How to Start HRT: Your First 90 Days, Step by Step

How do I start HRT? The six steps at a glance

Most women start HRT the same way, whatever their age or insurance. Here is the order, from the day you decide to your first review.

Not sure yet whether hormones are for you? Our guide on whether you need HRT helps you decide first.

• Step 1: Prepare. Track your symptoms for a few weeks and gather your health history.
• Step 2: Pick your door. Your own doctor, a menopause specialist or an online menopause service.
• Step 3: Have the visit. Talk through symptoms, history and goals. Hormone blood tests are rarely needed.
• Step 4: Get a plan. Usually a low dose of estrogen, plus progesterone if you have a uterus.
• Step 5: Start on day one. Learn where the patch goes, how to apply the gel or when to take the capsule.
• Step 6: Review at about three months. Your prescriber checks how you feel and adjusts the dose or route.

Still weighing HRT against other treatments? Our guide to menopause treatment options compares them side by side. Everything below assumes you've decided to try it.

Step 1: What to track and bring before you book

A good first visit runs on details, not on a perfect speech. A few weeks of notes give your prescriber far more to work with than memory alone.

• A symptom log. Note hot flashes, night sweats, sleep, mood and anything else that bothers you. Rate how much each one disrupts your day.
• Your period pattern. Write down the date of your last period and how your cycles have changed.
• No periods to track? Say why. A hysterectomy, a hormonal IUD or an endometrial ablation can all hide your stage. An ablation is a procedure that removes the lining of the uterus.
• Your personal history. Any past blood clot, stroke, heart attack, breast or uterine cancer, or liver disease.
• Family history. Breast, ovarian or uterine cancer, and blood clots in close relatives.
• Current medicines and supplements. Include herbal products and any hormone creams you already use.
• Recent screening. The date of your last mammogram and a recent blood pressure reading, if you have one.
• Your top goal. Better sleep, fewer hot flashes or relief from vaginal dryness. One clear priority shapes the plan.

You'll be asked about most of this anyway. Our page on getting an HRT prescription lists the questions prescribers usually ask.

Step 2: Who to see, from your own doctor to getting HRT online

Any licensed prescriber can start standard HRT. The best door is the one you can get through soon, with someone who listens.

• Your own doctor or gynecologist. A good fit if you have insurance and a clinician you trust. Our page on finding an HRT doctor covers how to ask.
• A menopause specialist. Worth it if your history is complicated or a first doctor said no. Our guide to finding menopause care explains where to look.
• An online menopause service. Often the fastest route, with a video or written visit and medicine mailed to your door. See our ranking of the best online HRT services.

Step 3: What happens at the first visit, and do I need blood tests first?

The first visit is mostly a conversation. Expect questions about your symptoms, your periods, your health history and what you most want to change.

Hormone blood tests are usually not part of it. The Menopause Society's 2022 position statement says serum hormone testing, meaning a blood test of hormone levels, is rarely needed.

The same statement calls saliva and urine hormone tests unreliable for setting a dose. If a clinic sells you one as step one, that's a reason to ask questions.

Age changes the picture. Under 45, and especially before 40, periods that stop or turn irregular can point to early menopause. Before 40 it is called premature ovarian insufficiency, meaning the ovaries slow down early.

Blood work matters there. FSH is a hormone that rises as the ovaries wind down. The 2024 international guideline, co-written by the American Society for Reproductive Medicine, sets two criteria. Your periods have been irregular or absent for at least 4 months, and one FSH result is above 25 IU/L.

Other checks are practical. A blood pressure reading is common. The estrogen labels also ask for yearly breast exams and a mammogram unless your clinician says otherwise.

You'll usually leave with a prescription or a short list of options. Our guide to perimenopause labs explains which tests help when the picture is unclear.

Step 4: What you'll most likely start on

Your plan has two parts at most. Estrogen treats the symptoms, and progesterone protects your uterus if you still have one.

Estrogen: patch, gel or pill

Estradiol is the main estrogen used in HRT. It is chemically the same as the estrogen your ovaries make.

Many prescribers start with a patch or gel. These are transdermal, meaning the hormone passes through your skin rather than through your liver first.

The Menopause Society notes that transdermal routes and lower doses may lower the risk of blood clots and stroke. Head-to-head trials proving it are still lacking.

A daily pill is also a standard choice. It suits women who would rather swallow something than stick or rub it on.

Starting doses are low. Labels for two common estradiol patches start at 0.025 or 0.0375 mg a day, depending on the brand.

The full chart by route lives in our HRT dosage guide. If you want to start gently, read how low HRT doses go.

