Women’s Health Update

by Tori Hudson, ND

Pretreatment Evaluation of Perimenopause and Menopause: An Apparently Controversial Opinion

The onset of perimenopause/menopause is an important time for a comprehensive health and lifestyle evaluation. A complete medical history and physical exam are essential before intitiating menopausal hormone therapy (HT) of any kind. Asessment of risk factors for stroke, coronary heart disease, venous thrombolic embolism, osteoporosis, diabetes, and breast/ovarian/uterine cancer is highly recommended. DEXA (dual-energy X-ray absorptiometry) testing, lipid profiles, fasting glucose, and mammography should be performed according to national guidelines and age, and based on medical judgement. Other selected tests depend on age, symptoms, and other medical problems.

There is no one test for menopause. Tests to determine ovarian function are not routinely done because the diagnosis of perimenopause or menopause can be made largely based on the medical history. Practitioners can use hormone testing on an individual basis, mostly to differentiate menopause from thyroid problems, abnormal causes of a lack of menses such as elevated prolactin levels, or premature ovarian failure (premature menopause).

The follicle stimulating hormone (FSH) test is not as accurate as we would like in a perimenopausal woman. The difficulty with FSH tests is that they can fluctuate immensely during perimenopause. A woman’s FSH values on any given day are not meaningful in diagnosing whether her symptoms are due to menopause changes. In a woman still having menses, especially irregular/random cycles as is often the case in perimenopause, her FSH values fluctuate unpredictably and can easily be within normal range on one day and elevated on another. In fact, FSH tests are frequently normal in perimenopausal women, and a physician with lack of expertise in menopause/midlife women will mistakenly then attribute her symptoms to depression, anxiety or unknowns, rather than the proper diagnosis of perimenopause.

There are two regular scenarios in which I will likely order an FSH test:

1. If a woman is suspected to be perimenopausal or menopausal and is using contraception, the FSH test can be useful in determining whether she still needs contraception. If FSH is above 30 mIU/mL, and then when repeated one month later is also above 30 mIU/mL, then a diagnosis of menopause can be established. It is important to continue the contraception during that one-month period until this is determined.

2. If a woman is reporting irregular menses, irritablity, fatigue, insomnia, and so on, then I will order an FSH and a thyroid stimulating hormone (TSH) test to help sort out if her problems are perimenopause and/or hypothyroid.

There is a recent popular notion, especially among alternative health-care providers, that saliva or serum testing or urinary hormone testing can be done to determine hormone management dosing. I would argue that there is little to no value in these tests in a perimenopausal woman for the purpose of diagnosing her hormone levels. The only information that you glean is her levels on the hour/day/days of the test, but these are not diagnostic of perimenopause and, as I mentioned, incredibly variable.

There is no scientific evidence to support any claims that there is increased efficacy, enhanced safety, or need for the testing in order to determine the dosing of the hormone prescriptions. There are numerous problems with saliva testing of estrogen and progesterone; in particular:

• only a very small amount of these hormones in the saliva

• high false positive elevations in those who are already taking a sublingual hormone

• contamination of the saliva collection tube if already using topical hormone creams/gels

• no proficiency testing

• variable technologies that yield broad differences in results

• technical challenges that are not adequately addressed with all laboratories conducting these tests

• lack of scientifically proven accuracy

• interfering components such as food, beverages, medications and chewing gums

Salivary testing of cortisol and DHEA levels holds more promise, as these do not fluctuate so much from day to day, we have a known daily rhythm of cortisol production, and there are naturally higher amounts in the saliva than of estrogen and progesterone.

Serum testing of estrogen, progesterone, and testosterone is proven to be more accurate; however, I would argue that it is not often that even these are necessary tests in perimenopausal and menopausal women. For one, the reference ranges are often wide, and with testosterone in particular, we are not even sure the normal reference range of testosterone for women. Again, in a perimenopausal woman, estrogen levels in particular are flucuating from day to day and therefore are not valuable in diagnosis or management. In a postmenopausal woman, her estrogen and progesterone levels are predictably low – they are supposed to be.

