While there are no compulsory investigations for menopausal women, some key tests can identify potential risks and improve lifelong health. Experts answer common questions about symptoms and red flags that warrant further assessment.

When should you order hormone tests?

Perimenopause and menopause are assessed clinically, and hormone testing is rarely needed for women over the age of 45, says Hobart GP Dr Karen Magraith, past president of the Australasian Menopause Society (AMS) and Clinical Senior Lecturer at the University of Tasmania.

In this group, hormone blood test results can be “confusing or misleading,” she says.

“FSH and estradiol levels fluctuate a lot during perimenopause, and they don’t tell us whether someone will respond to treatment.”

Adelaide GP Dr Jane Elliott, also a past president of the AMS, adds that hormone levels do not correlate with menopausal symptom severity or duration.

Dr Magraith says hormone testing is sometimes warranted in younger women, particularly those under 40, who need to be investigated thoroughly.

“If someone’s having oligomenorrhea, we want to think carefully about whether they have premature ovarian insufficiency,” she says, noting POI increases the risk of osteoporosis and cardiovascular disease, so it’s essential to identify—even in asymptomatic women.

“We want to be proactive in managing them and, in most cases, advising them to have MHT until the usual age of menopause, unless there’s a specific contraindication.”

For women aged 40-44, hormone testing may help clarify the clinical picture and guide treatment decisions, she adds.

When should you investigate bleeding?

While it’s normal for bleeding patterns to change during perimenopause, some issues should prompt further investigation.

“What we’re really looking for is bleeding that is much heavier than before, prolonged bleeding, bleeding that’s erratic or intermenstrual, and postcoital bleeding,” Dr Magraith says.

Any postmenopausal bleeding also needs to be investigated.

In both cases, investigations should take place before prescribing MHT.

Initial assessment should include an examination, cervical screening co-test where indicated, consideration of STI testing and pelvic ultrasound.

“This should ideally be a transvaginal scan,” Dr Magraith says. “The best time to do it is on day five to 10 after the start of a bleed. And it’s great if this can be done by a specialist women’s ultrasound service, if possible.”

These services are more likely to specify endometrial thickness in millimetres, which is important for applying guidelines like those from the Cancer Council, she explains.

“And if the ultrasound is abnormal, then they should be referred for assessment by a gynaecologist, who will make a decision about endometrial sampling.”

Practice tip: Noting whether your patient is pre-, peri- or postmenopausal on the ultrasound request form is helpful for the person interpreting the scan.

Which baseline blood tests are useful?

Menopause consults are a good opportunity to assess general health, and testing should be guided by the woman’s presentation, Dr Magraith says.

For women with heavy bleeding or fatigue, a full blood count, ferritin and thyroid function testing are often warranted, she says.

“We have a fairly high yield for these investigations, especially for iron deficiency in this age group.”

Other reasonable investigations include renal and liver function, lipids, blood glucose and vitamin D levels where indicated.

For women with amenorrhoea or irregular cycles, pregnancy testing may sometimes be appropriate, Dr Magraith adds.

The 2023 Practitioner’s Toolkit for Managing Menopause has more details on which tests to consider.

Should women have a mammogram before starting MHT?

Menopause consults are a great opportunity to encourage breast screening, but asymptomatic women do not need a new mammogram before starting treatment, Dr Magraith stresses.

“If they are up to date with their screening mammograms, in my mind there’s no need to delay prescribing hormone therapy.”

Even if they’re overdue, treatment and screening can often occur concurrently.

“If we have a patient who is on the screening program but they’re running a bit late, I don’t see this as a reason to withhold MHT from them,” she says.

“And if someone doesn’t want to screen at all, then we should discuss with them why we advise screening, and document this. They should also be advised to present if they develop any breast symptoms. But in the end, it’s the patient’s choice.”

Dr Elliott agrees, noting that delaying treatment until after screening can unnecessarily prolong suffering.

“My approach is certainly to do them in parallel, because I think people have waited and they’re often desperate. We need to get them feeling better. However, we should document these nuanced discussions about breast imaging in our consult notes and flag for follow up at the next and subsequent follow-ups.”

With many states now reporting breast density, it’s important to discuss this with patients and consider whether supplemental imaging may be appropriate, she adds.

When should you order a DEXA?

While Medicare rebates for DEXA scanning are only available under limited circumstances (e.g. in women with early menopause or after a minimal trauma fracture), Dr Magraith cautions against using eligibility criteria alone to guide clinical decisions.

“The first question to ask is, would we recommend this patient has a DEXA? I find that women are increasingly interested in their bone density. They’re often asking us for these tests. And if we just say, no, you’re not eligible yet, I don’t think we’re doing them a service.”

“I do offer them to most patients who I see,” she says. “There’s quite a high yield of abnormal results actually. And it can really help set women up for the best trajectory for their bone health if they know what it is at menopause.”

Dr Elliott advises against assuming patients cannot afford it, noting the results can influence treatment decisions—especially for women who may be uncertain about MHT.

“If we are going to start MHT, I don’t feel it’s so urgent to get a private DEXA because I know that the MHT is going to preserve bone,” she says.

But in women with fewer symptoms who are declining MHT, identifying osteopenia or osteoporosis can have important implications.

“In those women, I say this is part of decision making. It could be good to get a DEXA because it may change whether you want to use it.”

Dr Magraith agrees.

“Over the years, I’ve seen so many women who find out they have osteoporosis when they’re 65 or 70 and they say, why didn’t I know about this earlier?”

What about cardiovascular risk assessment?

“We know that cardiovascular risk rises after menopause,” Dr Magraith says. “In fact, the change starts during perimenopause. So the menopause transition is a good time to assess the risk.”

She recommends using the Australian cardiovascular risk calculator, noting the goal is to optimise risk factor management while considering the most appropriate treatment for menopausal symptoms.

Importantly, cardiovascular risk factors do not contraindicate MHT, she says.

“I would usually be suggesting transdermal estradiol in this group.”

Dr Elliott notes that a coronary calcium score is not necessary unless it is indicated for other reasons, but it can help to guide treatment decisions—especially if you’re considering statin therapy in a patient who’s reluctant to commence it.

How should you approach testing in someone with genitourinary symptoms?

“If someone has genitourinary symptoms, we should be offering them an examination,” Dr Magraith emphasises.

“We don’t want to miss a diagnosis of lichen sclerosus. And there are plenty of women out there who might have been itchy for years and no one’s examined them.”

Dr Elliott agrees, noting many women present with years of “chronic thrush”.

“And we may suppose that it is chronic thrush, as the patient says, and/or some oestrogen deficiency, vaginal atrophy. But when I have examined them, I have seen a number of women with the white patches of lichen sclerosus. You will miss it if you don’t examine it.”

Urine testing is appropriate if symptoms suggest urinary tract infection.

Practice tip: You can schedule a follow-up appointment for the examination and initiate vaginal oestrogen in the interim. It is unlikely to do any harm and provides useful information if symptoms improve.

More information

Cancer Council | Flow chart for managing abnormal peri- and postmenopausal vaginal bleeding

Breast Screen Australia | Breast density information for GPs

Healthy Bones Australia/RACGP | Osteoporosis risk assessment and management flowchart

Climacteric | The 2023 Practitioner’s Toolkit for Managing Menopause

Australasian Menopause Society | Perimenopausal, postmenopausal and breakthrough bleeding on MHT/HRT information sheet

Post Reproductive Health | Management of unscheduled bleeding on HRT guidelines