Initial Laboratory Testing for Menopause
For women presenting with perimenopausal symptoms, the core laboratory panel should include FSH, estradiol, TSH, and prolactin, though menopause remains primarily a clinical diagnosis based on symptoms and menstrual pattern changes. 1
Essential Hormone Panel
- FSH is the primary marker for perimenopause, as it rises progressively due to declining inhibin B secretion from the ovaries 1, 2
- Estradiol levels should be obtained, particularly when assessed serially in women with irregular bleeding, though levels fluctuate widely during perimenopause and are unreliable as isolated measurements 1, 2
- LH measurement is recommended as part of the core evaluation for determining menopausal status 1
- Prolactin testing is included in the standard workup to exclude hyperprolactinemia as an alternative cause of menstrual irregularity 1
Important caveat: During the menopausal transition, hormone levels frequently vary markedly—hence, measures of FSH and estradiol are unreliable guides to menopausal status when obtained as single measurements 2. FSH should be measured twice, at least 4 weeks apart, if confirmation is needed 3.
Thyroid Function Assessment
- TSH should be checked liberally in perimenopausal women, as thyroid disorders commonly mimic menopausal symptoms and occur frequently in this age group 1, 4
- Thyroid peroxidase antibodies (TPO-Ab) should be included when thyroid dysfunction is suspected 1
- The indications for measuring TSH in perimenopausal women should be kept broad rather than restrictive, as hyperthyroidism and menopause have similar symptoms 4
Metabolic Screening
- Fasting glucose or 2-hour oral glucose tolerance test should be obtained if insulin resistance is suspected, as metabolic changes accelerate during the menopausal transition 1
Cardiovascular Risk Assessment
- Fasting lipid profile should be checked every 6-12 months, as cardiovascular disease risk accelerates with estrogen decline 1
Additional Considerations
- Mammography is necessary for malignancy exclusion before considering hormone replacement therapy 5
- Women entering perimenopause must be counseled about endometrial cancer risks and instructed to report any unexpected vaginal bleeding or spotting immediately 6, 1
- Bone densitometry (DXA) is recommended as a baseline examination in postmenopausal women aged 65 years and in younger postmenopausal women with one or more risk factors for premature bone loss 6, 1
When to Suspect Primary Ovarian Insufficiency (POI)
If amenorrhea occurs before age 40, additional testing is warranted:
- Two elevated FSH levels (>25 IU/L) obtained at least 4 weeks apart with low estradiol levels 3
- Karyotype analysis to identify X-chromosome abnormalities 3
- Fragile X premutation testing in all women with POI 3
- 21-hydroxylase antibodies and thyroid function tests when autoimmune disorders are suspected 3