What are the protocols to test for perimenopause in a woman likely between 40 and 55 years old presenting with symptoms such as hot flashes, mood changes, or irregular periods?

Testing Protocols for Perimenopause

Perimenopause should be diagnosed clinically based on menstrual history and age alone, without relying on laboratory testing, as no single test is accurate enough to confirm or exclude the diagnosis. 1

Clinical Diagnosis (First-Line Approach)

The most reliable diagnostic approach combines:

• Age assessment: Women aged 40-55 years have the highest prior probability of perimenopause 1
• Menstrual pattern changes: 3-11 months of amenorrhea or irregular menstrual cycles defines perimenopause 1
• Self-assessment: When women report they believe they are "going through the transition," this has a positive likelihood ratio of 1.53-2.13 1

The negative likelihood ratio for self-assessment (0.18-0.36) makes it the single most useful tool for ruling out perimenopause when a woman does not believe she is transitioning. 1

Symptom Assessment (Diagnostic Value)

Key symptoms that increase the likelihood of perimenopause include:

• Hot flashes: Positive likelihood ratio of 2.15-4.06, experienced by 80% of perimenopausal women 1, 2
• Night sweats: Positive likelihood ratio of 1.90 1
• Vaginal dryness: Positive likelihood ratio of 1.48-3.79 1
• Sleep disturbances, mood changes, and cognitive difficulties: Common but less specific 3

Laboratory Testing (Limited Role)

Laboratory tests should only be ordered "as clinically indicated" and are not reliable markers of menopausal status in most situations. 3

When laboratory evaluation is pursued, consider:

• FSH levels: Positive likelihood ratio of 3.06 for elevated levels, but FSH is unreliable in women with prior chemotherapy, pelvic radiation, or those taking tamoxifen 3, 1
• Estradiol levels: May be useful in amenorrheic women to determine return of ovarian function, but levels are often erratically elevated (averaging 26% higher) rather than decreased during perimenopause 3, 2
• LH and prolactin: Check only as clinically indicated 3
• Inhibin B: Low levels have a positive likelihood ratio of 2.05, but provide limited additional diagnostic value 1
• Anti-Müllerian hormone (AMH): May provide supplementary information but is not reliable alone 3

Critical Pitfall

Do not order FSH testing routinely—it adds minimal diagnostic value beyond clinical assessment and is particularly unreliable in women on hormonal therapies or with history of chemotherapy/radiation. 3, 1

Exclude Medical Causes

Before confirming perimenopause, screen for conditions that mimic menopausal symptoms:

• Thyroid disease: Essential to rule out, as thyroid dysfunction can cause similar symptoms 3
• Diabetes: Should be assessed in symptomatic women 3

Special Populations Requiring Modified Assessment

• Cancer survivors: FSH is not a reliable marker; use serial estradiol levels if needed to assess ovarian function 3
• Women on tamoxifen or aromatase inhibitors: May experience menopausal symptoms without meeting the definition of menopause 3
• Post-chemotherapy patients: 33-73% become perimenopausal or postmenopausal after treatment; may have primary ovarian insufficiency with irregular menses but potential fertility 3

Confirmation of Menopause

Menopause is confirmed by 12 consecutive months of amenorrhea in the absence of chemotherapy or tamoxifen use, or after surgical removal of all ovarian tissue. 3 Contraception should continue until menopause is definitively confirmed. 4