What tests should be included in a standard hormone panel for a perimenopausal female, specifically a 47-year-old woman?

Standard Hormone Panel for a 47-Year-Old Perimenopausal Woman

For a 47-year-old woman, measure FSH and estradiol during the early follicular phase (days 3-6 of the menstrual cycle), but recognize that these values fluctuate markedly during perimenopause and should not be used alone to diagnose menopausal status—clinical assessment of menstrual patterns and symptoms is more reliable. 1, 2

Core Hormone Panel

Essential Tests

• FSH (Follicle-Stimulating Hormone): Measure during early follicular phase (days 3-6 of cycle) 1

  • Expected finding: FSH rises significantly in perimenopausal women (mean ~13.0 IU/L vs. 4.9-5.5 IU/L in younger women) 3
  • FSH >35 IU/L suggests ovarian insufficiency 1
  • Critical caveat: FSH fluctuates dramatically during perimenopause, with both ovulatory cycles showing minimal elevation and anovulatory cycles showing marked increases 4, 5

• Estradiol (E2): Measure during early follicular phase (days 3-6 of cycle) 1

  • Perimenopausal women paradoxically may show hyperestrogenism (mean 76.9 ng/mg Cr vs. 40.7 ng/mg Cr in younger women) 6
  • Low estradiol (<25 pg/mL) combined with elevated FSH suggests approaching menopause 2

• LH (Luteinizing Hormone): Measure during early follicular phase 1

  • Calculate LH/FSH ratio 1
  • LH/FSH ratio >2 suggests polycystic ovary syndrome 1
  • LH remains relatively normal during perimenopause while FSH rises 5

Additional Hormones Based on Clinical Presentation

• Progesterone: Measure during mid-luteal phase (3-12 days before next menses) 1

  • <6 nmol/L indicates anovulation 1
  • Perimenopausal women show diminished luteal phase progesterone 6

• Prolactin: Morning resting level (not post-ictal) 1

  • 20 μg/L is abnormal 1

  • Rule out hypothyroidism or pituitary tumor if elevated 1

• TSH and Free T4: Essential screening 1

  • Thyroid dysfunction commonly presents with menstrual irregularity 1

Important Clinical Considerations

Timing of Blood Draw Matters

Draw FSH, LH, and estradiol between days 3-6 of the menstrual cycle for meaningful interpretation 1. Random timing renders these values uninterpretable given the marked hormonal fluctuations throughout the cycle 4.

FSH is Unreliable as a Sole Marker

Do not rely on a single FSH measurement to diagnose perimenopause or predict menopause timing 1, 2, 4. FSH levels fluctuate wildly during the menopausal transition, with values ranging from normal in ovulatory cycles to markedly elevated in anovulatory cycles 4, 5. Women can have ovulatory cycles with normal FSH even after entering late menopausal transition 4.

Anti-Müllerian Hormone (AMH)

While AMH shows promise as an ovarian reserve marker, it has limitations 1:

• Wide range of normal values in healthy young women 1
• Should be interpreted with extra caution if assessed before age 25 1
• Correlates with follicle numbers and reaches undetectable levels at menopause 4
• Not yet standard of care for routine perimenopause assessment 1

When to Expand Testing

If Menstrual Irregularity Present

Add testosterone, androstenedione, DHEAS, and fasting glucose/insulin if oligomenorrhea, amenorrhea, or signs of hyperandrogenism exist 1:

• Testosterone (days 3-6): >2.5 nmol/L abnormal 1
• Androstenedione: >10.0 nmol/L (rule out adrenal/ovarian tumor) 1
• DHEAS: Age-specific cutoffs (age 30-39: >2700 ng/mL abnormal) 1

If Galactorrhea or Amenorrhea

Pelvic ultrasound to assess for polycystic ovaries (>10 peripheral cysts, 2-8 mm diameter) 1.

Key Pitfalls to Avoid

• Never diagnose perimenopause based solely on laboratory values—menstrual history and age are more reliable 2
• Do not check FSH in women on hormone replacement therapy or oral contraceptives—ovarian function cannot be assessed during HRT 1
• Recognize that "normal" FSH does not exclude perimenopause—ovulatory cycles with normal FSH occur throughout the transition 4
• A single elevated FSH does not confirm menopause—repeat testing may show normal values 4, 5