What are the initial steps in a perimenopause workup?

Perimenopause Workup

The initial perimenopause workup requires clinical diagnosis based on age and menstrual pattern changes, with selective laboratory testing only when diagnosis is uncertain or specific clinical scenarios warrant it.

Clinical Assessment

History and Symptom Evaluation

• Document menstrual pattern changes: irregular cycles, changes in flow, and duration of amenorrhea 1, 2
• Screen for vasomotor symptoms: hot flashes, night sweats (occur in 46-73% of perimenopausal women) 1
• Assess genitourinary symptoms: vaginal dryness, dyspareunia, urinary complaints 1, 2
• Evaluate neuropsychiatric symptoms: sleep disturbance, mood changes, depression, cognitive dysfunction, anxiety 1, 2
• Document musculoskeletal complaints: arthralgias, myalgias 1
• Review sexual function: changes in libido, dyspareunia 1

Physical Examination

• General health assessment: vital signs, weight, BMI 1
• Breast examination: evaluate for masses, discharge 1
• Pelvic examination: assess for vaginal atrophy, pelvic organ prolapse (if genitourinary symptoms present) 3

Laboratory Testing

When Laboratory Testing is Indicated

Laboratory evaluation is not routinely necessary for diagnosis in women over 45 with typical symptoms and menstrual irregularity 1. However, testing should be performed in specific scenarios:

• Age <45 years with suspected premature menopause 1
• Unclear menopausal status (e.g., post-hysterectomy without oophorectomy) 1
• Women considering aromatase inhibitor therapy 1
• Therapy-induced amenorrhea (post-chemotherapy) where ovarian function status affects treatment decisions 1

Specific Laboratory Tests

When testing is indicated:

• FSH and estradiol levels: FSH in postmenopausal range with low estradiol suggests menopause 1, 2
• Serial measurements may be needed: single measurements unreliable due to hormonal fluctuations during perimenopause 1

Critical Limitations of Laboratory Testing

• FSH is unreliable in women with prior chemotherapy, pelvic radiation, or those taking tamoxifen 2
• Amenorrhea after chemotherapy does not confirm menopause: ovarian function may resume despite anovulation 1
• Cannot assign menopausal status to women receiving LHRH agonists/antagonists 1

Diagnostic Criteria for Menopause

Use clinical criteria rather than laboratory values 1:

• Prior bilateral oophorectomy 1
• Age ≥60 years 1
• Age <60 years with ≥12 months amenorrhea in absence of chemotherapy, tamoxifen, toremifene, or ovarian suppression, AND FSH/estradiol in postmenopausal range 1
• If taking tamoxifen/toremifene and age <60: require FSH and estradiol in postmenopausal ranges 1

Additional Workup Based on Symptoms

For Abnormal Uterine Bleeding

• Endometrial assessment: transvaginal ultrasound or endometrial biopsy to exclude malignancy 1
• Imaging of uterine cavity: if fibroids suspected 1

For Women with Therapy-Induced Amenorrhea

• Oophorectomy or serial FSH/estradiol measurements: required to confirm postmenopausal status if aromatase inhibitors are being considered 1
• Contraception counseling: women may still be fertile despite amenorrhea 1, 4

Baseline Health Screening

• Complete blood count: assess for anemia if heavy bleeding 1
• Liver and renal function tests: baseline if considering hormone therapy 1
• Lipid panel and cardiovascular risk assessment: perimenopause increases cardiovascular risk 3
• Bone density screening: consider if risk factors for osteoporosis present 3

Common Pitfalls to Avoid

• Do not rely on single FSH measurement for diagnosis in perimenopausal women due to wide hormonal fluctuations 1, 2
• Do not assume amenorrhea equals infertility in perimenopausal women, especially post-chemotherapy 1, 4, 5
• Do not order extensive laboratory workup in women >45 with typical symptoms and menstrual changes 1
• Do not use FSH to assess menopausal status in women on tamoxifen, after chemotherapy, or receiving LHRH therapy 1, 2