Progesterone: only if you have a uterus

Estrogen alone can make the lining of the uterus, called the endometrium, overgrow. Progesterone prevents that. After a hysterectomy, you usually take estrogen alone.

Micronized progesterone is a common pick. It is sold as Prometrium and as generics. Micronized means ground into fine particles so your body absorbs it well.

Its FDA label lists one schedule for this use: a capsule at bedtime for 12 days in each 28-day cycle.

Prescribers also use a lower nightly dose every day. That is off-label, meaning outside the label's wording, but it is a common way to avoid a monthly bleed.

The Menopause Society notes that observational studies hint at a lower long-term risk of uterine cancer with continuous schedules than with cyclic ones.

If vaginal dryness is your only problem

Low-dose vaginal estrogen treats dryness and painful sex right where they happen. It comes as a cream, a small tablet or a soft ring. It is not meant to treat hot flashes.

Why FDA-approved products come first

Compounded hormones are mixed by a pharmacy and are not FDA-approved. The Menopause Society says they make sense only when a woman cannot tolerate an approved product. Preference alone, it says, is not a reason.

Step 5: Day one, and how to actually use it

The FDA labels and patient leaflets are surprisingly practical. Here is what they say for the common forms.

Estradiol patch

• Where. A clean, dry area of the lower belly or buttocks. Never on your breasts, and away from the waistline, where clothes can rub it off.
• How often. Most patches are changed twice a week. A few brands, such as Climara, are changed once a week.
• Pick fixed days. Monday and Thursday, for example. Put them in your phone calendar.
• Rotate. Wait at least a week before using the same spot again. Skip skin that is cut, red or irritated.
• Showers. The Vivelle-Dot leaflet says showering will not make the patch fall off.
• If it falls off. Press the same patch back on, or apply a new one somewhere else. Then keep your usual changing days.
• Throwing it away. Fold the sticky sides together and put it in a sturdy container out of children's reach. Don't flush it.

Our guide to hormone patches for menopause covers brands and everyday wear in more depth.

Estradiol gel

• Where. It depends on the brand. Divigel goes on the upper thigh, switching sides each day. EstroGel is spread thin over one arm, from wrist to shoulder.
• When. Once a day, around the same time.
• Keep it off. Your face, your breasts and in or around the vagina.
• Dry time. Let it dry before you dress. Divigel's label says not to wash the spot for one hour.
• After. Wash your hands. If you put sunscreen or lotion on that skin, ask about timing, since sunscreen changed absorption with some estrogen gels.
• Missed dose. Don't double up. Divigel's leaflet says to skip it if your next dose is less than 12 hours away.

Estradiol pill

Swallow one tablet a day. Tying it to a habit you already have, like brushing your teeth, makes it easy to remember.

Progesterone capsule

• Bedtime. The Prometrium label says to take it at bedtime, because some women become very drowsy or dizzy.
• Driving. The label advises caution with driving or machinery until you know how it affects you.
• Peanut allergy. Prometrium contains peanut oil, so it is not for anyone allergic to peanuts. Mention any allergy before you fill it.
• Trouble swallowing. The label suggests taking it with a glass of water while standing.

Weeks 1 to 8: what you'll feel first, and which start-up effects are normal

Hot flashes and night sweats tend to move first. Better sleep often follows, partly because nights get quieter.

For when each symptom usually improves, from hot flashes to bone, see how long HRT takes to work.

Speed depends on dose. In the trials behind the Vivelle patch, the two higher doses beat a placebo, or dummy treatment, by week 4. The two lower doses took until about week 6.

The Menopause Society notes that lower doses may take 6 to 8 weeks to bring relief. A quiet first month on a low dose is not a sign that HRT has failed.

Some effects show up early while your body adjusts. These are the ones the label leaflets list most often.

• Breast tenderness. Sore or swollen breasts, listed for both estrogen and progesterone.
• Spotting or irregular bleeding. Covered in the next section, because it gets the most questions.
• Bloating and cramps. Abdominal bloating appears on the leaflets for both hormones.
• Headache. One of the most frequent complaints in the label trials.
• Drowsiness from progesterone. The reason it is taken at night.
• Skin redness. Mild irritation where a patch sits.

These often fade over the first weeks to months. If one stays bothersome, your prescriber can change the dose or the route.

Our guide to HRT side effects covers each one and how long it tends to last. For the why behind them, see how HRT works.

Keep your symptom log going through these weeks. Comparing week 8 with your notes from before you started is the most useful data your prescriber will get.

Weight and body shape change more slowly, if at all. Our guide to HRT results walks through that timeline.

Bleeding after starting HRT: what's expected and what isn't

Bleeding is the most common early worry. What counts as normal depends on your schedule.

