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Can blood tests help to manage menopause and HRT?
There is increasing interest in whether blood testing can predict the onset of menopause, and whether it is useful in the management of hormone replacement therapy (HRT). We ask the experts if blood tests to assess hormones are worth considering.
In the UK, the average age a woman will reach menopause is 51, though anywhere between 45 and 55 is still considered to be within the normal range. For some women, menopausal night sweats, painful joints, depression, and vaginal and bladder issues can be hugely debilitating. Hormone replacement therapy (HRT) is one option to help manage these symptoms and alternatives to HRT are also available.
Blood tests to measure hormone levels are not necessary for most women at menopause and the reality is that symptoms are often a better indicator says Dr Paula Briggs. Briggs is a member of the British Menopause Society (BMS) council and a consultant in sexual and reproductive health based in Liverpool.
"I've seen lots of women who are told they're not menopausal based on 'normal range' blood tests, yet they have raging menopausal symptoms," she explains. "In the perimenopause, hormone levels will be all over the place and change day to day. You might do a test and it would show a normal estradiol level and a low follicle-stimulating hormone (FSH) level, but that could change; it's just a snapshot in time. Patients can get quite hung up on getting blood tests done, but it can be counterproductive."
Dr Susanna Unsworth is a menopause and women's health specialist based in Cambridge. She agrees that in women over 45, blood tests are not required to diagnose menopause.
"Though for women who are aged 40-45 who have noticed their periods have stopped, assessing hormones can sometimes be helpful to decide if this is due to menopause, or some other reason," she adds.
"Women aged under 40 should be thoroughly investigated to find the cause of their periods stopping, as they may have potential premature ovarian insufficiency," she continues. "This needs appropriate management as it has long-term health implications."
Predicting menopause - the AMH blood test
An AMH blood test measures the amount of anti-Müllerian hormone in the blood and can provide an indication of how many eggs a woman still has in her ovaries. The test has recently been touted in the media as a way of predicting whether a woman will have her last period within the next two years.
"AMH is not an appropriate test for menopause," says Briggs. "Yes, it gives you an idea of your ovarian reserve, but it is mainly used in infertility. Symptoms are a much better guide when diagnosing menopause."
Unsworth agrees that for most women approaching menopause the AMH test may not be particularly useful. She also adds that there is no accurate way to know how quickly the level may decline, so it cannot be very precise in its prediction.
"A study in the USA found the AMH test was fairly helpful in predicting women (aged 42 and over) who were likely to go through menopause in the next one to three years," she explains. "This may have some limited benefit. For example, in women wanting to decide whether to have major surgery to help with period problems - if their periods are likely to stop in the next year, they may feel surgery is not worth it."
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Blood tests and HRT
Most HRT specialists will check with patients to see how they are responding to treatment and rely on symptom control as a gauge before doing blood tests. They are likely to suggest increasing the dose so see if that helps ease symptoms before doing further investigations.
"Testing levels prior to starting HRT is not usually helpful," says Unsworth. "Hormone levels fluctuate significantly in perimenopause. In women post-menopause, it can in a minority of cases be helpful to check oestrogen levels during HRT treatment if their symptoms are not well controlled. This is to ensure they are absorbing the oestrogen effectively (usually more of an issue with oral HRT). If the levels are low, a higher dose can be used. If the levels are good, it may be that an alternative diagnosis may need to be considered.
"Blood tests are occasionally needed in women whose symptoms fail to respond to adequate doses of HRT. Occasionally women don't absorb hormones well, even with transdermal (skin) therapy. Also, there's a syndrome where women can get high levels of hormones in the blood, but still feel symptomatic. So blood tests are worth doing in this instance."
You may be surprised to learn that women's ovaries produce more testosterone than oestrogen. We tend to think of testosterone as 'the male hormone', but it is an important in helping women with their energy, well-being and libido, and it declines from the twenties onwards. Testosterone is not yet licensed for use on the NHS as a menopause treatment, but may be issued on private prescription by doctors in certain circumstances. Products currently licensed to be used in higher doses in men can be used to treat women, out of product licence.
"In women who are struggling with symptoms that suggest low testosterone, it is sensible to do a testosterone blood test before starting any treatment, and also around three months afterwards," says Unsworth. "This will ensure their levels do not become too high, which can potentially cause some 'masculinising' side-effects."
Both doctors point out that if you are considering having a blood test for testosterone levels it is a free androgen index that is required. This measures the level of 'free testosterone' that is active in the body, as it is this which helps ease symptoms in menopause. Testosterone binds to sex hormone-binding globulin (SHBG) and bound testosterone has fewer beneficial effects. Measuring both testosterone and SHBG enables the free androgen index to be calculated.
Blood tests versus other indicators
Saliva testing which can measure the level of hormones circulating in the bloodstream is now available. Proponents of saliva testing claim it is much more specific and correctly identifies the level of hormones at the cellular level, in contrast to a blood serum test.
"There are a number of new tests becoming available privately," says Unsworth. "These include hormone tests based on saliva and urine samples. At present, I do not feel there is enough evidence to support the accuracy and reliability of these tests. Given they often have a very high price tag, I would consult a doctor before considering them."
Both Briggs and Unsworth are keen to point out that, as with all areas of medicine, blood tests can provide helpful information, but should not be used in isolation to make clinical decisions. Most tests provide doctors and patients with a 'normal range', but this can vary hugely in some cases, so should only be used in conjunction with an overall picture of symptoms and a full medical history.
How to seek help
"It's a good idea to see if there's a GP at your practice who specialises in menopause and HRT," advises Briggs. "And if you feel you need extra support ask to be referred to your local menopause clinic or a specialist consultant."
The National Institute for Health and Care Excellence provides guidelines on when blood tests are necessary in menopause.
"I would not recommend accessing any blood tests without consulting a doctor," adds Unsworth. "However, not all doctors may be confident in interpreting these types of hormone results, so I would recommend seeking out a doctor with an interest in menopause to ensure you are given the correct answers and treatment."