What labs should be checked in women in perimenopause?

Laboratory Testing for Women in Perimenopause

For women in perimenopause, laboratory evaluation should include estradiol, follicle-stimulating hormone (FSH), luteinizing hormone (LH), and prolactin, as clinically indicated, to assess menopausal status and rule out other causes of symptoms. 1

Core Laboratory Tests for Perimenopausal Women

Hormonal Assessment

• Estradiol levels: May be erratically higher rather than declining in perimenopause 2, 3
• FSH and LH levels: Often elevated but not reliable markers of menopausal status in perimenopause 1
• Prolactin: To rule out hyperprolactinemia as a cause of menstrual irregularities 1

Metabolic and Cardiovascular Screening

• Complete lipid profile: Should be performed every 4-6 years between ages 20-79 years 4
  • Target values: total cholesterol <200 mg/dL, HDL >50 mg/dL, LDL <100 mg/dL, triglycerides <150 mg/dL
• Fasting blood glucose or HbA1c: Particularly important for overweight women (BMI ≥25 kg/m²) 4
  • Target values: fasting glucose <100 mg/dL or HbA1c <5.7%
  • Repeat testing at minimum 3-year intervals if results are normal
• Thyroid function tests (TSH): To rule out thyroid disease as a cause of symptoms that can mimic perimenopause 1, 4

Additional Testing Based on Symptoms

For Women with Menstrual Irregularities

• Serial estradiol levels: Can be useful to determine return of ovarian function in women who have become amenorrheic and later develop bleeding 1
• Anti-Mullerian hormone (AMH): May provide additional information on ovarian status and potentially predict menopause proximity better than FSH or Inhibin B 1, 3

For Women with Vasomotor Symptoms

• Rule out medical causes of hot flashes such as thyroid disease and diabetes with appropriate testing 1

For Women with Bone Health Concerns

• Bone densitometry: Consider for perimenopausal women with risk factors for premature bone loss 1, 4
  • Risk factors include low body weight (<70 kg), family history, smoking, decreased physical activity

Preventive Screening During Perimenopause

• Cervical cancer screening: Every 3 years with Pap test or every 5 years if combined with HPV testing 4
• Clinical breast examination: Every 1-3 years depending on age 1, 4
• Depression screening: Using standardized screening tools 1, 4
• Blood pressure measurement: At every regular healthcare visit, target <120/80 mmHg 4

Important Considerations

• FSH is not a reliable marker of menopausal status in perimenopausal women 1, 3
• Contrary to common belief, estradiol levels in perimenopause average 26% higher and fluctuate erratically rather than steadily declining 5, 2, 3
• The most symptomatic women often have higher estradiol and lower progesterone levels 5
• Perimenopause is characterized by three major hormonal changes: erratically higher estradiol levels, decreased progesterone levels, and disturbed ovarian-pituitary-hypothalamic feedback 3

Clinical Pitfalls to Avoid

1. Don't rely solely on FSH levels to determine menopausal status in perimenopausal women, as these can fluctuate widely and are not reliable indicators 1, 3
2. Don't assume estrogen deficiency is the cause of perimenopausal symptoms - many women actually have higher, erratic estradiol levels 2, 3
3. Don't overlook other medical conditions that can mimic perimenopausal symptoms, such as thyroid disorders, diabetes, or hyperprolactinemia 1
4. Don't miss the opportunity to address cardiovascular and bone health during this transition period 4, 6

Laboratory testing should be guided by the woman's specific symptoms and concerns, with attention to both reproductive hormones and general preventive health screening appropriate for her age.