• Cyclic progesterone. If you take progesterone for part of each month, a period-like bleed usually comes after each course ends. That bleed is expected.
• Continuous combined. If you take both hormones every day, irregular spotting is common in the first months. For many women it fades with time.
• Estrogen alone after a hysterectomy. With no uterus, there is no bleeding to expect.

The Menopause Society's 2022 statement draws a clear line. On combined therapy, meaning estrogen plus a progestogen such as progesterone, unscheduled bleeding that starts more than 6 months in should be checked.

When to call your prescriber right away

The FDA patient leaflets for estrogen list these warning signs as reasons to call your healthcare provider right away.

• Breasts. A new breast lump.
• Bleeding. Unusual vaginal bleeding.
• Vision or speech. Changes in how you see or speak.
• Headache. A sudden, new, severe headache.
• Chest or legs. Severe pain in your chest or legs, with or without shortness of breath, weakness and fatigue.
• Swelling. Swelling of the face, lips or tongue, with or without red, itchy bumps.
• On progesterone. Blurred vision, slurred speech or trouble walking, which the Prometrium label flags early in treatment.

Sudden chest pain or sudden trouble speaking is an emergency, so call 911.

Step 6: The follow-up at about 3 months, and how the dose gets adjusted

The first review is where your plan gets tuned. The FDA leaflets ask you and your prescriber to talk regularly, for example every 3 to 6 months, about your dose and whether you still need it.

Bring your symptom log. Most reviews cover the same ground.

• Symptoms. Which ones improved, which didn't, and by how much.
• Bleeding. Your pattern since starting, compared with what your schedule should produce.
• Side effects. Anything that lingered past the first weeks.
• Blood pressure. Often rechecked.

You probably won't need a blood estradiol level. The Menopause Society says hormone blood testing is rarely needed, so adjustments rest on your symptoms and side effects.

What an adjustment looks like

• A dose increase. Hot flashes still breaking through often mean a step up in estrogen.
• A dose decrease. Breast soreness or bloating that won't settle can mean a step down.
• A route switch. A patch that irritates your skin can become a gel, or a pill can become a patch.
• A progesterone change. Moving between cyclic and daily schedules, or to another progestogen, can help with bleeding or mood side effects.

Once you're settled, your yearly breast exam and mammogram become natural checkpoints. The Menopause Society calls for periodic reevaluation, a regular look at whether the benefits still outweigh the risks for you.

Our HRT dosage guide lists the signs a dose may be too high or too low.

Starting HRT in perimenopause, while you still have periods

You don't have to wait for your periods to stop. Many women start during perimenopause, the years of change before the final period.

Standard HRT doses are not birth control. The CDC's 2024 contraception guidance says women are generally advised to keep using birth control until menopause or age 50 to 55.

Our guide to hormone therapy in perimenopause covers these options in detail.

Why the leaflet in your box may still show the old warning

In February 2026, the FDA began approving new labels for menopause hormone therapy.

Heart disease, breast cancer and probable dementia came off the boxed warning, the strongest alert a drug label carries. Those risks still appear in other warning sections.

Labels are being updated in batches, so the leaflet in your box may still show the older wording for a while.

Is it too late to start HRT after 60?

Not automatically. The Menopause Society's 2022 statement finds the balance favorable under 60, or within 10 years of menopause, for women with no medical reason to avoid HRT.

After that, it looks less favorable, because the absolute risks of heart disease, stroke, blood clots and dementia are higher. HRT is also not a way to protect your heart.

Before your visit, read who qualifies for HRT and HRT benefits and risks.

What starting HRT costs in the first 3 months

Expect two bills. One is for the visit and one is for the medicine.

With insurance, the visit is billed like any office or telehealth appointment. Generic estradiol and progesterone are on many plans' drug lists, so your copay, your share at the pharmacy counter, may be modest.

Online services usually charge a membership or visit fee. The medicine is either billed on top or bundled in. Because hormone tests are rarely needed, lab fees are often not part of the start.

Current numbers live in our HRT cost guide. For coverage questions, read HRT and insurance, or HRT without insurance if you are paying cash.

If the first prescription doesn't work, or your doctor says no

A first prescription is a starting point, not a verdict. When symptoms linger at three months, the usual fix is a dose or route change rather than giving up on HRT.

Some side effects come from the progestogen rather than the estrogen. Changing its type or schedule can make a real difference.

If your doctor won't prescribe, ask what specifically rules you out. Then a second opinion from a menopause-focused clinician is a reasonable next step.

Our page on getting an HRT prescription explains why some doctors still say no. To weigh online options side by side, see our menopause telehealth comparison.