What labs do you order for a patient concerned about perimenopause?

Laboratory Testing for Perimenopause

For patients concerned about perimenopause, order follicle-stimulating hormone (FSH) and estradiol levels, but recognize these tests have limited diagnostic value and should not be relied upon as the sole means of diagnosis.

Understanding Perimenopause Laboratory Testing

Perimenopause represents a transitional phase characterized by fluctuating hormone levels rather than consistent deficiencies. Laboratory testing during this period has significant limitations:

• FSH and estradiol measurements: These have poor diagnostic reliability during perimenopause as levels fluctuate widely

  • FSH levels can abruptly change, rising into postmenopausal range and falling back to premenopausal range 1
  • Estradiol levels may actually average 26% higher than normal and fluctuate erratically during perimenopause 2
  • There is only minimal negative correlation between FSH and estradiol levels 3

• Clinical diagnosis is preferred: Perimenopause should be diagnosed primarily based on menstrual history and age rather than laboratory testing 3

Recommended Laboratory Evaluation

Despite limitations, the following tests may be helpful in evaluating perimenopausal patients:

1. Basic hormone panel:

   • FSH and estradiol (recognizing limitations)
   • Consider anti-Müllerian hormone (AMH) for assessing ovarian reserve in women concerned about fertility 4

2. Rule out other conditions with similar symptoms:

   • Thyroid function tests (TSH, free T4)
   • Complete blood count (to assess for anemia if menorrhagia present)
   • Pregnancy test (if appropriate)

3. Assess for health risks that may influence treatment decisions:

   • Lipid profile
   • Fasting blood glucose or HbA1c
   • Liver function tests (especially if considering hormone therapy)

Bone Health Assessment

• Consider bone mineral density testing for women with risk factors for osteoporosis:
  • DXA scan of lumbar spine and hip is appropriate for women with risk factors 4
  • Particularly important for women with estrogen deficiency symptoms 5

Cancer Screening Considerations

Follow age-appropriate cancer screening guidelines:

• Cervical cancer screening: Pap test and HPV DNA test every 3-5 years depending on age and test combination 4
• Colorectal cancer screening: Beginning at age 50 using appropriate modality 4
• Breast cancer screening: According to standard guidelines
• Endometrial assessment: For women with abnormal uterine bleeding, particularly those on selective estrogen receptor modulators (SERMs) 4

When to Refer

Consider referral to specialists in the following situations:

• Endocrinology/gynecology referral for:
  • Persistent abnormal hormone levels
  • Severe or treatment-resistant symptoms
  • Concerns about premature ovarian insufficiency
  • Complex medical history affecting treatment options 4

Important Considerations

• Laboratory values alone cannot definitively diagnose perimenopause
• Symptoms and menstrual pattern changes are more reliable indicators
• Testing is more valuable for ruling out other conditions than confirming perimenopause
• Repeat testing may be necessary due to hormonal fluctuations
• Consider contraceptive needs, as pregnancy is still possible during perimenopause 6

Remember that perimenopause is primarily a clinical diagnosis, and laboratory testing should be used as a supportive tool rather than the definitive diagnostic approach.