The hormone therapy first year follow-up checklist

Before the initiation visit

• Send the baseline symptom instrument before she arrivesScore vasomotor, sleep, mood, and genitourinary items at least two days ahead. The visit should open with a number, not with a description of her worst week.
• Screen the contraindications against her documented historyWork through personal breast cancer history, unexplained vaginal bleeding, active liver disease, prior venous thromboembolism, and cardiovascular history, and record what you checked rather than what you concluded.
• Decide the lab set before the visit, not during itFor a woman over forty five the diagnosis is usually clinical. Order only what would change the plan, such as thyroid function, ferritin, or a lipid panel, and note the reason next to each.
• Pull the current class labeling for the products you prescribeCounsel from the labeling in force today for systemic and vaginal estrogen products, not from a handout printed in a prior year. Keep a dated copy of what you counseled from.
• Book the visit length the work actually needsAn initiation visit that includes scoring, risk counseling, and a titration plan does not compress into thirty minutes. Schedule the time and price it accordingly.

At the initiation visit

• Record the baseline score in a field you can graph laterA total plus subscales in a structured field beats a sentence in the narrative. If it cannot be compared to a later number without retyping, it is not a baseline.
• Name the target symptom and write it in the noteAsk which symptom she most wants gone, whether that is waking at three in the morning, flushing during meetings, or painful intercourse, and record it as the endpoint for the next twelve weeks.
• Document the breast cancer and boxed warning conversationCapture what was asked, what absolute risk framing you used, and what she decided. This is the entry most often missing when a chart is reviewed years later.
• Write the titration plan with dates rather than intentionsState the starting dose and route, the earliest review date, and the size of score change that would justify moving up or holding steady.
• Agree the check-in schedule before she leaves the roomWeek two, week six, and week twelve is a workable default. Tell her the questions will be the same each time, and that the answers drive the dose.
• Give her the bleeding and red flag rules in writingSet out what to report immediately, what to report at the next check-in, and how to reach the clinic. Verbal instructions at the end of a long visit do not survive week five.

Weeks two to twelve, the titration window

• Send the same instrument, not a revised oneChanging the wording between weeks destroys comparability. Freeze the items for the whole first year even if you later prefer a different questionnaire for new patients.
• Read the subscales before the totalA flat total can hide vasomotor improvement alongside worsening sleep, which is a dose timing question rather than a dose size question. The subscales tell you which lever to pull.
• Chase any check-in that has not returned within four daysA missing week six response is clinical information. Treat the non-responder list as a discontinuation risk list, because that is what it usually is.
• Change one variable at a time and date the changeAdjust dose or route or progestogen schedule, not all three, and write the date beside the score that prompted it. This is what makes the trend readable at month six.
• Act on unscheduled bleeding by a written ruleDecide in advance what triggers an evaluation and what is watchful waiting inside the first months of therapy, so the response does not depend on who picks up the message.

Months four to twelve, maintenance and the record

• Re-score at least quarterly, including the patients who say they are fineQuiet patients drift. A quarterly score catches the slow return of night sweats before she decides on her own that the therapy stopped working.
• Review the genitourinary items on their ownSystemic therapy often leaves genitourinary symptoms behind, and those items are the ones patients least often raise unprompted. A separate look prompts the vaginal estrogen conversation on time.
• Flag the three common first year exit signalsPersistent breast tenderness, unresolved bleeding, and no measurable score change by week twelve are the patterns that precede most quiet discontinuations. Treat each as a call, not a message.
• Rebuild the annual review from the trend, not from memoryOpen the year as a chart of dated scores against dated dose changes. The conversation about continuing therapy should reference that picture directly.
• File the counseling and consent record where a reviewer would find itKeep the boxed warning counseling, risk discussion, and consent in a predictable place in the chart. If a board complaint arrives in year three, retrieval time is the whole game.