What is the recommended workup for perimenopause and menopause in women?

Recommended Workup for Perimenopause and Menopause in Women

The recommended workup for perimenopause and menopause should include assessment of menopausal symptoms, laboratory evaluation of hormone levels as clinically indicated, and appropriate screening for other medical conditions that may mimic or exacerbate menopausal symptoms. 1, 2

Initial Assessment

Symptom Evaluation

• Assess for classic menopausal symptoms:
  • Vasomotor symptoms (hot flashes/night sweats)
  • Sleep disturbances
  • Mood changes (anxiety, depression)
  • Cognitive changes ("brain fog")
  • Vaginal dryness and urogenital complaints
  • Sexual dysfunction
  • Arthralgias/myalgias
  • Fatigue

Laboratory Evaluation

• Laboratory tests to consider:
  • Follicle-stimulating hormone (FSH)
  • Luteinizing hormone (LH)
  • Estradiol
  • Thyroid-stimulating hormone (TSH)
  • Prolactin (if clinically indicated)

Important note: FSH is not a reliable marker of menopausal status in women with prior chemotherapy, pelvic radiation exposure, or in women taking tamoxifen 1

Physical Examination

• Blood pressure measurement
• Weight assessment
• Pelvic examination (to assess for vaginal atrophy if vaginal dryness is reported)

Special Considerations for Perimenopause

• Irregular menstrual cycles are common during perimenopause and should be documented
• For women with abnormal uterine bleeding, further workup may be necessary to rule out pathology
• Contraception counseling is essential as pregnancy is still possible during perimenopause 3
• For perimenopausal women with amenorrhea who later develop bleeding, serial estradiol levels can help determine return of ovarian function 1

Additional Diagnostic Considerations

• Rule out medical conditions that may mimic menopausal symptoms:

  • Thyroid disorders
  • Diabetes
  • Anxiety disorders
  • Depression
  • Sleep apnea

• For women with vaginal symptoms:

  • Pelvic examination to assess for vaginal atrophy
  • Consider referral to appropriate specialist 1

Monitoring and Follow-up

• Initial follow-up at 3-6 months after starting any treatment
• Annual assessments including:
  • Blood pressure
  • Weight
  • Lipid profile
  • Cancer screening as appropriate
  • Symptom control evaluation 2

Treatment Considerations

Non-hormonal Options

• First-line therapy for most women with menopausal symptoms includes:
  • SSRIs/SNRIs (paroxetine, venlafaxine)
  • Anticonvulsants (gabapentin)
  • Certain antihypertensives (clonidine) 1, 2

Hormonal Options

• For women considering hormone therapy, a thorough risk assessment is necessary
• Contraindications to hormone therapy include:
  • History of hormone-dependent cancers
  • Active liver disease
  • History of abnormal vaginal bleeding
  • History of venous thromboembolism or stroke 1, 2

Common Pitfalls to Avoid

1. Relying solely on FSH levels to diagnose menopause, especially in women with history of chemotherapy or on tamoxifen
2. Failing to provide contraception counseling to perimenopausal women
3. Not ruling out other medical conditions that may cause similar symptoms
4. Overlooking the impact of menopausal symptoms on quality of life
5. Assuming all symptoms will resolve without treatment (vaginal symptoms typically do not improve without intervention) 1, 4

The workup for perimenopause and menopause should be thorough but targeted, focusing on symptom assessment, appropriate laboratory testing, and consideration of both hormonal and non-hormonal treatment options based on the individual's risk profile and symptom burden.