Hi @rswartz. Your doctor may be hesitant to have you start HRT because nicotine can interfere with this medication.

According to an article in PubMed, from the National Institute of Health, “It has been proven that, depending on the type, duration and intensity of nicotine consumption, smoking can reduce or completely cancel the efficacy of orally administered estrogens. Not only does smoking diminish the otherwise well-established beneficial effects of estrogen on hot flashes and urogenital symptoms and its positive effects on lipid metabolism, i.e. by reducing cholesterol, but smoking also specifically reduces estrogen's ability to prevent osteoporosis.”
Here is the complete report:
https://pubmed.ncbi.nlm.nih.gov/15638743/

It sounds as though your doctor may have concerns that the medication won’t be able to work as well as intended for you. Are you having menopause symptoms?

@rswartz

Did your provider talk about other drugs beside HRT that might help.

This Mayo Clinic web site list some drugs that might be an alternative.
https://www.mayoclinic.org/diseases-conditions/hot-flashes/diagnosis-treatment/drc-20352795

I went thru menopause multi times, once early in life after a hysterectomy due to endometriosis. Eventually the provider put me on HRT. Then later in life when stopped HRT. It is terrible and definitely effects your quality of life.
I use to lay in bed with fan blowing on me.

Hope you find a solution.