What is the diagnostic approach for a woman suspected to be in menopause, including relevant tests and evaluations?

Diagnosing Menopause: Laboratory Testing Approach

Menopause is primarily a clinical diagnosis based on age and 12 months of amenorrhea, and routine laboratory testing is generally not necessary for diagnosis in typical cases. 1, 2

When Laboratory Testing Is NOT Needed

• Women over age 45 with typical symptoms (hot flashes, night sweats, irregular periods) do not require hormone testing 2
• The diagnosis should be made based on menstrual history and age alone 2
• Self-assessment of perimenopausal status combined with age is sufficiently accurate (likelihood ratio 1.53-2.13) 2
• Hot flashes provide strong diagnostic support (likelihood ratio 2.15-4.06) without needing blood tests 2

When Laboratory Testing IS Indicated

Order FSH and estradiol levels in these specific situations: 3, 4

Cancer Treatment Context

• Women taking tamoxifen or toremifene who need confirmation of postmenopausal status 3
• Women with amenorrhea after chemotherapy (amenorrhea alone is unreliable) 3
• Women under age 60 who are amenorrheic for ≤12 months before starting adjuvant endocrine therapy 3
• Serial measurements are required if considering aromatase inhibitor therapy 3

Uncertain Clinical Scenarios

• Women in their 40s with atypical symptoms where diagnosis is unclear 4
• When determining if ovarian function has returned after a period of amenorrhea 4

The Correct Test Panel

When testing is indicated, order: 3, 4

• FSH (follicle-stimulating hormone) - primary marker
• Estradiol - must be measured alongside FSH
• LH (luteinizing hormone) - recommended as part of core evaluation 4
• Prolactin - to rule out other causes of amenorrhea 4

Interpretation Requirements

• Both FSH AND estradiol must be in the postmenopausal range to confirm menopausal status 3
• A single elevated FSH is insufficient for diagnosis 3
• High FSH has a positive likelihood ratio of 3.06 for perimenopause 2

Critical Testing Limitations

Do not attempt to assign menopausal status in women receiving: 3

• LHRH agonists or antagonists (GnRH agonists)
• Testing must be deferred until after discontinuation of these medications 3

Important caveat: Aromatase inhibitors can stimulate ovarian function, so any vaginal bleeding while on an AI requires immediate physician contact 3

Additional Testing to Consider

Thyroid Function

• TSH and TPO antibodies should be checked if thyroid dysfunction is suspected, as thyroid disorders commonly mimic menopausal symptoms in this age group 4

Metabolic Screening

• Fasting glucose or oral glucose tolerance test if insulin resistance is suspected, given accelerated metabolic changes during menopause 4

Clinical Pitfalls to Avoid

• Do not rely on laboratory tests alone - hormone levels fluctuate significantly during perimenopause, making single measurements unreliable 2, 5
• Do not order tests in straightforward cases - this adds unnecessary cost without improving diagnostic accuracy 2
• Do not assume amenorrhea after chemotherapy equals menopause - serial hormone measurements are mandatory 3
• Do not forget to counsel about endometrial cancer - women should be instructed to report any unexpected vaginal bleeding immediately 4