What is the appropriate workup for menopause (perimenopause or postmenopause)?

From the Guidelines

A menopause workup should begin with a thorough clinical assessment, reserving laboratory testing for women under 45 or when the diagnosis is unclear, and may include follicle-stimulating hormone (FSH) and estradiol levels, thyroid function tests, and assessment of cardiovascular risk factors and bone density. The most recent and highest quality study on this topic is not explicitly provided in the given evidence, but based on the information available, the approach to menopause workup prioritizes clinical assessment over extensive laboratory testing. Key points to consider in a menopause workup include:

• Clinical assessment for typical symptoms such as hot flashes, night sweats, and irregular periods in women over 45
• Laboratory testing for women under 45 with menopausal symptoms or when the diagnosis is unclear, which may include:
  • FSH and estradiol levels, with FSH levels above 30 IU/L on two occasions 2-8 weeks apart suggestive of menopause 1
  • Thyroid function tests (TSH, free T4) to rule out thyroid disorders
  • Antimüllerian hormone (AMH) to assess ovarian reserve in some cases
• Assessment of cardiovascular risk factors and bone density, as these health concerns often emerge during the menopausal transition 1
• Consideration of karyotyping and FMR1 gene testing for women with premature menopause (before age 40) to identify genetic causes This approach aims to balance the need for diagnostic clarity with the avoidance of unnecessary testing in women with typical presentation of natural menopause, prioritizing morbidity, mortality, and quality of life outcomes.

From the FDA Drug Label

Adequate diagnostic measures, such as directed or random endometrial sampling, when indicated, should be undertaken to rule out malignancy in postmenopausal women with undiagnosed persistent or recurring abnormal genital bleeding.

The workup for menopause should include adequate diagnostic measures to rule out malignancy in postmenopausal women with undiagnosed persistent or recurring abnormal genital bleeding, such as:

• Directed endometrial sampling
• Random endometrial sampling 2

From the Research

Menopause Workup

• The diagnosis of menopause is typically made clinically, based on a 12-month period of consecutive amenorrhea in a compatible age group (after 45 years of age) 3.
• No hormonal dosage or imaging is indicated to make a diagnosis of menopause in a classic situation 3.
• In women using hormonal contraception, hormonal assays or pelvic ultrasound are neither recommended to make a diagnosis of menopause nor to decide to stop contraception 3.
• The proposed strategy for women using hormonal contraception is the discontinuation of oral contraception, removal of the implant or intrauterine device, and clinical follow-up (occurrence of amenorrhea) 3.

Special Considerations

• In women with a history of hysterectomy, a repeat FSH≥40 combined with low estradiol (<20pg/ml) at least 3 months after the procedure could be a diagnostic orientation towards menopausal status 3.
• After cancer, in women who have received gonadotoxic treatment, the classic clinical criteria of 12 months of amenorrhea cannot be used to make a diagnosis of menopause with certainty 3.
• In breast cancer, the hormonal status to be taken into account when choosing initial hormone therapy is the one found before starting any treatment 3.

Management Options

• Hormone therapy (HT) treatment can be effective for perimenopausal symptoms, but its use has been limited by concerns about health risks observed in postmenopausal HT users who are older than 60 and/or women who have been postmenopausal for greater than 10 years 4.
• Medroxyprogesterone acetate (MPA) has been shown to have a small increase in relative risk for breast cancer and stroke, and a decline in cognitive function, in older women using MPA with an estrogen for postmenopausal HT 5.
• Short-term (less than 5 years) use of MPA with an estrogen in the years immediately after the onset of menopause for the management of vasomotor symptoms does not appear to be associated with any increased risk of these disorders 5.

Symptoms and Treatment

• Vasomotor and vaginal symptoms are cardinal symptoms of menopause, with a reported prevalence of 50-82% among U.S. women who experience natural menopause 6.
• The occurrence of vasomotor symptoms increases during the transition to menopause and peaks approximately 1 year after the final menstrual period 6.
• Treatment options for vasomotor and vaginal symptoms related to natural and surgical menopause are available, including hormone therapy and non-hormonal management options 4, 6.