In this article we discuss the many benefits of testing in perimenopause, including whether it’s possible to diagnose perimenopause through testing, the 10 key hormones and health markers we believe are particularly important to test in this phase of life and the impact of HRT and contraception on testing.
What’s going on during perimenopause?
Perimenopause is a time of huge change, similar to puberty, and can last for 2–12 years in the lead up to menopause. We can experience a wide range of symptoms during this time, including weight gain, hot flushes and night sweats to headaches, brain fog and low mood, and many more.
These symptoms are largely because of the changing levels of our hormones. Initially, we start to lose progesterone, as ovulation becomes more sporadic. Estrogen can fluctuate wildly, before finally lowering as we get closer towards menopause. And because our hormones have such wide-reaching effects throughout the brain and body, we need to go through a period of recalibration and adaptation – and this is perimenopause.
Related article: the four stages of perimenopause.
We know that your symptoms can be difficult and can make you feel stressed and overwhelmed. We are here to help you feel more in control of your health during this time.
If you are going through perimenopause, testing can be incredibly beneficial because we can get a more accurate picture of what is really going on and therefore we can make more targeted diet, lifestyle and supplement recommendations to support you.
Can you use testing to diagnose perimenopause?
There are currently no tests available that can actually diagnose perimenopause. Instead perimenopause is diagnosed based on the presentation of a variety of new symptoms.
However, hormone testing is still very beneficial during perimenopause. We will cover reasons why this is the case later in this article.
What about FSH blood testing?
You may have heard of an FSH blood test. This stands for follicle stimulating hormone.
Typically GPs on the NHS use FSH testing to determine whether you are in menopause. They follow the rule that if your FSH is more than 40 IU/L on two consecutive tests taken at least 6 weeks apart and you have had either no period or very infrequent periods for more than 4 months you are likely to be in menopause.
Your NHS GP may also follow a general rule that a reading of more than 30 IU/L may indicate perimenopause. However, FSH testing in blood serum is very unreliable, especially in perimenopause. This is because your FSH will be fluctuating high and low throughout this time and so it can be difficult to get a reliable reading.
Sometimes it can be beneficial to use FSH testing to rule out other conditions, such as PCOS. However new signs and symptoms are a much more reliable indicator of whether or not you’re in perimenopause.
What are the benefits of testing your hormones in perimenopause?
During perimenopause, hormone testing can be hugely beneficial as it can provide you with insights into the following key areas of hormone health:
- Hormone production: are you producing enough estrogen, progesterone and testosterone? For example, low progesterone levels in perimenopause can lead to symptoms such as anxiety, loss of confidence, shorter cycles and poor sleep. If you’re considering HRT, understanding your basic hormone levels will help you understand which hormones you really need and in what dosage.
- Hormone balance: are your hormones in balance? As an example, progesterone should be 100x higher than estrogen in the second half of a healthy menstrual cycle. If progesterone is too low, leaving estrogen unopposed, you’re more likely to experience worsening PMS and heavier or more painful periods.
- Hormone metabolism: how well are you metabolising your hormones, particularly your estrogen? Poor estrogen metabolism can exacerbate symptoms like PMS and hot flushes even if your overall estrogen levels are low. And it can also put us at greater risk for certain cancers. It’s particularly important to test your metabolites if you are on (or considering) hormone therapy.
- Stress and other contributing factors: are other factors, like stress or nutrient deficiencies contributing to your symptoms? Stress in particular can put pressure on the adrenal glands which become even more important in menopause as they take over hormone production from the ovaries.
What’s the best method to test hormones in perimenopause?
You may be familiar with blood testing for hormones, but in actual fact, urine testing for hormones has been shown to provide a more accurate and comprehensive picture. Our FUTURE WOMAN hormone tests involve collecting 4 dried urine samples across one day in your cycle to make it as easy (and pain free!) as possible.
Why is urine testing more accurate than blood testing for hormones?
Our hormones pulse, which means that the glands that produce and release hormones actually secrete them in short bursts instead of in a steady stream throughout the day. With a single blood test you might be capturing your hormone levels at a peak, a trough or somewhere in between. But with 4 dried urine samples, we can capture a more accurate reading of your hormone levels by taking a simple average.
