1
Intake
2
Risk Profile
3
Recommendation
4
Formulary
5
Guidelines
Patient Demographics
Core clinical identifiers and menopausal staging
Age & Menopausal Timing
Menopausal Classification
Perimenopausal
Postmenopausal
Surgical/oophorectomy
POI (<40)
Early meno (40β45)
Unsure
Intact uterus
Total hysterectomy
Subtotal/supracervical
Still menstruating (regular)
Menstruating (irregular / skipping cycles)
Spotting only
Amenorrhea <12 months
Amenorrhea β₯12 months
Post-hysterectomy / no uterus
Normal for stage
Heavy/prolonged (HMB)
Intermenstrual bleeding
Postcoital bleeding
Post-menopausal bleeding
β οΈ Heavy, intermenstrual, or postmenopausal bleeding requires TVUS Β± endometrial biopsy before initiating HRT
Indications & Symptoms
Select all active clinical indications for HRT consideration
Hormonal Indications
Symptom Severity
None
Mild
Moderate
Severe / debilitating
0β2/day
3β6/day
7β12/day
β₯13/day
No
Yes
Unsure
Never used
Currently on HRT
Prior HRT (stopped)
Laboratory Values
Enter available labs β abnormal values will flag clinical guidance
Hormonal Markers
Metabolic Panel
Hematologic / Renal
Bone Health Imaging
Normal
Osteopenia
Osteoporosis
Current (normal)
Current (abnormal/pending)
Not current
Contraindication Screening
Absolute contraindications preclude systemic HRT; relative require route modification
Absolute Contraindications
Relative Contraindications
Breast Cancer Risk Profile
WHI, ESTHER, CGHFBC data Β· FDA 2026: boxed warning removed for breast cancer
Personal History
None
Yes β ER+ / PR+
Yes β ERβ / triple-neg
Yes β DCIS
None / benign
Atypical hyperplasia
LCIS
DCIS (treated)
A: Fatty
B: Scattered
C: Heterogeneous
D: Extremely dense
Hereditary & Family Risk
None
1 first-degree relative
β₯2 first-degree relatives
2nd-degree only
Not tested
Tested β negative
BRCA1 positive
BRCA2 positive
Other pathogenic variant
<15% (average)
15β20% (intermediate)
>20% (high)
Not calculated
Cardiovascular & VTE Risk
ACC/AHA ASCVD 2023 Β· ESTHER trial Β· WHI re-analysis 2025
ASCVD Risk Factors
ASCVD Risk Score & VTE
Unknown
<5% (low)
5β7.5% (borderline)
7.5β20% (intermediate)
>20% (high)
VTE Risk Factors
Additional Clinical Context
Bone, cognitive, metabolic, and psychosocial factors
Cognitive & Neurological
Never
Former
Current
Metabolic & Other
Good candidate
Candidate with modification
Marginal candidacy
Non-candidate
Complete Patient Intake (Step 1) and Risk Assessment (Step 2), then click Generate Full Recommendation to view the clinical decision summary.
HRT Formulary Reference
Approved formulations, doses, and route comparison β FDA 2026
Systemic Estrogen Options
| Product | Route | Dose Range | Notes |
|---|---|---|---|
| Estradiol patch (Vivelle-Dot, Climara, generic) | Transdermal | 0.025β0.1 mg/day | β Preferred: lower VTE, stroke, gallbladder. Change 1β2Γ/wk |
| Estradiol gel (EstroGel, Divigel) | Transdermal | 0.25β1.5 mg/day | β Preferred. Apply to arm. Avoid contact transfer. Good titration |
| Estradiol spray (Evamist) | Transdermal | 1.53 mg/spray (1β3/day) | β Preferred. Apply to forearm. Rapid absorption |
| Oral micronized estradiol (generic, Estrace) | Oral | 0.5β2 mg/day | β οΈ First-pass hepatic effect. Higher TG, SHBG, CRP risk. Avoid if TGβ, thrombophilia |
| Conjugated estrogen (Premarin) | Oral | 0.3β1.25 mg/day | β οΈ Used in WHI; older formulation. Multiple estrogenic compounds |
| Estradiol valerate (Progynova) | Oral | 1β2 mg/day | β οΈ Oral; same first-pass caveats as estradiol |
Clinical Guideline Summary
Key evidence base and 2025β2026 updates
FDA Labeling Update β February 2026 (JAMA Jan 2026; Makary et al.): Boxed warnings for cardiovascular disease, stroke, breast cancer, and probable dementia have been removed from all systemic HRT products. The "lowest dose, shortest duration" recommendation was removed. Endometrial cancer boxed warning retained for unopposed estrogen in women with intact uterus. Timing window (initiation within 10 years of menopause or age <60) emphasized. Topical vaginal estrogen boxed warnings removed separately.
