What is the appropriate workup and management for a perimenopausal woman in her 40s or 50s presenting with symptoms?

Perimenopause Workup

The workup for perimenopause is primarily clinical based on age (typically 40s-50s) and symptom pattern, with laboratory testing reserved only for atypical presentations or when diagnosis is uncertain. 1, 2

Clinical Diagnosis

Perimenopause is diagnosed clinically without routine laboratory testing in women aged 40-55 presenting with menstrual irregularities and vasomotor symptoms. 2, 3

Key Clinical Features to Assess:

• Menstrual pattern changes: Cycle length variability, skipped periods, or prolonged intervals between menses 3, 4
• Vasomotor symptoms: Hot flashes and night sweats (present in most women, moderately-to-severely problematic in approximately one-third) 4
• Sleep disturbances: Increased prevalence during transition, often interacting with hot flashes 4
• Mood changes: Depressed mood and anxiety increase abruptly in later stages of transition with longer amenorrhea periods 4
• Genitourinary symptoms: Vaginal dryness, dyspareunia, urinary symptoms (affecting approximately one-third of women in later stages) 1, 4
• Sexual dysfunction: Assess for decreased desire and intimacy problems 5

Laboratory Testing (When Indicated)

FSH is NOT a reliable marker of menopausal status and should not be routinely ordered. 5

Order Labs Only When:

• Age <40 years (to confirm premature menopause) 5
• Atypical presentation requiring confirmation 5
• Patient on tamoxifen (FSH unreliable) 5
• History of chemotherapy or pelvic radiation (FSH unreliable) 5

Specific Tests When Indicated:

• TSH and glucose: Rule out thyroid disease and diabetes as alternative causes of symptoms 5
• Estradiol, FSH, LH, prolactin: Only as clinically indicated in atypical cases 5
• Serial estradiol levels: Useful in amenorrheic women who later develop bleeding to determine return of ovarian function 5

Essential Screening During Workup

Rule Out Other Pathology:

• Abnormal uterine bleeding: Requires endometrial sampling when persistent, recurrent, or undiagnosed 6
• Coeliac disease screening: Check tissue transglutaminase antibodies if iron deficiency anemia present 5
• Cardiovascular risk assessment: Blood pressure, lipid levels, BMI (women with early menopause have 20% higher cardiovascular mortality risk) 7
• Bone health evaluation: Consider DEXA scan for osteoporosis risk assessment 1

Pelvic Evaluation:

• Perform pelvic exam for complaints of vaginal dryness to assess for vaginal atrophy 5
• Image uterine cavity if surgical intervention planned 5

Critical Pitfalls to Avoid

• Do not rely on FSH alone: FSH is unreliable in women with prior chemotherapy, pelvic radiation, or on tamoxifen 5
• Do not dismiss bleeding: Any bleeding in amenorrheic women requires evaluation for return of ovarian function or endometrial pathology 5, 6
• Do not overlook cardiovascular risk: Early menopause increases stroke risk by 32% and requires aggressive risk factor modification 7
• Do not assume all symptoms are menopausal: Screen for thyroid disease, diabetes, and other medical causes 5

Annual Health Examination Components

The annual visit should include comprehensive screening for physical and psychological problems with appropriate lifestyle counseling. 2

• Cardiovascular screening: Blood pressure, lipids, BMI monitoring 7
• Cancer screening: Age-appropriate breast, cervical, and colorectal cancer screening 2
• Mental health assessment: Screen for depression and anxiety (prevalence increases during transition) 4
• Bone health: Assess fracture risk and consider DEXA if indicated 1
• Lifestyle counseling: Weight management, smoking cessation, alcohol limitation, exercise 1, 7