What is the recommended approach for a menopause workup?

Menopause Workup

A menopause workup is primarily a clinical diagnosis based on age and symptom assessment, not laboratory testing—routine hormone measurements (FSH, estradiol) are unnecessary in women over 45 with typical symptoms and amenorrhea. 1

Clinical Diagnosis Approach

Primary Assessment Criteria

The diagnosis of menopause is fundamentally clinical and requires:

• Age assessment: Median age of menopause is 51 years (range 40-60 years in the US) 2, 1
• Menstrual history: Document pattern of menstrual irregularity or cessation 1, 3
• Symptom evaluation: Assess for vasomotor symptoms (hot flashes, night sweats), genitourinary symptoms (vaginal dryness, dyspareunia, urinary urgency), sleep disturbances, mood changes, and sexual dysfunction 3, 4, 5

When Laboratory Testing Is NOT Needed

For women ≥45 years with typical menopausal symptoms and amenorrhea, no hormonal testing is required for diagnosis. 1 The clinical presentation alone is sufficient.

When Laboratory Testing MAY Be Indicated

Laboratory workup should be reserved for specific clinical scenarios:

• Premature menopause (age <40): FSH levels can help confirm premature ovarian insufficiency 1
• Unclear menopausal status: Women on hormonal contraceptives or with irregular bleeding patterns where diagnosis is uncertain 1
• Surgical or treatment-induced menopause: Women who underwent chemotherapy, radiation, or oophorectomy requiring confirmation 1

If testing is performed: Elevated FSH (>25-30 mIU/mL) and low estradiol (<20 pg/mL) support the diagnosis, but these values fluctuate significantly during perimenopause and should not be used as sole diagnostic criteria 4, 6

Comprehensive Symptom Assessment

Vasomotor Symptoms

Document the following specific characteristics:

• Frequency and severity of hot flashes: recurrent, transient episodes of flushing, perspiration, and sensation of warmth to intense heat on upper body and face 1
• Night sweats: hot flashes occurring with perspiration during sleep 1
• Impact on quality of life: whether symptoms interfere with daily activities or sleep 5, 7

Genitourinary Symptoms

Assess for:

• Vaginal dryness, pruritus, dyspareunia 3
• Urinary urgency, frequency, or recurrent infections 3
• Sexual dysfunction including decreased libido 3, 4

Other Menopausal Manifestations

Evaluate for:

• Sleep disturbances (independent of night sweats) 3, 5
• Mood changes or depression 3, 4
• Cognitive changes (difficulty concentrating, memory concerns) 3, 4
• Arthralgias/myalgias and fatigue 3

Risk Assessment for Treatment Planning

Cardiovascular Risk Stratification

Before considering hormone therapy, assess:

• Age and time since menopause onset: Most favorable benefit-risk profile exists for women <60 years or within 10 years of menopause 1, 5
• Cardiovascular disease history: coronary heart disease is an absolute contraindication to HRT 1
• Stroke or venous thromboembolism history: absolute contraindications 1
• Blood pressure measurement: required before prescribing any hormonal therapy 2

Contraindications to Hormone Therapy

Absolute contraindications include:

• History of breast cancer or other hormone-sensitive cancers 1, 3
• Active liver disease 1
• Antiphospholipid syndrome or positive antiphospholipid antibodies 1
• Previous venous thromboembolic event 1
• History of coronary heart disease or stroke 1

Relative contraindications:

• History of gallbladder disease (increased risk with oral HRT) 1
• Women ≥60 years or >10 years past menopause (less favorable risk-benefit profile) 1, 5

Bone Health Assessment

When to Screen for Osteoporosis

• DEXA scan: Consider in postmenopausal women based on age and risk factors, following USPSTF osteoporosis screening guidelines 2
• Fracture risk assessment: Document history of fragility fractures, family history, smoking, low body weight 2

Important caveat: While HRT reduces fracture risk by 30-50%, it should NOT be initiated solely for osteoporosis prevention—other effective interventions include weight-bearing exercise, bisphosphonates, and calcitonin 2, 1

Breast and Gynecologic Assessment

Breast Cancer Screening

• Mammography: Ensure age-appropriate breast cancer screening is current 2
• Breast examination: Not required before prescribing oral contraceptives or HRT per Choosing Wisely guidelines, but should be part of routine preventive care 2

Pelvic Assessment

• Pelvic examination is NOT required to prescribe hormonal therapy 2
• Assess for abnormal vaginal bleeding: This is a contraindication to HRT until evaluated 1
• Endometrial assessment: Only if abnormal bleeding is present 1

Common Pitfalls to Avoid

Critical errors in menopause workup:

• Over-reliance on FSH/estradiol testing: These fluctuate wildly during perimenopause and add little diagnostic value in typical cases 1, 4
• Initiating HRT solely for chronic disease prevention: HRT should NOT be started for osteoporosis or cardiovascular disease prevention—symptom management is the only appropriate indication 2, 1
• Delaying treatment until postmenopause: HRT can be initiated during perimenopause when vasomotor symptoms begin; waiting is unnecessary 1
• Failing to reassess women already on HRT at age 65: Women should be evaluated for discontinuation or dose reduction at this age 1

Algorithm for Menopause Workup

1. Confirm age ≥45 with amenorrhea or irregular menses → Clinical diagnosis of menopause, no testing needed 1

2. If age <40 with amenorrhea → Check FSH and estradiol to confirm premature ovarian insufficiency 1

3. Assess symptom severity using specific questions about vasomotor, genitourinary, sleep, mood, and sexual symptoms 3, 5

4. Screen for absolute contraindications to HRT: breast cancer, cardiovascular disease, VTE, stroke, liver disease, antiphospholipid syndrome 1

5. Measure blood pressure before any hormonal therapy consideration 2

6. If moderate-to-severe symptoms AND age <60 or within 10 years of menopause AND no contraindications → Offer HRT with transdermal estradiol as first-line (plus progestin if uterus intact) 1, 5

7. If contraindications exist or patient declines HRT → Offer SSRIs/SNRIs, gabapentin, or lifestyle modifications for vasomotor symptoms; vaginal estrogen or non-hormonal lubricants for genitourinary symptoms 2, 1

8. Ensure appropriate cancer screening and bone health assessment per standard guidelines 2