What labs are recommended for perimenopause diagnosis and management?

Recommended Laboratory Tests for Perimenopause Diagnosis and Management

For perimenopause diagnosis and management, laboratory evaluation should include estradiol, follicle-stimulating hormone (FSH), luteinizing hormone (LH), and prolactin, as clinically indicated. 1

Core Laboratory Tests

• Estradiol, FSH, and LH should be measured during the early follicular phase (days 3-6 of the menstrual cycle) for accurate assessment 1
• FSH is not a reliable marker of menopausal status alone, especially in women with prior chemotherapy, pelvic radiation exposure, or those on tamoxifen 1
• Serial estradiol levels can be useful to determine return of ovarian function in perimenopausal women who have become amenorrheic and later develop bleeding 1
• Prolactin should be measured to rule out hyperprolactinemia as a cause of menstrual irregularity 1

Additional Tests Based on Clinical Presentation

• Thyroid function tests to rule out thyroid disease that may mimic menopausal symptoms 1
• Fasting glucose/insulin levels if insulin resistance is suspected, particularly with weight gain 1
• Anti-Müllerian hormone (AMH) may provide additional information on ovarian status and reserve, though it should be interpreted with caution in women under age 25 1
• Inhibin levels may provide supplementary information on ovarian status but are not reliable alone 1
• Testosterone levels if hirsutism or other signs of hyperandrogenism are present 1

Timing and Interpretation Considerations

• Laboratory tests should be performed without hormonal contraception or hormone replacement therapy for accurate assessment 1
• FSH fluctuates significantly during perimenopause and a single elevated value does not confirm menopause 1
• For women with irregular cycles, testing should be performed on day 3-6 of the cycle when possible 1
• Multiple measurements may be necessary due to the erratic hormone fluctuations characteristic of perimenopause 2

Clinical Correlation

• Laboratory results should be interpreted in conjunction with menstrual history and symptoms 1
• Menstrual irregularity (cycles <23 days or >35 days) is a key clinical indicator of perimenopause 1
• Common perimenopausal symptoms requiring assessment include vasomotor symptoms, sleep disturbances, mood changes, and sexual dysfunction 1, 3
• The most prevalent symptoms during menopausal transition are fatigue, excitability, and irritability 3

Pitfalls and Caveats

• A normal FSH level does not rule out perimenopause, as levels fluctuate widely during this transition 1
• AMH levels have wide normal ranges in young women and should not be used alone for diagnosis 1
• Women may still be fertile during perimenopause despite irregular cycles and should be counseled about contraception 4
• Symptoms alone are not diagnostic of perimenopause and require laboratory confirmation when making management decisions 1

When to Refer

• Endocrinology or gynecology referral is indicated for delayed puberty, persistently abnormal hormone levels, or hypogonadism 1
• Reproductive endocrinology consultation for infertility evaluation or fertility preservation concerns 1
• Consider specialist referral for severe or persistent symptoms affecting quality of life 1

Laboratory assessment is essential for confirming perimenopause status and guiding appropriate management decisions to address symptoms and prevent long-term health consequences.