Should I check dihydrotestosterone (DHT) levels during perimenopause?

Dihydrotestosterone Testing During Perimenopause

Measuring dihydrotestosterone (DHT) levels is not recommended as part of routine evaluation during perimenopause, as there are no clinical guidelines supporting this practice and it provides limited clinical value for managing perimenopausal symptoms.

Understanding Hormonal Changes in Perimenopause

Perimenopause is characterized by fluctuating hormone levels, primarily affecting estrogen and progesterone. While androgens also undergo changes during this transition, current clinical guidelines do not recommend routine testing of DHT for perimenopausal women.

Research shows that during perimenopause:

• Testosterone and DHT levels actually decrease rather than increase during the menopausal transition 1
• DHT measurements using liquid chromatography-tandem mass spectrometry (LC-MS/MS) show that DHT levels do not significantly change across the menstrual cycle in premenopausal women, unlike estradiol and testosterone 2
• After menopause, DHT levels are significantly lower than in premenopausal women 2

Clinical Guideline Recommendations

Current guidelines focus on managing perimenopausal symptoms rather than measuring specific androgen levels:

• The American Thyroid Association, American College of Physicians, and Canadian Task Force on Periodic Health Examination recommend maintaining a high index of clinical suspicion for thyroid dysfunction in perimenopausal women, but do not mention DHT testing 3
• Guidelines for hormone replacement therapy focus on estrogen and progesterone management rather than androgens 4
• No major medical society or guideline specifically recommends DHT testing during perimenopause

When DHT Testing Might Be Considered

DHT testing might be considered in specific clinical scenarios:

• Women with hirsutism, as research shows significantly higher DHT levels in women with hirsutism compared to those without 5
• Women with female pattern hair loss, although research suggests that unlike male pattern baldness, women with female pattern baldness show increased production rates of testosterone but not DHT 6

Recommended Approach to Perimenopausal Evaluation

Instead of DHT testing, guidelines recommend:

1. Assessing for symptoms of thyroid dysfunction, particularly in high-risk individuals 3
2. Considering thyroid function testing in women with nonspecific symptoms that could be caused by thyroid disease 3
3. Evaluating cardiovascular risk factors, as perimenopause is associated with changes in blood pressure and cardiovascular health 3
4. Considering bone health assessment, as perimenopause is associated with accelerated bone loss 3

Potential Pitfalls

• Ordering unnecessary hormone tests like DHT without clear clinical indications can lead to unnecessary costs and patient anxiety
• Misinterpreting normal fluctuations in hormone levels during perimenopause as pathological
• Focusing on DHT levels may distract from addressing more clinically relevant perimenopausal symptoms and health concerns
• DHT assays have technical limitations and may lack standardization across laboratories

Summary

There is insufficient evidence to support routine DHT testing during perimenopause. Management should focus on addressing specific symptoms and known health risks associated with the menopausal transition, including vasomotor symptoms, bone health, cardiovascular risk, and thyroid function when clinically indicated.