What does elevated FSH and LH mean for a postmenopausal woman considering Hormone Replacement Therapy (HRT)?

Elevated FSH and LH Confirm Postmenopausal Status and Support HRT Candidacy

Your patient's FSH of 106.0 and LH of 31.5 confirm she is definitively postmenopausal, as these markedly elevated gonadotropin levels reflect the loss of ovarian estrogen production and the absence of negative feedback on the pituitary. 1, 2

What These Lab Values Mean

• FSH >40 IU/L and elevated LH are diagnostic of menopause, reflecting the pituitary's attempt to stimulate non-functional ovaries through increased gonadotropin secretion 1, 3
• After menopause, circulating estrogens exist primarily as estrone and estrone sulfate (from peripheral conversion of adrenal androgens), with estradiol production essentially ceased 3
• Estrogens normally suppress FSH and LH through negative feedback; the loss of this feedback mechanism causes the dramatic elevation you're seeing 3, 4

Clinical Implications for HRT Decision-Making

At age 62, your patient is outside the optimal "window of opportunity" for initiating HRT (under 60 or within 10 years of menopause), which significantly alters the risk-benefit profile. 1, 2, 5

If She Has Moderate-to-Severe Vasomotor or Genitourinary Symptoms:

• HRT can still be considered, but only at the absolute lowest effective dose for the shortest duration necessary to control symptoms 1, 2
• The American College of Physicians explicitly states that for women over 60, risks increasingly outweigh benefits, particularly for cardiovascular events and stroke 1, 5
• Transdermal estradiol 0.05 mg (50 μg) twice weekly plus micronized progesterone 200 mg nightly is the preferred regimen if she has an intact uterus 1, 2
• Transdermal delivery bypasses hepatic first-pass metabolism, reducing cardiovascular and thromboembolic risks compared to oral formulations 1, 2, 6

Critical Contraindications to Screen For:

Before initiating HRT at age 62, you must exclude absolute contraindications: 1, 2, 5

• History of breast cancer or hormone-sensitive malignancies
• Active or prior venous thromboembolism or stroke
• Coronary heart disease
• Active liver disease
• Antiphospholipid syndrome or positive antiphospholipid antibodies
• Unexplained vaginal bleeding

If She Is Asymptomatic:

Do not initiate HRT solely for chronic disease prevention (osteoporosis, cardiovascular disease)—this carries a Grade D recommendation from the USPSTF, as harms exceed benefits in asymptomatic postmenopausal women. 1, 2, 5

Why These Gonadotropin Levels Don't Guide HRT Dosing

• FSH and LH levels are NOT used to titrate HRT dosing or monitor treatment response 1, 4
• Even on adequate HRT, FSH and LH remain elevated (though reduced from baseline) and never return to premenopausal values 7, 4
• Symptom control is the primary endpoint for dose adjustment, not hormone levels 1, 4
• A serum estradiol level of 15-25 pg/mL is sufficient to suppress gonadotropins and relieve vasomotor symptoms, while ≥15 pg/mL is needed for bone protection 4

Risk Profile at Age 62

For every 10,000 women over 60 taking combined estrogen-progestin for 1 year, expect: 1, 2

• 7 additional coronary heart disease events
• 8 additional strokes
• 8 additional pulmonary emboli
• 8 additional invasive breast cancers
• Balanced against 6 fewer colorectal cancers and 5 fewer hip fractures

The absolute risks are modest but increase with age and duration beyond 5 years. 1, 8

Non-Hormonal Alternatives to Consider First

If she has primarily genitourinary symptoms: 1, 5

• Low-dose vaginal estrogen (rings, suppositories, creams) improves symptoms by 60-80% with minimal systemic absorption
• Vaginal moisturizers and lubricants reduce symptom severity by up to 50%

If she has primarily vasomotor symptoms: 5

• Cognitive behavioral therapy or clinical hypnosis can reduce hot flashes
• SSRIs or gabapentin are alternatives for high-risk patients

Common Pitfalls to Avoid

• Do not assume elevated FSH/LH require "replacement" to normal levels—this is not the goal of HRT 1, 4
• Do not use oral estrogen in women over 60 due to excess stroke risk; transdermal is mandatory if HRT is used 1, 5
• Do not continue HRT beyond symptom management needs—breast cancer risk increases significantly beyond 5 years 1, 8
• Do not prescribe estrogen without progestin if she has an intact uterus, as this increases endometrial cancer risk by 90% 1, 2

Annual Reassessment Protocol

If HRT is initiated: 1

• Attempt dose reduction or discontinuation at 3-6 month intervals
• Annual clinical review focusing on ongoing symptom burden and compliance
• Mammography per standard screening guidelines