This is the exact list we wish every woman walking into a perimenopause appointment had with her. It works whether your clinician is NAMS-certified or a generalist. Bring it printed. The act of having it on paper changes the conversation.
Goal: leave with an evidence-based decision, not a deflection.
The 12 questions
- Confirm training: "Are you menopause-society certified, and how recently did you update your HRT protocols?"
- Position-statement alignment: "Do you follow the 2022 NAMS position statement on HRT for symptomatic women under 60?"
- Timing window: "Based on my symptoms and timing, am I in the window where the risk-benefit ratio favors HRT?"
- Delivery preference: "What's your view on transdermal versus oral estrogen for my profile?"
- Progesterone choice: "If I have a uterus, would you prescribe micronized progesterone rather than synthetic progestin? Why or ohy not?"
- Dose philosophy: "What's the lowest effective dose you'd consider starting me at, and how would we titrate?"
- Symptom targeting: "Beyond hot flashes, which of my symptoms (sleep, mood, cognition, joint pain, sexual function) do you expect HRT to address?"
- Monitoring schedule: "What's your follow-up schedule for the first 12 months — labs, symptom reviews, mammogram?"
- Risk-personalization: "Given my personal and family history, what's the calculated risk-benefit, and how does it compare to the population numbers?"
- Exit plan: "What's the protocol if I want to taper off in 5-7 years, and how do we make that decision together?"
- Local-symptom track: "If systemic HRT isn't right for me, what's your view on vaginal estrogen for genitourinary symptoms? (It has a different risk profile.)"
- Lifestyle layering: "What lifestyle interventions amplify HRT's effects in your experience — and which ones do you consider essential alongside it?"
The 4 labs to request
1. FSH (Follicle-Stimulating Hormone)
Confirms menopausal status. Often elevated above 30 mIU/mL in menopause. Less useful in perimenopause where it fluctuates — but worth the baseline.
2. Estradiol (E2)
Baseline ovarian output. Useful for trending once HRT begins. Levels under 30 pg/mL are typical post-menopause; HRT typically aims for 50-100 pg/mL on transdermal.
3. TSH + Free T4
Perimenopause and hypothyroidism share many symptoms. Rule out the thyroid story before assuming the hormone story.
4. Lipid panel + fasting glucose / HbA1c
Baseline cardiometabolic risk affects HRT decision-making. Modern HRT may improve cardiovascular markers when started in the right window — measure to see.
One more thing. If your clinician dismisses any of these questions, asks why you're "obsessing" about hormones, or quotes the 2002 WHI uncritically — book a second opinion with a NAMS-certified clinician. The North American Menopause Society maintains a public directory at menopause.org/for-women/find-a-menopause-practitioner. The directory is free. The conversation is worth the trip.