Perimenopause and Hormonal Disorders

Diagnosis and Evaluation

A complete female hormone workup should include assessment of testosterone, free testosterone, estradiol, follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin, and thyroid-stimulating hormone (TSH), with timing of collection optimally performed between days 2-4 of the menstrual cycle for accurate assessment of ovarian reserve, as recommended by the American College of Obstetricians and Gynecologists 1
Anti-Müllerian Hormone (AMH) is a reliable marker for assessing ovarian reserve, correlating well with antral follicle count, and is better than age, basal FSH, estradiol, and inhibin B for this purpose, according to the Endocrine Society 1
The LH:FSH ratio can help diagnose PCOS and FHA, with a ratio >2 indicating PCOS and ≤1 indicating FHA, as shown in the following table:

Transvaginal ultrasound is recommended for assessment of ovarian morphology, endometrial thickness, and to rule out structural abnormalities, according to the American Institute of Ultrasound in Medicine 1
Bone mineral density testing is recommended for patients with suspected hypogonadism, as stated by the National Osteoporosis Foundation 1
Pelvic MRI may be necessary for further evaluation of suspected pituitary or adrenal abnormalities, as recommended by the Radiological Society of North America 1

Refer to endocrinology for delayed puberty, persistently abnormal hormone levels, or hypogonadism, as recommended by the Endocrine Society 1
Refer to reproductive endocrinology for infertility evaluation and consultation on assisted reproduction, according to the American Society for Reproductive Medicine 1
Consider gynecology referral for structural abnormalities or complex hormonal issues, as stated by the American College of Obstetricians and Gynecologists 1

Lifestyle modifications, such as weight loss (if BMI >25), regular exercise, and balanced diet, are recommended as the first-line treatment for PCOS, according to the American College of Obstetricians and Gynecologists 4
Clomiphene citrate and letrozole are first-line pharmacological treatments for ovulation induction, with metformin considered for patients with insulin resistance, as recommended by the American College of Obstetricians and Gynecologists 4
Testosterone replacement therapy may be considered for symptomatic hypogonadism, but consider risks of testosterone therapy, including potential increased coronary artery plaque volume and cardiovascular events in older men, as recommended by the American Diabetes Association 5
Gonadotropin therapy with low-dose FSH protocols can prevent ovarian hyperstimulation, but requires careful monitoring with ultrasound and estradiol levels, with a strength of evidence rated as high 4
In vitro fertilization (IVF) is recommended if other treatments fail, and may use GnRH antagonist protocols to prevent OHSS, with a strength of evidence rated as high 4

Donor eggs represent the most successful fertility option for women with POI, while spontaneous pregnancies occur in 5-10% of women with POI, as reported by the American Society for Reproductive Medicine 1
Hormone replacement therapy is recommended for women with POI to prevent long-term health consequences, and should be continued until the average age of natural menopause (approximately 51 years), as recommended by the American College of Obstetricians and Gynecologists 1
Regular follicular monitoring with ultrasound is essential during treatment to prevent ovarian hyperstimulation syndrome (OHSS) and multiple pregnancy risk, with a strength of evidence rated as high 4

For patients with risk factors for osteoporosis, consider 25-hydroxyvitamin D level and calcium levels, and provide bone density testing, calcium, and vitamin D supplementation, and weight-bearing exercise to prevent bone loss, with a strength of evidence rated as strong 6, 7, 1
Hormonal imbalances, particularly low testosterone in men, may increase cardiovascular risk, as reported by the Mayo Clinic Proceedings, and consider evaluating for pituitary/hypothalamic disorders and providing testosterone replacement or reproductive health evaluation 8, 9

Psychological support should be addressed in patients with POI, highlighting the importance of comprehensive care, as recommended by the American Psychological Association 1