How Do You Diagnose Menopause?

By: Tiffany Cochran, MD • Posted on October 01, 2020

October is World Menopause Awareness Month. Menopause is a natural aging process that women will eventually go through in their lifetime.

Did you know?

• Approximately 6,000 women in the US reach menopause daily.
• Women still have one-third to even one-half of life to live after reaching menopause.
• The population of women over age 55 will continue to grow.

The Difference Between Perimenopause and Menopause

Perimenopause and menopause are two commonly used terms to describe stages to the end of a woman's reproductive years. Diagnosing these two transitional stages can be a tricky ordeal. Hopefully, after reading this column the mystery of how physicians diagnose perimenopause and menopause won't be such a mystery anymore!

Perimenopause

Perimenopause means being "around" menopause. You still have your periods, except the timing of these periods may be more sporadic and unpredictable. You are in early perimenopause if your periods are late by a week. Late perimenopause occurs when your periods are 60 days or more apart. We now know perimenopause can be worse symptom-wise than actual menopause.

Menopause

A woman reaches menopause when she no longer has menstrual bleeding for 12 months. The average age of menopause is about 52, with an age range between 40-58. There are a variety of other terms used to label menopause.

Early Menopause

Early menopause happens if the onset of menopause occurs before 40 years of age. Late menopause refers to menopause onset after 55 years of age.

Early Transition into Menopause

Moreover, some circumstances lead to early transition into menopause.

• Bilateral oophorectomy is a procedure to remove ovaries surgically. Following this procedure, a perimenopausal woman suddenly goes into menopause.
• Medical treatments can also shock the ovaries, causing a decrease in hormone production temporarily. These women can experience menopausal symptoms until the ovaries start producing hormones again.

Menopause Symptoms

Compared to a woman's early reproductive years, the ovaries are not as active in perimenopause and menopause. This change leads to significant fluctuations in hormonal levels. Once you are in menopause, the estrogen and progesterone level in the blood is usually low. As a consequence of these hormonal changes on the body, women may experience the following symptoms:

1. Hot flashes
2. Hot flushes (the flash with color change)
   
3. Night sweats
   
4. Mood swings
   
5. Low sex drive
   
6. Word-finding difficulties and brain fog
   
7. Insomnia
   
8. Weight gain
   
9. Hair and skin changes
   
10. Vaginal dryness, burning, or itching
    
11. Urinary symptoms such as frequent urinary urgency
    

Steps to Diagnosing Menopause

1. Talk to a Women's Health Expert About Menopausal Symptoms

• Women may present to their primary care physicians, their gynecologist or their advanced practice registered nurse seeking relief from these signs and symptoms.
• A physician can clinically diagnose menopause and perimenopause although both can be tricky. Your clinician should review your signs and symptoms, medical history, medication list, and perform a physical exam if indicated.
• At times, the diagnosis is not clear cut as other medical conditions mimic menopause such as thyroid dysfunction, depression, and anemia. Besides, irregular menses are challenging to investigate with a history of uterine ablation or dilatation and curettage.

2. Ordering Diagnostic Labs

The next step is to order diagnostic labs. A physician may order blood tests such as:

• Follicle Stimulating Hormone (FSH)
• Estrogen
• Thyroid Stimulating Hormone
• Lipid panel
• 25- OH vitamin D level
• Anti-Mullerian Hormone (AMH) level - the newest test. Although, many labs may not carry the AMH test

Follicle Stimulating Hormone (FSH)

A physician has greater confidence in the diagnosis of menopause if a woman has not had menstrual bleeding for 12 months, with two consistently high FSH serum level 30 mIU/ml or more and she is over age 50. Perimenopausal women frequently have fluctuation in their hormones. FSH values may vary and a single elevated FSH is not very valuable to make a diagnosis. A woman can appear to be in menopause by history and lab tests, yet later ovulate.

The FSH level is only reliable if you are not on combined estrogen and progestins contraception or high dose progestins. Salivary hormones are expensive and not reliable due to hormone fluctuation throughout 24 hours and other than cortisol are NOT validated.

Anti-Mullerian Hormone (AMH) Level

Anti-Mullerian Hormone (AMH) is being raved as a new marker for menopause onset. AMH is a protein that plays a role in sexual differentiation. In men, it is responsible for the development of male genitalia. In women, AMH helps the ovaries mature eggs needed for pregnancy to happen. Ovaries make and secrete AMH before birth until menopause. With loss of ovarian function, the AMH plummets.

Newer research shows that there is a steady decline in serum AMH with age, which may reflect ovarian reserve better compared to other hormonal markers like FSH and inhibin B. AMH secretion is not affected by the menstrual cycle, making it more desirable as a marker for ovarian activity.

ELISA Test

The AMH enzyme-linked immunosorbent assay (ELISA) test may be the new diagnostic test used to help diagnose menopause. In 2018, the United States Food and Drug Administration approved the use of the Pico AMH ELISA diagnostic test to help determine menopausal status.

• This test measures the level of anti-mullerian hormone in the blood. Low AMH serum level helps to confirms the diagnosis of menopause.
• This test was able to identify women who are in menopause and those women five years or more away from it.
• The test is for women ages 42-62.

There are few factors shown to affect AMH levels:

1. Polycystic Ovarian Syndrome (PCOS)
2. Obesity
3. Oral contraception
4. Ovarian surgery
5. Chemotherapy
6. Vitamin D deficiency
7. BRCA gene mutations

Consequently, this test is to be used along with other clinical evaluation and laboratory findings to identify women in menopause. More research is currently undergoing of the use of AMH as a marker for both menopause onset and fertility.

Why a Menopause Diagnosis is Important

The age of menopause may become a crucial marker of a woman's health. With the ability to predict the age of menopause, appropriate preventative therapy could be provided to women.

Menopausal women have a higher prevalence of cardiovascular diseases, loss of bone density, osteoporosis, and dementia. These health complications can be debilitating for menopausal women causing socioeconomic trickle effects. Early diagnosis can facilitate steps taken to prevent these damaging consequences of menopause. Hormonal therapy provided to the right population, at the right time, for a suitable duration can help counteract the harmful complications that can occur with menopause.

Women who enter menopause later have been shown to live longer and have a reduced risk for osteoporosis. Yet, late menopause increases the risk for cancers such as breast, endometrial and ovarian cancers. Recognizing this risk will lead to physicians taking the preventative steps needed for perimenopausal and menopausal women to enjoy good health.

Awareness of menopause and perimenopause will help women embrace this bodily change. Menopause is a natural process but education, assessment and medical intervention, if needed, can be very helpful to both quality of life and potentially longevity.

Be Strong, Be Healthy, Be in Charge!

-Tiffany Cochran, MD

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