The best time is during perimenopause (the transition period before menopause when hormone levels fluctuate, causing irregular periods and symptoms like hot flashes, sleep disruption, and mood changes) or within the first 10 years of menopause (generally before age 60). This is the "window of opportunity" when HRT has the greatest benefits for your heart, bones, and brain. If you're considering starting more than 10 years after your last period, you'll want tests to check your arterial health first.

Yes! Your hormonal IUD provides local progesterone to protect your uterine lining, so if you need estrogen for menopausal symptoms, you can add it. The combination generally works well together. The IUD handles the progesterone component while estrogen addresses other symptoms. You don’t need to wait until your periods stop to get relief; many women begin treatment during perimenopause.

Generally yes. Multiple studies show that having a family history of breast cancer doesn't mean you can't safely use HRT. Research (for example Kotsopoulos et al. 2016) has even found that women with BRCA1 or BRCA2 mutations who had their ovaries removed and then used HRT showed no increased breast cancer risk compared to those who didn't use hormones. That said, this is definitely a conversation to have with your clinician to weigh your individual situation.

Not usually. For most healthy women starting HRT at menopause, you don't need special bloodwork or hormone level testing before beginning. Why? Because hormone levels fluctuate significantly throughout the day and from day to day, and there's substantial variation between individuals, so testing is considered unreliable for guiding treatment decisions (North American Menopause Society Position Statement, 2022). Your symptoms and health history are what guide the decision. The exception is if you're starting more than 10 years past menopause, when there's a small risk of worsening pre-existing arterial plaque in that first year. In that case, your clinician might want to assess your arterial health and heart strength with tests like a coronary calcium scan to make sure it's safe to start.

There's no one-size-fits-all answer. The old "lowest dose for shortest time" advice isn't evidence-based. The right dose is whatever effectively manages your symptoms based on your individual needs. Your clinician should personalize your treatment, the dose that works for you might be different from what works for someone else.

As long as you need it! Current medical guidelines say there's no mandatory stop date. The benefits continue as long as you take it, which is especially important for bone protection and possibly brain health. Many medical societies like the North American Menopause Society (NAMS) and the American College of Obstetricians and Gynecologists (ACOG) now recommend that women can continue HRT beyond age 65 if they still have symptoms or want the ongoing protective benefits.

"Bio-identical" technically means the hormone's molecular structure matches what your body makes, like estradiol. But, the term is often misused. Some FDA-approved HRT products are already bio-identical, like estradiol patches, creams, and tablets. The term itself doesn't determine safety or effectiveness, nor does it mean that the hormones are “natural", even compounded bio-identical hormones have been formulated in a lab.
What matters most is working with a knowledgeable clinician who can help you choose safe, evidence-based therapies based on your specific needs and health history.