What comprehensive blood lab tests are recommended for a perimenopausal female patient to evaluate hormone status, thyroid function, bone health, and cardiovascular risk factors?

Blood Lab Testing Protocol for Perimenopause

For perimenopausal women, obtain baseline FSH, LH, and estradiol (ideally on cycle days 3-6 if still menstruating), TSH with free T4, fasting lipid panel, and fasting glucose every 2 years, with additional mid-luteal progesterone if cycles are irregular to assess for anovulation. 1

Core Hormone Panel

Reproductive Hormones

• FSH, LH, and estradiol should be measured in women with irregular menses, amenorrhea, or clinical signs of estrogen deficiency 1
• Optimal timing is days 3-6 of the menstrual cycle for accurate interpretation 1, 2
• Mid-luteal phase progesterone (approximately day 21 of a 28-day cycle) is indicated when irregular cycles are present to assess for anovulation; levels <6 nmol/L indicate anovulation 1, 2
• Perimenopausal women characteristically show elevated FSH (range 4-32 IU/g Cr vs 3-7 in younger women), elevated LH, and paradoxically higher estrone levels compared to younger reproductive-aged women 3

Thyroid Function

• TSH testing is the recommended initial screening test with 98% sensitivity and 92% specificity for detecting thyroid disease 1
• Consider thyroid testing in perimenopausal women with nonspecific symptoms consistent with hypothyroidism, as subclinical hypothyroidism occurs in 18% of perimenopausal females 1, 4
• TSH with free T4 should be measured annually, as subclinical hypothyroidism is associated with dyslipidemia, hypertension, and increased cardiovascular risk in this population 5, 4, 6
• The prevalence of thyroid disease increases significantly in postmenopausal women (23.2% subclinical disease, 2.4% clinical disease), making screening particularly important 6

Cardiovascular Risk Assessment

Lipid Panel

• Fasting lipid profile every 2 years including total cholesterol, LDL, HDL, and triglycerides 5
• Calculate atherogenic indices: TC/HDL-c, LDL-c/HDL-c, and TG/HDL-c ratios as these are particularly relevant in perimenopausal women with subclinical hypothyroidism 4
• TSH levels positively correlate with total cholesterol and elevated TC/HDL-c ratio, even in euthyroid postmenopausal women 4, 7

Metabolic Screening

• Fasting glucose every 2 years to screen for diabetes risk 5
• Consider fasting insulin if signs of insulin resistance are present (central obesity, acanthosis nigricans, irregular cycles suggestive of PCOS) 2

Androgen Assessment (When Indicated)

Clinical Triggers for Testing

• Order androgen panel if patient presents with acne plus additional signs of androgen excess 1
• Test for hirsutism, especially when accompanied by menstrual irregularities 1
• Typical screening panel includes: free and total testosterone, DHEA-S, androstenedione, LH, and FSH 1
• An LH:FSH ratio >2:1 suggests PCOS, which affects 4-6% of the general female population 2

Bone Health Screening

Timing and Indications

• Routine bone density screening is not recommended before age 65 unless specific risk factors are present 5
• For women aged 60-64, screen if body weight <70 kg (the single best predictor of low bone mineral density) or if not currently using estrogen therapy 5
• Additional risk factors warranting earlier screening include: smoking, family history of osteoporosis, decreased physical activity, or early menopause (before age 45) 5, 1

Special Considerations and Pitfalls

Timing and Interpretation

• Avoid hormone testing in women currently on oral contraceptives; stop them for at least 2 months before assessment to avoid suppression of normal FSH and LH patterns 2
• If patient has irregular or absent cycles, document menstrual pattern over 6 months before making definitive diagnoses 2
• Women with early menopause (before age 45) require evaluation and modification of vascular risk factors due to elevated stroke risk 1

Cancer Survivors

• Cancer survivors who received gonadotoxic therapy should have hormone testing to assess for premature ovarian failure 1
• Women with history of Hodgkin lymphoma treatment have increased risk of premature ovarian failure and require monitoring 1

Anti-Müllerian Hormone (AMH)

• AMH correlates well with ovarian reserve and may be more reliable than FSH, estradiol, and inhibin B in assessing ovarian function 1
• Consider AMH testing if fertility preservation or ovarian reserve assessment is clinically relevant

Monitoring Frequency

• Annual TSH (or TSH with free T4) 5
• Lipid panel and fasting glucose every 2 years 5
• Repeat FSH/LH/estradiol only if clinically indicated by symptom changes or treatment decisions, as these fluctuate significantly during perimenopause 3
• If subclinical hypothyroidism is detected and treatment initiated, recheck TSH at 12 weeks after starting therapy 6