Do you need to have blood test to diagnose menopause? Gynaecologist Vikram Talaulikar gives you a guide.
When you sit down with your GP and tell them you’re feeling irritable, waking in a pool of sweat every night or feeling like you’re lacking in energy, they may think you’re on the path to menopause. The first thing they might do is ask you to have a blood test to establish your hormone levels, in particular oestrogen and follicle stimulating hormone (FSH).
These days though it’s not considered necessary unless the GP has reason to believe there are other underlying problems causing the problems such as an under-active thyroid.
Instead a diagnosis is should be made on the symptoms you present with and how you feel.
By definition, menopause means the cessation of periods. It is a retrospective diagnosis, made 12 months after the last recorded period. The lead up to this is known as peri-menopause and this is when symptoms start to appear as oestrogen levels begin to drop. The symptoms of menopause can continue for many years after you have stopped menstruating.
Why isn’t a blood test considered a good guide anymore?
Your body releases hormones in short spurts around every 90 minutes or so. This means the levels can fluctuate throughout the day.
Additionally, other things can affect the hormone levels such as certain medications or medical conditions.
As a result the hormone levels found in the blood tests may not be an accurate reflection of your real hormone level. They are a snap-shot of that particular moment in time.
A better guide is your symptoms – and there are many. These are some of the common ones. You may not have any of these, or may have many and to varying degrees. Everyone’s menopause is an individual journey.
- Hot flushes/flashes
- Night sweats
- Insomnia (waking and being unable to get back to sleep)
- Moodiness and irritability
- Changes in body odour
- Dry and itchy skin
- Weight gain
- Stress incontinence (peeing when sneezing, laughing etc)
- Dry vagina
- Painful during or after sex
- Frequent UTIs or thrush
- Thinning bones (osteoporosis)
- Brittle nails
- Thinning hair on head, increased hair on face
- Irregular heart beat
- Changes in menstrual patterns (heavier, lighter, more frequent or further apart)
- Joint pain
- Breast pain
- Low libido
- Brain fog or an inability to concentrate
- Feeling anxious and/or stressed
- Lack of energy
- Feeling low/depressed and/or loss of interest in life.
Sometimes these last five can be taken as a sign of depression rather than a symptom of menopause.
This leaves many women feeling frustrated as they are prescribed anti-depressants and not hormone replacement therapy (HRT), as recommended in the NICE guidelines.
That’s not to say that anti-depressants can’t be useful in some circumstances. Some anti-depressants, an anxiety drug called Gabapentin and blood pressure medication called Clonidine can be used to help reduce the vasomotor symptoms like hot flushes, but in general, the first line treatment for women who do not have a risk of breast cancer or have had breast cancer, is HRT. (See below for more on anti-depressants and HRT risks.)
Are there times when a blood test is appropriate?
Yes. As mentioned before, one reason is if a thyroid condition is suspected.
Another reason is if the woman is young and facing premature menopause. The average age that women become menopausal is 51. Around 10% of women go through menopause in their 40s. A very small number – around 1%, go through menopause under the age of 40. In this instance a blood test is a required to see if the oestrogen is lower than average and the FHS is higher than you’d expect at this early age.
A suspicion of an iron deficiency may also be a reason for a blood test, especially if there is a history of frequent and heavy periods.
Are there other tests you should have?
Yes. You should have:
- Your blood pressure monitored regularly. A decrease in oestrogen can mean an increase in blood pressure and coronary heart disease.
- A bone scan – a decrease in oestrogen can also affect your bones, making them brittle and prone to fractures and breakage. It’s vital to have a bone density test early on (especially if you have had an early menopause or there is osteoporosis in the family) so that a base line can be established and repeat the tests every 3-4 years to see if the HRT, exercise or vitamin D3 supplements have improved the bone density.
- Regular cervical screening until 65 (in the UK – every 3 years until 50 and then every 5 years until the age of 65.)*
- Regular Breast screening/mammograms (In the UK – every 3 years for women between 50-70 years of age.)*
*(These time frames will vary from country to country.)
Why are anti-depressants prescribed for HRT?
It was the 2002 Women’s Health Institute study that raised fears over HRT as a risk factor for breast cancer. After its release there was a steep rise in antidepressant prescriptions while prescriptions for HRT declined.
These days it’s well recognised that the conclusions of this study were not generalisable and that the risk of breast cancer or blood clots from modern HRT is lower than previously thought and HRT is, in fact, associated with a number of long-term health benefits.
Since the study results were published, HRT prescribing has been radically transformed with safer and body-identical hormones replacing non-human and oral hormones. There are now different hormone therapy options such as patches, gels, coils and pessaries, and some of these preparations may pose no higher risk of developing breast cancer, but will be beneficial for the brain, heart and bones in the long-term.
What are the risks of HRT?
The statistics these days show that:
- 23/1000 women will develop breast cancer with or without HRT.
- If you take combined HRT orally (oestrogen and progesterone) there will be an extra 4 cases or 27/1000. This is the same risk as taking the contraceptive pill.
- If you drink two or more units of alcohol a day there is an extra 5 cases – so 28/1000.
- If you smoke, there are an extra 3 cases or 26/1000.
- If you are overweight an extra 24 cases will be recorded – so that means 47/1000.
- If however, you exercise regularly the risk of developing breast cancer drops considerably. There will be 7 fewer cases per 1000 – so just 16/1000 instead of 23/1000.
The take home message is then that lifestyle is a greater risk factor in developing breast cancer than HRT. Regularly drinking alcohol, being overweight and smoking will add an extra 32 cases/1000.
Keeping a healthy weight and exercising regularly will mean your risk is lowered by just under a third.
The decision to take HRT is of course a personal one that will depend on your own family history and preference. Finding a practitioner who can explain the risks so you can make an informed decision is important.
Finding the right advice on HRT can be difficult. The NHS does have menopause clinics so ask your GP for a referral or make an appointment to see me at the Menopause Clinic London.