Perimenopause and menopause are periods of significant hormonal changes in a woman's life.
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Hormones are biologically active molecules that balance all the basic processes of the body's internal homeostasis - growth, metabolism, reproduction, and stress response.
Perimenopause and menopause are often accompanied by hormonal imbalances, which in turn affect bone density and cardiovascular risk. Proper monitoring and individualized management can help reduce symptoms and improve quality of life.
Menopause – which tests should be done and when?
The diagnostics of menopause is mainly based on the clinical picture and assessment of menstrual history. Laboratory studies are more informative in cases where symptoms appear at an early age, the clinical picture is not clear, or other pathologies need to be differentiated.
However, if typical symptoms of menopause – hot flashes, irregular menstrual cycles – develop after age 45, routine laboratory tests may not be necessary, according to the guidelines.
Basic hormone panel
A menopausal transition assessment panel typically includes four hormones: follicle-stimulating hormone, luteinizing hormone, estradiol, and progesterone. Each of these provides different information about how the ovaries are functioning.
Follicle stimulating (The hormone FSH is one of the most commonly used markers. This hormone stimulates the production of eggs in the ovaries.
When ovarian function declines, the pituitary gland compensates by increasing the production of follicle-stimulating hormone. However, a single increase in the level does not confirm menopause - a persistently high level is diagnostic.
Estradiol It is the main form of estrogen produced by the ovaries. Its levels are usually low in postmenopausal women. During the transition period, levels can fluctuate significantly from month to month, making testing difficult during perimenopause.
Maluteinizing The hormone works in conjunction with FSH. As ovarian function declines, luteinizing hormone levels also increase, and its combined assessment with follicle-stimulating hormone provides a more complete picture of reproductive hormonal regulation.
Progesterone It reflects whether ovulation is occurring. Its low level indicates that the follicle is not maturing and producing eggs, which is one of the main signs of the onset of menopause.
How informative is testing during perimenopause?
If a woman is already experiencing the initial symptoms of menopause after the age of 40, there is often an expectation that laboratory tests will answer the question of whether menopause has begun. However, in most cases, hormone levels are unstable, fluctuating from month to month and week to week.
FSH may be high for one month and then return to normal, while estradiol may fluctuate unpredictably.
Therefore, it is often more informative for the clinician to assess symptoms and observe changes in the menstrual cycle than to rely solely on laboratory values.
When are hormonal studies appropriate?
There are clear situations when hormone testing is clinically important. If a woman is under 40 years of age and her periods have stopped or their frequency has changed significantly, laboratory testing is critical for early detection of ovarian failure.
In such a case, elevated follicle-stimulating hormone and low estradiol levels have a different clinical significance than the same levels in a patient over 50 years of age.
Testing is also necessary after a hysterectomy, as well as after treatment with certain medications that suppress the natural cycle. At this time, since the menstrual cycle is no longer a natural indicator of observation, determining hormone levels becomes an important tool for assessing reproductive status.
Anti-Mullerian hormone and the prediction of menopause timing
Unlike follicle-stimulating hormone and estradiol, which reflect current hormonal status, anti-Müllerian hormone indicates ovarian reserve and estimates egg supply. A decreased level of anti-Müllerian hormone is also generally associated with approaching menopause.
Thyroid gland research
One of the most important additional studies in the laboratory package for the evaluation of menopause is the assessment of thyroid function. Symptoms of thyroid dysfunction (hot flashes, changes in heart rhythm, sweating, etc.) often coincide with the symptomatic picture of menopause, which is why it is necessary to study the hormonal spectrum.
- TSH: Assesses the functional status of the thyroid gland
- Free T4 and Free T3: Active hormone levels
- Reverse T3: May indicate decreased function due to stress or illness
- Anti-TPO and Anti-TG antibodies: Detection of autoimmune diseases (e.g. Hashimoto's thyroiditis, Graves' disease)
Thyroid-stimulating hormone (TSH) A simple analysis allows you to detect the functional state of the thyroid gland – both hyperthyroidism and hypothyroidism, which are often mistaken for menopause. Since these conditions are treatable, their timely detection is important to prevent unnecessary symptomatic burden.
In which phase should we determine hormones?
