Staging the transition properly — because 'she's probably menopausal' is a diagnosis that misses thyroid disease, anaemia and depression.
In a woman over 45 with a typical picture, diagnose menopause or perimenopause clinically and do not order FSH. Take a menstrual history precise enough to stage her: cycle variability of 7 days or more marks the early transition; a gap of 60 days or more marks the late transition, which is when symptoms usually peak. Screen for the common mimics (thyroid, iron, glycaemia, mood, sleep apnoea) rather than for hormones.
Use STRAW+10 as the shared language for referrals and trial eligibility. Under 40, POI requires two FSH levels >25 IU/L at least 4–6 weeks apart plus 4 months of oligo/amenorrhoea, with karyotype, FMR1 premutation and adrenal/thyroid autoantibody testing. Between 40 and 45, use the same biochemical confirmation but a lower threshold to treat. Surgical menopause (bilateral oophorectomy) produces an abrupt estradiol and androgen withdrawal that is symptomatically and metabolically distinct from natural menopause.
STRAW+10 (Harlow 2012) folded in the SWAN and Melbourne cohort data, but note the explicit caveats: staging is less reliable with PCOS, chronic illness, high BMI and smoking, and the endocrine criteria were derived from largely non-obese cohorts. AMH-based staging models (e.g. Finkelstein 2020) predict the final menstrual period at the population level but have unacceptably wide individual prediction intervals — do not use AMH for individual prognostication.
“A high FSH confirms menopause; a normal FSH rules it out.”
During the transition FSH oscillates wildly between cycles; a single value has poor discriminant accuracy. Guidelines (NICE NG23, NAMS/Menopause Society) explicitly advise against FSH testing in women over 45, and against it in any woman on combined hormonal contraception.
Menopause in a woman over 45 can be diagnosed clinically without biochemistry
Established — RCT / guideline-grade — NICE NG23 and Menopause Society position statements concur.
Two FSH values >25 IU/L confirm POI in a woman under 40 with 4 months of amenorrhoea
Established — RCT / guideline-grade — ESHRE POI guideline diagnostic criteria.
Untreated POI increases fracture and cardiovascular risk
Supported in defined populations — Consistent cohort data; hormone therapy until ~51 is standard of care despite absence of RCT mortality endpoints.
AMH can predict an individual woman's date of final menstrual period
Biologically plausible, unproven — Population-level association only; individual prediction intervals span years.
Salivary hormone testing guides menopause management
Refuted or actively misleading — No analytic validity for clinical decisions; marketed heavily by compounding pharmacies.
A 49-year-old attends asking for 'a full hormone panel' after reading about perimenopause online. Cycles have shortened from 28 to 22 days over 18 months, with new night sweats and irritability. She is on no medication.
What is the most defensible response?
A 36-year-old with confirmed POI asks whether she still needs contraception, and whether she should take hormones 'given the WHI risks'.
Which counselling is correct?
A 47-year-old with 5 months of amenorrhoea, hot flushes and disrupted sleep. Which investigation is most appropriate?
STRAW+10 late menopausal transition is defined by:
A 34-year-old with 6 months amenorrhoea and FSH 42 IU/L on two occasions. Beyond hormone therapy, which workup is indicated?
Compared with natural menopause, bilateral oophorectomy at 45 is associated with: