Who is a candidate for BHRT?

The clinical detail.

Candidacy for BHRT is a clinical decision based on three streams of evidence: symptoms, labs, and the absence of disqualifying conditions. None of the three is sufficient on its own. Symptoms without lab confirmation may have non-hormonal causes. Labs without symptoms rarely justify treatment. And both can be present while a contraindication makes treatment inappropriate.

Symptomatic indicators.

The symptom picture that brings most patients to BHRT consultation includes one or more of these patterns:

• Women in perimenopause and menopause: hot flashes, night sweats, sleep disruption, mood lability, vaginal dryness, decreased libido, cognitive fog, fatigue, weight gain around the midsection, joint stiffness, hair changes. Cycle changes (irregular periods, shorter cycles, heavier or lighter flow) frequently appear in perimenopause.
• Men with hormone decline: reduced libido and morning erections, fatigue and motivational flatness, slower recovery from exercise, decreased lean mass, abdominal fat gain, mood changes, sleep changes.
• Both sexes with thyroid dysfunction: cold intolerance, fatigue, weight changes, dry skin, hair thinning, slow cognition.
• Both sexes with cortisol or DHEA dysregulation: exhaustion, poor stress tolerance, salt cravings, blood-sugar instability.

Lab confirmation.

Before initiating BHRT we obtain a comprehensive baseline panel. For women: estradiol, progesterone, FSH, LH, testosterone, free testosterone, SHBG, DHEA-S, full thyroid (TSH, free T3, free T4, reverse T3, thyroid antibodies), cortisol assessment, plus the metabolic context (HbA1c, lipids, hsCRP, vitamin D, ferritin, CBC, comprehensive metabolic panel). For men: total and free testosterone, SHBG, estradiol, LH, FSH, DHEA-S, prolactin, thyroid panel, PSA, plus the same metabolic context.

The labs do two things. First, they confirm whether hormonal decline is contributing to the symptom picture. Second, they establish the baseline against which we'll measure protocol response and against which we'll detect any unintended consequence at the 8-12 week follow-up.

Absolute contraindications.

BHRT is not appropriate for patients with:

• Active hormone-sensitive cancer (active breast cancer with estrogen-receptor-positive disease, active prostate cancer, active ovarian or endometrial cancer). Patients in confirmed remission may be candidates with oncology co-management.
• Active venous thromboembolism or recent thrombotic event. Personal history of clotting disorders requires careful evaluation; transdermal routes have a different risk profile from oral routes.
• Severe uncontrolled cardiovascular disease without cardiology clearance.
• Undiagnosed abnormal uterine bleeding in women — this must be worked up before initiating any hormone therapy.
• Active liver disease — affects hormone metabolism and clearance.
• Pregnancy.
• Severe untreated obstructive sleep apnea in men starting testosterone — testosterone can worsen sleep apnea if untreated.

Relative contraindications and modifiers.

These are not absolute exclusions but require careful evaluation: personal or strong family history of hormone-sensitive cancer, prior thrombotic event with subsequent recovery, migraines with aura (relevant to oral estrogen), uncontrolled hypertension, severe metabolic dysfunction, certain medication interactions, very high baseline hematocrit. We evaluate these on a patient-by-patient basis and sometimes co-manage with the patient's specialist before initiating.

Who is often NOT a candidate but thinks they are.

A few patient categories present asking for BHRT who often benefit more from a different intervention:

• Patients with symptoms but normal labs in a normal life context. These often respond better to upstream interventions (sleep, stress, nutrition, training) than to hormone therapy.
• Patients seeking "anti-aging" or "performance enhancement" with no clinical deficiency. We don't offer hormones for these indications.
• Patients whose primary symptom is depression or anxiety without a hormone-correlated pattern. Mental health treatment is the first-line intervention.
• Young patients with secondary hypogonadism from a correctable cause (severe stress, undertraining, overtraining, medication side effect). Addressing the cause is the first move.

Where this fits in our methodology.

The CLARITY methodology evaluates candidacy through the full diagnostic intake: comprehensive symptom rubric, baseline labs, medical history review, contraindication screen, and a clinical conversation about goals. We don't initiate BHRT without all four. See the methodology in full.

For deeper context, see the BHRT service page, menopause, and low testosterone.