In perimenopause, this is especially important because of our changing hormone levels. The accuracy of our tests can help to determine which stage of perimenopause you are in and therefore which approach to take to alleviate your symptoms, as well as which type of hormone therapy is right for you at this time if you’re considering HRT.
Why is urine testing more comprehensive for hormones?
While blood testing can reveal overall sex hormone levels and whether they are in balance, with urine testing we can also look at sex hormone metabolites. And metabolites provide so much valuable information!
Each of our sex hormones need to be used, processed and finally eliminated from the body via urine or the gut, and we can test how well your body is doing this. If we struggle to effectively process or metabolise our hormones, then we can get a lot of unwanted symptoms and it can even put us at greater risk for things like breast cancer.
In perimenopause, if you have poor estrogen metabolism for example, it can exacerbate symptoms like PMS, hot flushes and heavy periods. We want to see which pathway your estrogen is going down so we can better support you.
Comprehensive also means looking at the bigger picture. Our test doesn’t just show your estrogen and progesterone and their metabolites but also androgens (male hormones), cortisol, neurotransmitters and key nutrients. All in one simple test.
10 key markers to test in perimenopause
Everyone’s perimenopause is different. By gaining insights into these 10 key markers in perimenopause (available with our Advanced and Advanced+ hormone tests), our practitioners will be able to understand what’s driving your unique symptoms and to make more personalised and targeted recommendations to feel better.
- Estrogen: high, unopposed estrogen can contribute to or worsen many perimenopause symptoms such as PMS, heavy/painful periods, rage and hot flushes. And low estrogen, as we get close to menopause, can cause new symptoms like low mood and depression. We look at all three estrogens – E1, E2 and E3 in testing.
- Estrogen metabolites: we look at Phase 1 and Phase 2 estrogen metabolites. Issues with estrogen metabolism can worsen all symptoms of perimenopause and even put us at greater risk for certain cancers. If you’re considering HRT, it’s especially important to test your estrogen metabolites to check these are working optimally first. And if you’re on HRT, testing metabolites will ensure your hormone therapy is being metabolised correctly and safely. For more information on estrogen metabolism, you can read our handy guide to the basics of estrogen detoxification.
- Progesterone and progesterone metabolites: this can help to determine if you are ovulating, and if so, whether you are producing enough progesterone. Progesterone is one of the first hormones we start to lose in perimenopause and low levels can lead to symptoms such as anxiety, poor sleep and shorter cycles. It’s also important to look at progesterone metabolism – if you favour the beta pathway you are less likely to feel progesterone’s beneficial effects and so many need to increase your dosage if you’re on progesterone hormone therapy.
- Testosterone: it is important to look at testosterone in perimenopause due to the increased risk of testosterone dominance. Testosterone dominance is common in later perimenopause when both estrogen and progesterone levels are low. Testosterone dominance can lead to symptoms such as weight gain around the middle and mood changes in perimenopause. Testosterone dominance can also lead to an increased risk of worsening insulin resistance which can in turn worsen nearly all symptoms of perimenopause. Therefore it is important to test to ensure that your body is not making excess testosterone in order to reduce symptoms of perimenopause.
- DHEA and DHEA-S: predominantly made in the adrenal glands, DHEA and DHEA-S can convert to testosterone, contributing to testosterone dominance in perimenopause if these levels are too high.
- Androstenedione: this hormone can convert into both testosterone and estrogen in the body, which means it can contribute to higher levels of both hormones in perimenopause.
- 5a reductase and 5b reductase: when we look at androstenedione, we also look at its two metabolism pathways – 5a and 5b. If you favour the 5a pathway, then you are more likely to experience symptoms like weight gain around the middle and mood changes even if your androgen levels are normal.
