What labs should be ordered to evaluate female hormones in menopause?

Laboratory Evaluation for Menopausal Status

For diagnosing menopause, follicle-stimulating hormone (FSH) and estradiol are the primary laboratory tests that should be ordered, with FSH being the most reliable marker. 1

Primary Laboratory Tests

• Follicle-stimulating hormone (FSH):

  • Most important test for evaluating menopausal status
  • Levels rise significantly during perimenopause and menopause due to declining ovarian function
  • Values >30-40 mIU/mL suggest perimenopause or menopause
  • Best drawn during early follicular phase (days 2-5) of menstrual cycle if cycles are still present

• Estradiol:

  • Decreases during perimenopause and menopause
  • Values <30 pg/mL typically indicate menopause
  • Complements FSH testing for a more complete picture

Additional Tests to Consider

• Anti-Müllerian hormone (AMH):

  • Emerging as a valuable marker of ovarian reserve
  • Correlates well with antral follicle count
  • Less affected by menstrual cycle day or hormonal contraceptive use
  • Very low levels indicate ovarian failure or approaching menopause 2
  • Particularly useful in women aged ≥25 years as it inversely correlates with increasing age 2

• Luteinizing hormone (LH):

  • Often elevated in menopause
  • Less specific than FSH for diagnosing menopause
  • Can be measured alongside FSH for additional confirmation

Important Clinical Considerations

Timing of Testing

• For women with irregular cycles, testing should be performed when symptoms suggest perimenopause
• For women with regular cycles, testing should be done during early follicular phase (days 2-5)

Limitations of Testing

• FSH levels can fluctuate markedly during perimenopause 3
• A single FSH or estradiol measurement is not reliable for diagnosing perimenopause 4
• Hormone measurements become more reliable when no menses have occurred for at least 3 months 3

When Testing is Most Useful

• When menopause diagnosis is unclear (e.g., women in their 40s with irregular cycles)
• When considering hormone therapy for symptom management
• In women with premature ovarian insufficiency (before age 40)
• In cancer survivors who received gonadotoxic treatments 2

Special Populations

Cancer Survivors

For female cancer survivors at risk of premature ovarian insufficiency:

• Regular monitoring of FSH and estradiol is recommended
• AMH testing should be considered as it may be useful to distinguish women with POI who have few remaining follicles from those still at risk 2
• For prepubertal females who fail to initiate or progress through puberty, FSH and estradiol evaluation is strongly recommended 2

Surgical Menopause

• Laboratory testing is generally not necessary to confirm menopause after bilateral oophorectomy
• Baseline hormone levels may be useful before initiating hormone therapy

Common Pitfalls to Avoid

1. Relying on a single hormone measurement: Hormone levels fluctuate significantly during perimenopause; repeated testing may be necessary
2. Ignoring clinical symptoms: Laboratory tests should complement, not replace, clinical assessment of menopausal symptoms
3. Testing at inappropriate cycle times: Timing within the menstrual cycle affects hormone levels
4. Misinterpreting normal age-related changes: FSH may rise and estradiol may fall gradually with age, even before clinical menopause
5. Over-reliance on laboratory values: The diagnosis of menopause is primarily clinical, based on amenorrhea for 12 consecutive months in women over age 45

Remember that menopause is primarily a clinical diagnosis based on the absence of menses for 12 consecutive months, and laboratory testing serves as a supporting tool rather than the definitive diagnostic criterion.