Hormonal Testing for Suspected Menopause
For women under 60 years of age who suspect they are menopausal, measure both follicle-stimulating hormone (FSH) and estradiol levels after 12 months of amenorrhea to confirm postmenopausal status—FSH should be in the postmenopausal range and estradiol should be low. 1
Age-Based Testing Strategy
Women Under 60 Years
- Both FSH and estradiol must be measured together after 12 months of amenorrhea to confirm menopause, as the combination provides stronger diagnostic certainty than either hormone alone 1
- FSH levels should be in the postmenopausal range (typically >40 mIU/mL based on most laboratory standards) and estradiol should be low (typically <20-30 pg/mL) 1, 2
- Serial measurements rather than single values should be considered, as hormone levels can fluctuate significantly during the perimenopausal transition 1, 3
Women 60 Years or Older
- No laboratory testing is required—age alone is sufficient for clinical diagnosis of menopause in this population 1
- This recommendation simplifies the diagnostic approach and avoids unnecessary testing costs 1
Special Clinical Situations Requiring Modified Approach
Women on Selective Estrogen Receptor Modulators (SERMs)
- For women taking tamoxifen or toremifene who are under 60 years, both FSH and plasma estradiol levels in postmenopausal ranges are required for diagnosis 1, 4
- FSH alone is unreliable in this population due to the effects of these medications on the hypothalamic-pituitary-ovarian axis 1
Women with Chemotherapy-Induced Amenorrhea
- FSH is not a reliable marker of menopausal status in women who have undergone chemotherapy 1, 4
- Serial estradiol measurements are more useful to determine return of ovarian function, as amenorrhea after chemotherapy does not reliably indicate permanent menopause 1, 4
- Ovarian function may resume despite prolonged absence of menses 4
Women on GnRH Agonists/Antagonists
- It is not possible to accurately determine menopausal status while receiving LHRH agonists or antagonists 1, 4
- If definitive status determination is required, either oophorectomy or serial hormone measurements after discontinuation of therapy are needed 1
Additional Hormones to Consider
Luteinizing Hormone (LH)
- LH may be checked as clinically indicated to provide additional information about ovarian function, though it is not required for routine diagnosis 4
- Serial assessment of LH alongside FSH and estradiol is recommended when considering aromatase inhibitor therapy in women who become amenorrheic with chemotherapy 5
Other Hormones (Not Routinely Recommended)
- Prolactin should be measured only when clinically indicated to rule out other causes of menstrual irregularity (e.g., hyperprolactinemia) 4
- Anti-Müllerian hormone (AMH) may provide additional information on ovarian reserve, though normative data in perimenopausal women are limited and it is not part of standard diagnostic criteria 4
Common Pitfalls to Avoid
Relying on Single Measurements
- Hormone levels fluctuate dramatically during the perimenopausal transition—FSH can rise into the postmenopausal range and then fall back to premenopausal levels, and ovulation may still occur after apparently postmenopausal FSH levels 3
- A single elevated FSH does not confirm menopause in perimenopausal women 3, 2
Testing During Hormonal Therapy
- Menopausal status cannot be determined while receiving ovarian suppression therapy 5
- Aromatase inhibitors can stimulate ovarian function, making hormone level interpretation unreliable 5
Ignoring Clinical Context
- Hormone levels should always be interpreted in the context of menstrual history, age, and clinical symptoms rather than in isolation 2
- For women with regular menstruation who are perimenopausal, diagnosis should be based primarily on menstrual history and age without relying solely on laboratory testing 2