- Metabolised and free cortisol and cortisone: these are key markers to help us assess your HPA (hypothalamus-pituitary-adrenal) axis. Poor communication in the HPA axis during perimenopause can lead to increased stress, weight gain, hormone imbalance, sleep changes and mood changes. Increased cortisol can also contribute towards inflammation in the body which in turn increases testosterone production, worsens insulin resistance and causes hormone imbalance resulting in the worsening of symptoms. If you’re on or wanting to start HRT, addressing your stress response can be key to HRT being a success, so we need this information in order to help you as best we can.
- Cortisol awakening response (CAR): a mini stress test that provides valuable insight into your stress response across the day. An elevated CAR result suggests that you may have an overactive HPA response which could be worsening your perimenopause symptoms.
- Melatonin: melatonin is our darkness hormone and helps us sleep. Melatonin levels naturally decline with age and lower levels can worsen sleep issues in perimenopause.
Can I test my hormones if I’m on HRT?
Our testing was specifically designed to help optimise client’s HRT and so our tests are a powerful tool for monitoring your hormone therapy. Testing can help us to see whether there are things we need to work on before you start hormone therapy or while you’re on hormone therapy. We can monitor your HRT and make sure you’re taking the right type and the right dose.
Some types of hormone therapy can be measured better than others; therefore, it is best to get in touch with us to discuss your specific health picture. Urine testing works really well to monitor oral progesterone, vaginal estrogen and transdermal estrogen.
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Testing progesterone therapy
Urine testing is really helpful for monitoring oral progesterone and we can also see how you’re metabolising progesterone.
How are progesterone metabolites helpful? How someone is metabolising progesterone can help us to evaluate whether the therapy is appropriate. Progesterone is metabolised down the alpha and beta pathways. The alpha pathway makes something called allopregnenelone, which is calming and can help with sleep. However, if you’re pushing your progesterone down the beta pathway, which is the non-active pathway, and you’re not experiencing the benefits of progesterone, this might be the reason why. You therefore might need more progesterone to get the same effect as someone with a more dominant alpha pathway.
Testing estrogen therapy
When it comes to hormone therapy, we really want to look at your estrogen metabolism. Are you making more 16-OH in phase 1 metabolism? 16-OH is more potent and therefore this could make you more symptomatic. Are you making more 4-OH, which is potentially more carcinogenic?
We also want to look at phase 2 metabolism. How well are you methylating estrogen? This is an important step in estrogen metabolism. We need to know this information before you consider taking estrogen HRT and we can learn all this information by looking at your metabolites.
- Vaginal estrogen, transdermal estrogen (patches, gels): urine testing can be really helpful for monitoring vaginal estrogen. Gels and creams are going to give an up and down pattern of estrogen throughout the day. This is one reason why our test is much more useful than blood testing.
- Oral estrogen: urine testing can be helpful for monitoring the metabolism but not the dosing.
How often should I test if I’m on HRT?
We suggest every 6 months to monitor effects and metabolism of hormone therapy.
Can I test if I’m on hormonal contraception?
If you’re using the copper coil, then it is still possible to test your hormones as the copper coil does not suppress ovulation or alter your own natural hormonal levels.
However, if you’re on hormonal contraception then unfortunately we can’t test your hormone levels. This includes the mirena IUD, oral contraceptive pill and implants. These forms of contraception can shut down the communication pathways from the brain to the ovaries and therefore there is suppressed progesterone and estrogen hormone production. This means the tests will not be able to reveal what is truly happening with your hormones.
If you’re considering coming off hormonal contraception, we generally suggest waiting at least 1-3 months before testing your hormones. If you are looking for support in coming off hormonal contraception, or for more information on when you should test, please book a free 15 minute call with one of our women’s health experts.
Contraception in perimenopause
At FUTURE WOMAN we do encourage clients in perimenopause to revert to their natural cycles and to maintain them for as long as possible. This is because of the many benefits our hormones offer us throughout the body. For example, research has shown that progesterone is beneficial for breast health. However, we always recommend speaking to your GP before making any changes to your approach to contraception.
I'm ready to test, what's the next step?
If you’re struggling with symptoms of perimenopause and are interested in testing, you can check your symptoms now with our free symptom checker and we’ll show you which test is right for you.