01Reproductive Aging and the STRAW+10 Map
Staging the transition properly — because 'she's probably menopausal' is a diagnosis that misses thyroid disease, anaemia and depression.
Key takeaways
- —Menopause is a retrospective clinical diagnosis: 12 months of amenorrhoea, no biochemistry needed over 45.
- —The late transition — not postmenopause — is when vasomotor symptoms and mood disturbance usually peak.
- —POI is not 'early menopause you can wait out'; untreated it carries excess CVD, osteoporosis and all-cause mortality risk.
- —Roughly a quarter of midlife 'menopause' presentations have a coexisting or alternative driver: hypothyroidism, iron deficiency, OSA, depression, or alcohol.
Graded claims
Menopause in a woman over 45 can be diagnosed clinically without biochemistry
Established — RCT / guideline-gradeNICE 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-gradeESHRE POI guideline diagnostic criteria.
Untreated POI increases fracture and cardiovascular risk
Supported in defined populationsConsistent 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, unprovenPopulation-level association only; individual prediction intervals span years.
Salivary hormone testing guides menopause management
Refuted or actively misleadingNo analytic validity for clinical decisions; marketed heavily by compounding pharmacies.
Supporting references
- Executive summary of the Stages of Reproductive Aging Workshop +10 — Harlow et al., J Clin Endocrinol Metab 2012 https://pubmed.ncbi.nlm.nih.gov/22344196/
- ESHRE Guideline: Premature Ovarian Insufficiency (2024 update) — ESHRE https://www.eshre.eu/Guidelines-and-Legal/Guidelines/Premature-ovarian-insufficiency
- Menopause: diagnosis and management (NG23) — NICE https://www.nice.org.uk/guidance/ng23