What Lab Work Should Be Done Before Starting HRT?

Starting hormone replacement therapy (HRT) is a major decision that can significantly improve quality of life, especially during perimenopause, menopause, and andropause. But before diving in, it’s important to understand that hormones don’t function in isolation; they interact with your thyroid, liver, adrenals, and metabolic systems. That’s why comprehensive lab work is a non-negotiable first step to ensure safe, effective, and personalized care.

Here’s a deeper look into what lab work should be done—and why it matters.

Sex Hormone Panel

This panel gives insight into your current hormonal landscape and helps determine what type, dose, and delivery method of HRT may be best.

Key Labs to Include:

• Estradiol (E2): The main form of estrogen in premenopausal women. Levels fluctuate in perimenopause and drop significantly in menopause. Monitoring is crucial for estrogen-based HRT.

• Progesterone: Helps regulate mood, sleep, uterine lining, and counterbalances estrogen. Low levels are common in perimenopause.

• Testosterone (Total and Free): Essential for libido, energy, bone density, and muscle mass in both women and men. Free testosterone shows what’s biologically active.

• DHEA-S (Dehydroepiandrosterone Sulfate): An adrenal hormone that serves as a precursor to estrogen and testosterone. Often low in chronically stressed individuals.

• Sex Hormone-Binding Globulin (SHBG): A protein that binds hormones. High levels mean fewer free hormones available to your tissues.

Why it matters: These results help determine baseline deficiencies or imbalances and tailor your HRT strategy. For example, high SHBG may indicate that even if your total testosterone looks “normal,” your free (active) testosterone may be too low.

Thyroid Function Panel

Many symptoms of thyroid dysfunction (fatigue, brain fog, weight gain, mood changes) overlap with hormone imbalance. Supporting thyroid health is essential to a successful HRT plan.

Recommended Tests:

• TSH (Thyroid Stimulating Hormone): A signal from the brain to the thyroid—high levels suggest an underactive thyroid.

• Free T4 and Free T3: Measure active thyroid hormone levels, not just storage. Free T3 is the most metabolically active.

• Thyroid Peroxidase (TPO) and Thyroglobulin Antibodies (TGAb): Identify autoimmune thyroid disease (like Hashimoto’s), which can impact hormone metabolism.

Why it matters: Hormones like estrogen influence thyroid hormone transport and conversion. If your thyroid isn’t functioning optimally, HRT may not feel as effective, or could even worsen symptoms.

Comprehensive Metabolic Panel (CMP)

This panel assesses liver and kidney function, electrolyte balance, and glucose metabolism—all of which influence how hormones are processed and cleared.

Includes:

• Liver Enzymes (AST, ALT): The Liver metabolizes hormones. Elevated levels may indicate the liver is overburdened.

• Kidney Function (BUN, Creatinine): Ensures the kidneys can safely clear excess hormones or metabolites.

• Glucose, Calcium, Sodium, Potassium, Chloride: Helps evaluate hydration, blood sugar stability, and metabolic status.

Why it matters: If your liver or kidneys aren’t functioning well, it can impact how you metabolize HRT, increasing the risk of side effects.

Lipid Panel

Hormones—especially estrogen—impact lipid metabolism. Baseline cholesterol levels help assess cardiovascular risk and monitor changes after initiating hormone replacement therapy (HRT).

Includes:

• Total Cholesterol

• HDL (High-Density Lipoprotein)

• LDL (Low-Density Lipoprotein)

• Triglycerides

Why it matters: Estrogen typically improves HDL and lowers LDL. However, some hormone therapies may raise triglycerides, which is essential to watch in patients with insulin resistance or metabolic syndrome.

Complete Blood Count (CBC)

This test evaluates red and white blood cells, hemoglobin, and hematocrit.

Why it matters: Helps detect anemia, infection, or inflammation that could be contributing to fatigue, dizziness, or immune dysfunction—symptoms that overlap with hormone imbalance.

Vitamin & Nutrient Assessment

While not always standard, many providers recommend checking these levels before or during HRT:

• Vitamin D: Crucial for bone health, hormone synthesis, and immune function.

• Vitamin B12 and Folate: Support nervous system health and energy.

• Magnesium and Zinc: Cofactors for hormone production and adrenal support.

• Ferritin: Reflects iron stores. Low ferritin levels can mimic the fatigue and hair loss associated with hormone imbalance.

Why it matters: Deficiencies can make HRT less effective or exacerbate symptoms. For instance, low Vitamin D can blunt testosterone function.

Glucose and Insulin Testing

Insulin resistance is common in midlife and can affect how your body responds to hormones.

• Fasting Glucose

• Hemoglobin A1c (HbA1c): Reflects 3-month blood sugar control.

• Fasting Insulin: Assesses insulin resistance even before glucose levels rise.

Why it matters: Estrogen can improve insulin sensitivity, but unrecognized insulin resistance can worsen with certain therapies. It’s crucial to address both.

Inflammatory and Adrenal Markers (Optional, but Valuable)

• High-sensitivity CRP (hs-CRP): A marker of systemic inflammation.

• Cortisol (AM serum or saliva): To assess adrenal stress.

Why it matters: Inflammation and stress blunt hormone receptor sensitivity, meaning your body may not “hear” the hormones even when you’re supplementing them.

Final Thoughts: Lab Work Isn’t Just a Form—It’s a Foundation

Getting comprehensive lab work before starting HRT allows for:

• Safe prescribing practices

• Personalized treatment planning

• A reliable baseline to track progress

• Early detection of underlying issues

• Better long-term outcomes

If your provider isn’t ordering labs—or is only checking one or two hormones—it may be time to seek a more integrative, root-cause approach to care.