What hormones should be drawn to evaluate menopause, specifically follicle-stimulating hormone (FSH) and estradiol (E2) levels?

Hormones to Draw for Menopause Evaluation

Age-Based Testing Approach

For women under 60 years of age with amenorrhea, measure both FSH and estradiol levels together to confirm postmenopausal status, while women 60 years or older require no laboratory testing as age alone is sufficient for diagnosis. 1

Women Under 60 Years

• Order both FSH and estradiol after 12 months of amenorrhea to confirm postmenopausal status 1, 2
• Both hormones must be in the postmenopausal range (elevated FSH and low estradiol) to confirm the diagnosis 1, 2
• The combination of elevated FSH and low estradiol provides stronger diagnostic certainty than either hormone alone 1
• Use your local laboratory's definitions of postmenopausal ranges when interpreting results 1

Women 60 Years or Older

• No laboratory testing is required - age alone is sufficient for clinical diagnosis in this population 1
• This recommendation is supported by both the National Comprehensive Cancer Network and Journal of Clinical Oncology 1

Special Populations Requiring Modified Testing

Women on Tamoxifen or Toremifene

• FSH alone is unreliable in women taking selective estrogen receptor modulators 1, 2
• Measure both FSH and plasma estradiol levels, with both required to be in postmenopausal ranges for diagnosis 1, 2
• Hormone levels and absence of menses are unreliable indicators of menopause during tamoxifen treatment 3

Women with Chemotherapy-Induced Amenorrhea

• FSH is not a reliable marker of menopausal status in this population 1, 2
• Cessation of menses does not necessarily denote absence of ovarian function 3
• Serial estradiol measurements are more useful than FSH to determine return of ovarian function 1
• Premenopausal estradiol levels can be found in patients with transient chemotherapy-induced amenorrhea 3
• Consider serial measurements rather than single values when monitoring these patients 1

Women on GnRH Agonists/Antagonists

• It is not possible to assign menopausal status while receiving LHRH agonists or antagonists 2
• Testing should be deferred until after discontinuation of these medications 2
• If definitive status determination is required, oophorectomy or serial hormone measurements after stopping medication are needed 1

Important Clinical Caveats

Limitations of FSH Testing

• FSH levels can fluctuate dramatically during the perimenopausal transition, rising into the postmenopausal range and then falling back to premenopausal levels 4
• Postmenopausal FSH levels may be followed by endocrine evidence compatible with normal ovulation 4
• No single FSH cutoff value (including the frequently cited 40 IU/L) is reliable for distinguishing menopausal status 5
• FSH measurement is of little value during the menopausal transition because it cannot be interpreted reliably 4

Additional Monitoring Considerations

• For women under 60 who are amenorrheic for ≤12 months prior to starting adjuvant endocrine therapy, monitor estradiol and FSH/LH levels 2
• If vaginal bleeding occurs while on an aromatase inhibitor, immediate physician contact is required as AIs can stimulate ovarian function 2
• Monitor for clinical symptoms suggesting persistent ovarian function in women with chemotherapy history or on endocrine therapy 1

Hormone Level Patterns

• In postmenopausal women, FSH levels rise 10-15 fold with low estradiol levels 4
• The ratio between estrone (E1) and estradiol (E2) increases during the transition, reflecting declining follicular steroidogenesis 6
• There is significant but minimal negative correlation between serum FSH and estradiol levels 7