Menopause: The Most Important Blood Tests

What happens in the body during menopause?

Menopause is a natural process during which the ovaries gradually stop producing estrogen and progesterone. The average age of menopause is 51, but perimenopause -- the transitional period with subtle and fluctuating symptoms -- can begin after age 40 and last 4-8 years.

Hormonal changes affect more than just the reproductive system. They alter cardiovascular risk, bone density, metabolism, and even thyroid function. Therefore, during menopause it is important to monitor not only hormones but a broader spectrum of markers. This allows timely detection of changes and preventive action.

Menopause is not a disease -- it is a natural phase of life. However, by understanding what changes are occurring, women can actively manage their health and make informed decisions together with their doctor.

Hormones: FSH, LH, and estradiol

FSH (follicle-stimulating hormone) is the primary menopause marker. When the ovaries become less responsive to stimulation, the pituitary gland produces increasingly more FSH in an attempt to trigger ovulation. A level above 25 mIU/mL together with menstrual cycle changes indicates perimenopause. A level above 40 mIU/mL usually indicates that menopause has occurred (Source -- Harlow, 2017).

Estradiol -- the primary estrogen -- gradually declines and after menopause is typically below 20 pg/mL. This decrease is associated with many menopausal symptoms: hot flashes, night sweats, sleep disturbances, mood swings, vaginal dryness.

LH (luteinizing hormone) also increases, but more slowly than FSH. The change in LH/FSH ratio is one of the signs of perimenopause. During perimenopause, hormone levels can fluctuate significantly -- one test may show normal values, another -- altered ones. Therefore, doctors often evaluate the overall clinical picture rather than relying on a single test.

Cardiovascular risk: lipid panel

Estradiol has a protective effect on blood vessels -- it helps maintain elasticity, improves endothelial function, and promotes a favorable lipid profile. When it decreases, the lipid profile shifts unfavorably: LDL cholesterol increases by an average of 10-15% during the first 2 years after menopause, and HDL cholesterol may decrease (Source -- El Khoudary, 2020).

Cardiovascular disease is the leading cause of death in women after menopause -- a fact that is often underestimated. Before menopause, women's cardiovascular risk is lower than men's, but after menopause it quickly equalizes.

It is recommended to check the full lipid panel: total cholesterol, LDL, HDL, and triglycerides. Together with hs-CRP (high-sensitivity C-reactive protein), these tests help assess overall cardiovascular risk and determine whether lifestyle or pharmacological interventions are needed.

Thyroid: TSH

Thyroid disorders are 5 times more common in women than men, and their frequency increases further after age 50. Menopause and hypothyroidism symptoms can look very similar: fatigue, weight gain, dry skin, mood swings, hair loss (Source -- Benvenga, 2012).

Therefore, checking TSH during menopause is important -- it helps distinguish whether symptoms are due to hormonal changes or a thyroid disorder. Often these conditions can coexist -- a woman may have both menopause and subclinical hypothyroidism at the same time.

Normal TSH is typically 0.4-4.0 mIU/L. A value above 4.5 mIU/L may indicate the need for further evaluation -- free T4, T3, and TPO antibodies.

Bone health: vitamin D and calcium

After menopause, bone density decreases by 2-3% per year during the first 5-7 years due to estrogen deficiency. During the first decade after menopause, a woman can lose up to 20% of bone mass, significantly increasing fracture risk (Source -- Cauley, 2016).

Vitamin D and calcium are essential for bone protection. Vitamin D is required for calcium absorption in the intestine -- without it, even adequate dietary calcium will not be utilized effectively.

It is recommended to check 25(OH)D blood levels once a year. The optimal level is above 30 ng/mL (75 nmol/L). Blood calcium levels are usually kept stable by hormonal mechanisms, but testing it together with vitamin D and, when needed, parathyroid hormone (PTH), provides a more complete picture of bone health.

Metabolism: glucose and HbA1c

Menopause is associated with increased insulin resistance risk. The decline in estrogen alters glucose metabolism, body fat distribution (more fat accumulates in the abdominal area), and hormonal sensitivity to insulin. Therefore, type 2 diabetes risk increases after menopause.

Fasting glucose (normal up to 5.6 mmol/L) and HbA1c (glycated hemoglobin, normal up to 5.7%) help monitor metabolic health. HbA1c reflects average glucose levels over the past 2-3 months and is a valuable long-term indicator.

Practical testing plan

1. At the onset of perimenopause: FSH, estradiol (if diagnosis confirmation is needed), TSH, free T4. 2. After menopause, every 6-12 months in the first years: lipid panel (total cholesterol, LDL, HDL, triglycerides), glucose, HbA1c, hs-CRP. 3. Once a year: vitamin D, calcium, complete blood count (CBC). 4. Together with your doctor, evaluate bone density testing (DEXA) -- usually recommended from age 65 or earlier if risk factors are present. 5. Always record results chronologically so your doctor can monitor trends and respond in a timely manner.

When to act immediately

See your doctor if: you notice bleeding after menopause (more than 12 months without periods -- this always requires evaluation), you experience severe chest pain or shortness of breath, you notice sudden unexplained weight change or severe fatigue, or you have sustained a fracture from minimal trauma (this may indicate osteoporosis).

This is not medical advice. Consult your doctor for health decisions.