk factors and give you the numbers. This is a decision making appointment, not a five minute prescription.
Yes. There is no fixed commitment and no fixed stopping date. The decision is reviewed at three months and then annually against your symptoms and your age.
It depends on which tests are needed and whether treatment follows, so a single figure would be misleading. You get the full cost in the consultation before anything is arranged.
Evidence
Where this information comes from
Every figure on this page is taken from the sources below. All of them are free to read, so you can check them yourself.
This page is general medical information and does not replace a personal consultation. Trial results are averages across large groups, not a prediction for any one person.