If a woman is still having a menstrual cycle, the timing of the blood test has a significant impact on the interpretation of the results. FSH is most accurately determined on days 3–5 of the cycle, counting from the first day of menstruation. Estradiol testing is performed at different stages of the cycle (on days 5, 12, 21, as needed) to assess its variability, although in practice, a single, early phase determination is more often used.
Progesterone levels peak in the second week of the cycle (around day 21 in a 28-day cycle), so its determination is informative during this period.
During perimenopause, when cycles are often irregular, it is not always possible to choose the ideal time. In such cases, the doctor interprets the results of the tests taking into account the clinical context or, if necessary, repeat the analysis in a few weeks.
which laboratory indicators are the most important?
No single laboratory test can confirm or rule out menopause. The clinical definition of menopause is 12 consecutive months without menstruation, and this diagnostics is essentially retrospective—that is, it can only be confirmed retrospectively.
For example, a high FSH level and a low estradiol level in a woman who has not had a period for several months creates a fairly clear picture. However, in a 47-year-old woman with an irregular cycle and fluctuating levels, the results are much more difficult to interpret and often simply indicate the presence of a transitional period - which is also confirmed by the symptoms.
The most informative approach combines symptom history, menstrual changes, age, and laboratory data into a single clinical picture, rather than considering one specific number in isolation. And if symptoms significantly impair quality of life, treatment options, including hormone therapy, may be prescribed regardless of what the FSH showed on a particular day.
Interpretation of laboratory results
Follicle-stimulating hormone and estradiol results should always be evaluated in combination with the clinical picture.
- Elevated follicle-stimulating hormone concentration + low estradiol + cessation of menstruation for at least 12 months: mostly confirms menopause
- Elevated follicle-stimulating hormone concentration + normal estradiol levels: may indicate perimenopause
- Normal follicle-stimulating hormone level + estradiol deficiency: Other causes of amenorrhea should be considered
Factors to consider:
- Follicle-stimulating hormone levels fluctuate significantly during perimenopause and can sometimes return to normal.
- A single determination of follicle-stimulating hormone is insufficient, as studies have shown that approximately 7% of women over 45 with regular cycles may have FSH in the postmenopausal range (i.e., increased hormone concentration).
- Follicle-stimulating hormone concentrations naturally increase with age, even before menopause, while estradiol levels are often relatively stable until late perimenopause.
- LH/FSH ratio provides additional information; <1 is often found in perimenopause
Additional studies that may be considered:
- Thyroid function (TSH, free T4) — to rule out menopausal-like symptoms
- Transvaginal ultrasound — assessment of endometrial thickness, where a thin endometrium indicates estrogen deficiency
- Complete blood count: Used to detect anemia, infections, immune system disorders, and certain hematological diseases. Changes in leukocytes may indicate inflammation, infection, or an autoimmune process.
- Metabolic studies, which includes: assessment of liver and kidney function
- Lipid profile: Evaluates different fractions of cholesterol to assess cardiovascular risk.
- Diabetes Screening:Determination of glycated hemoglobin, determination of the average blood sugar level over the last 3 months
- Vitamins and mineral deficiency assessment
Vitamin D: Important for immunity, bones and mood regulation
Zinc: For immunity, wound healing and hormonal balance
Magnesium: Nervous system, muscle function, sleep and heart function
- Anemia Rate
Iron and ferritin: Determination of iron stores in the body
Vitamin B12: For the formation of nervous system and blood cells
Folate (B9): Cell renewal and blood formation
Inflammation markers:
Chronic inflammation is associated with the development of many diseases.
- C-reactive protein: Inflammation marker
- Erythrocyte sedimentation rate (ESR): Indirect indicator of ignition
- Coagulation tests:To assess the risk of thrombosis
What we need to know:
- Overemphasizing laboratory findings—diagnostics is based primarily on clinical presentation
- Assessment of the condition with a single FSH determination — the follicle-stimulating hormone level fluctuates during perimenopause
- Ignoring age context — FSH naturally increases with age
- Ignoring other causes of amenorrhea — pregnancy, hyperprolactinemia, thyroid dysfunction, etc.
In summary, FSH and estradiol are the main laboratory markers for the assessment of menopause, although their interpretation should always be taken into account in the context of age, duration of amenorrhea, and clinical presentation, as hormonal fluctuations during the perimenopausal period significantly reduce their diagnostic accuracy.
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source
https://my.clevelandclinic.org/health/diseases/8316-polycystic-ovary-syndrome-pcos
