Synopsis
Diagnose the menopausal transition from age, symptoms and menstrual context while using laboratory tests selectively and recognising pregnancy, premature ovarian insufficiency and important alternative disease.
- In an otherwise healthy person aged 45 or over, diagnose perimenopause clinically when newly developing vasomotor symptoms accompany menstrual-cycle change; routine hormone tests are unnecessary.
- Diagnose menopause clinically after at least 12 months without a period when the person is not using hormonal contraception; after hysterectomy, use the characteristic symptom pattern because bleeding cannot mark the transition.
- Do not use anti-Müllerian hormone, inhibins, oestradiol, antral-follicle count or ovarian volume to identify perimenopause or menopause in people aged 45 or over.
- Consider serum FSH only for people aged 40 to 45 with compatible symptoms and cycle change, or those under 40 in whom menopause or premature ovarian insufficiency is suspected.
- Do not use FSH to diagnose menopause during combined oestrogen-progestogen contraception or high-dose progestogen treatment because suppression makes the result misleading.
- Exclude pregnancy whenever biologically possible; HRT neither prevents ovulation nor provides contraception, and irregular cycles can still contain an ovulation.
- Investigate targeted alternatives when the pattern is atypical rather than ordering a broad menopause panel: examples include TSH, prolactin, full blood count or pelvic assessment according to the history.
- Record the effect on sleep, mood, sexual function, work, relationships and quality of life, then review any chosen treatment at three months and annually thereafter.
Key red flags
Vaginal bleeding more than 12 months after the final natural menstrual period requires assessment as postmenopausal bleeding rather than reassurance about cycle variability.
Amenorrhoea with pelvic pain, bleeding, syncope or shoulder-tip pain requires an immediate pregnancy test and urgent exclusion of ectopic pregnancy.
New focal neurological symptoms, exertional chest pain, severe breathlessness or unilateral leg swelling needs acute assessment and must not be attributed to hot flushes or anxiety.
Marked weight loss, persistent fever, galactorrhoea, visual-field change, virilisation or a pelvic mass indicates an alternative endocrine, malignant or structural diagnosis.
Severe depressive symptoms, mania, psychosis, self-neglect or thoughts of suicide require same-day mental-health risk assessment alongside symptom care.
Investigation priorities
Identify a typical transition and determine whether bleeding, treatment or surgery obscures the final menstrual period.
Management branches
Menopause-associated symptoms or menstrual change prompts assessment.
- Document menstrual chronology, vasomotor and genitourinary symptoms, functional effect, pregnancy possibility, contraception and treatment history.
- At age 45 or over with a typical pattern, make a clinical diagnosis without a routine reproductive-hormone panel.
- If hysterectomy or hormonal treatment obscures bleeding, interpret the symptom cluster and avoid inventing a final-menstrual-period date.