While saliva estrogen/progesterone testing has yet to prove accurate or efficacious, even if it is, neither salivary or serum hormone testing is necessary or even rarely helpful for the perimenopausal woman, as it is difficult to gather conclusions on test results, when the hormones are in such a fluctuating state. There are so many peaks and valleys and erratic hormone activity, testing offers little value in most situations.

For the women taking HT, it is tempting to think that we could test the blood or saliva to determine what dose to take. This is a popular recommendation in some consumer menopause books. However, there is no mathematical grid or equation comparing values of estrogen or progesterone or testosterone levels in the blood or saliva and how they would equate with a certain dose of the comparable hormone. There are reference ranges for these hormones, but we don’t know exactly what dose to give to keep the woman in the reference range. Women absorb and metabolize hormones differently.

The form of hormones and the delivery method – oral, transdermal, sublingual, injection – also behave differently from woman to woman. In very occasional and selective cases, serum testing may be a helpful guide. These are generally cases in which a woman is on HT and not doing well and, despite our best efforts with a good medical history and adjusting the dose, does not feel good. Most of the time, it requires the practitioner’s experience and menopause expertise and time to listen to the patient, to know what dose, dosing adjustments, and forms and deliveries of hormones may work best. Even if testing is done, it basically comes down to good clinical judgment and the willingness of the woman and her practitioner to try something else.

Urinary testing of estrogen metabolites can be considered in evaluating a woman’s risk of health-care problems that may be associated with higher or lower levels of certain estrogen metabolites. While these data are limited, using estrogen metabolism testing to gain insight as to her risk of cervical cancer and breast cancer in particular, or how to decrease her recurrence of these diseases, is a preventive-medicine practice that is hard to argue with.

I’m well aware that my position on the subject of hormone testing will be unpopular with some of my colleagues and those in the “alternative” laboratory industry. Nonetheless, I would strongly encourage practitioners to rethink the use of salivary and serum estrogen/progesterone testing in the diagnosis and management of perimenopause/menopause. In a perimenopausal woman, these hormones fluctuate within a day and from day to day. In the postmenopausal woman, not on hormones, I would also assert that this is a poor use of her funds. Her estrogen and progesterone levels are low, and Mother Nature had this in mind. For a postmenopausal woman on HT, it is rarely necessary to test her estrogen levels for prescription management; however, there are times when this may help determine absorption/delivery and dosing issues due to her lack of response or adverse response to customary prescriptions. For select and very difficult cases, it is likely more useful to utilize testing of her neurotransmitters, amino acids, and nutrients, while assuring that we’ve done our due diligence with the basics of history, physical exam, and conventional testing considerations.

I do realize – and do respect – that clinicians think through patient management issues differently. When we don’t need a test to actually rule out or rule in a condition/disease/syndrome, some of us may need more tests to feel assured of our advice. The health-care dollar has become more and more precious. In my experience these last 26 years, I find that those areas in which I have less expertise, I’m vulnerable to three shortcomings: unnecessary tests, too few tests, or the wrong tests. The more expertise one has in perimenopause/menopause, the less the need for any hormone testing for patient management. I also realize that some patients want one or more methods of hormone testing for their menopause issues. I respectfully listen to their needs, share my thoughts and provide pertinent education, make my recommendations, and order the tests if they really want them. If they already have tests that have been done previously, I politely review the results without disparaging comments as to lack of necessity or to their previous practitioner/s, and move on to dealing with the needs at hand.

I would rather see us increase our vigilance in evaluation and testing with midlife women for metabolic syndrome, diabetes, and dyslipidemia. We can make a dramatic difference in quality of life, morbidity, and mortality with comprehensive evaluation including laboratory testing, and then optimize our prevention strategies and interventions based on these results with ongoing monitoring of progress.

In our work with perimenopausal and menopausal women, I have found that the best results come with being a studious reader of menopause medicine, listening well to patients, assuring the basics of a comprehensive history and physical exam, avoiding shortcuts, and being flexible to the individual needs of the patient and the individual demands of the case. Whether hormone testing is necessary or not, in the end, if we think smart, think creatively, be trustworthy, behave honorably, proceed with good intentions, and do no harm, we will help more menopausal women more and even most of the time.