Key Guideline Statements
| Source | Year | Key Recommendation |
|---|---|---|
| NAMS Position Statement | 2022 | HRT is the most effective treatment for VMS. Benefit-risk favorable in women <60 y or <10 yr from menopause. No mandatory age cutoff for discontinuation. Individualize duration. |
| FDA Label Revisions | Feb 2026 | Boxed warnings removed (CV, stroke, breast ca, dementia). Timing window emphasized. Individualized clinical decision-making endorsed. "Shortest duration" guidance removed. |
| ACC/AHA Prevention Guidelines | 2023 | HRT not recommended for primary CV prevention. However, for symptomatic women within 10 yr of menopause without CVD, risk-benefit favorable. Transdermal preferred in high CV/VTE risk. |
| ACOG Practice Bulletin | 2022 | HRT remains first-line for moderate-severe VMS. Screen for contraindications. Individualize duration. Periodic reassessment recommended. |
| SOGC Guideline 422a | 2021 | MHT doesn't need to be stopped at age 65. Clinical decision based on ongoing benefit-risk. COCs acceptable in perimenopausal women if no contraindications. |
| NICE NG23 (UK) | 2024 | Offer HRT to menopausal women for VMS without routine duration limits. FSH testing not needed for diagnosis in women β₯45 with symptoms. Annual benefit-risk review. |
| IMS / EMAS Global Consensus | 2023 | Transdermal estradiol + micronized progesterone preferred for safety. HRT does not need to be avoided in women aged 51β60 who are candidates. Topical estrogen essentially risk-free. |
| Endocrine Society | 2022 | POI/premature menopause: HRT until average age of natural menopause (~51). Benefits clearly outweigh risks in this group. Higher doses may be needed. |
| WHIMS / WHI Estrogen-alone | 2004, re-analysis 2020 | Estrogen-alone (post-hysterectomy) may reduce breast cancer incidence (WHI). Benefits of ET in younger women clearly support use. Timing hypothesis validated. |
Key Evidence by Outcome Domain
| Outcome | Effect of HRT | Best Evidence | Key Citation |
|---|---|---|---|
| Vasomotor symptoms | π’ 70β90% reduction in frequency/severity | RCTs, meta-analyses | NAMS 2022; Cochrane 2017 |
| Bone fracture risk | π’ 50β60% reduction; maintains BMD | WHI, RCTs | Weiss et al.; WHI Osteoporosis |
| Cardiovascular mortality | π’ 25β50% reduction if started <60 or <10 yr | Meta-analysis, re-analysis | Barrett-Connor 1991; WHI re-analysis 2025 |
| Cognitive function | π’ 64% reduction in cognitive impairment if early | Observational; CAMS trial | Bagger et al. 2005; Paganini-Hill 1996 |
| Alzheimer's disease | π’ 35% risk reduction with early HRT | Observational | Paganini-Hill & Henderson 1996 |
| Breast cancer | π‘ Estrogen-alone: β risk (RR 0.80). E+P: slight β after 5 yr (MPA formulation) | WHI, CGHFBC | Chlebowski et al. JAMA 2020 |
| VTE | π΄ Oral: 2β3Γ β. Transdermal: no β (ESTHER) | ESTHER trial, WHI | Canonico et al. Circulation 2007 |
| Stroke | π΄ Oral: modest β. Transdermal: no β in healthy women <60 | Observational, WHI | Renoux et al. BMJ 2010 |
| Gallbladder disease | π΄ Oral: 30β50% β. Transdermal: lower or no β | WHI, observational | Cirillo et al. Ann Intern Med 2005 |
| All-cause mortality | π’ Reduced or neutral in women <60 / <10 yr from meno | Meta-analysis | Salpeter et al.; Collaborative re-analysis |
| Dementia (started β₯65) | π΄ WHIMS: β risk if initiated after 65 (CE+MPA) | WHIMS trial | Shumaker et al. JAMA 2003 |
| Endometrial cancer | π΄ Unopposed estrogen: significantly β. Add progestogen in intact uterus | RCTs, observational | Grady et al.; WHI |
| Colorectal cancer | π’ ~20% reduction with combined HRT | WHI | Chlebowski et al. |
| Genitourinary health | π’ 60β80% improvement in dryness, dyspareunia, UTIs | RCTs | NAMS GSM Position Statement 2022 |
| Quality of life / sleep | π’ Significant improvement; sleep especially with Prometrium | RCTs | Hachul et al.; WHI QOL |