Do You Need Bloodwork Before Starting Hormone Therapy?

If you are thinking about hormone therapy, you may have heard conflicting advice about testing. Some clinics will not start treatment until your hormone levels are tested, and they build their approach around repeated saliva or blood panels. Others offer bioidentical hormones without a blood test at all, which can sound like a corner being cut. The major medical societies take a position in between. For most women in their mid-forties and older, a hormone level is not what confirms perimenopause or menopause, and it is not what sets the dose. Blood tests still matter in some situations, though, and the sections below explain which ones.

In our post on questions to ask before starting bioidentical hormones, we noted that hormone therapy is generally guided by how your symptoms respond rather than by a number on a lab test. This is the longer answer to the testing question from that list.

Why a single hormone level tells you so little

During perimenopause, hormones do not decline in a straight line. ACOG’s patient guidance on hormone therapy says, “Your hormone levels can go up and down during perimenopause.” The Menopause Society describes the irregular periods of this stage as the result of “the ovaries’ erratic production of hormones,” and the Endocrine Society notes that estrogen levels at this age can fluctuate “from one minute to the next.” A blood draw captures one moment of that, and a result from one day may not match the next.

For that reason, the diagnosis usually rests on your history rather than a lab. The Endocrine Society’s patient page on menopause, discussing hot flashes, states that “the diagnosis is made clinically by classic symptoms during perimenopause or menopause, as determined by history and physical exam.” Guidance from the UK’s National Institute for Health and Care Excellence (NICE) is more specific. For otherwise healthy women aged 45 or over who have menopause symptoms, NICE advises identifying perimenopause and menopause “without laboratory tests,” and it lists estradiol, the main form of estrogen before menopause, among the tests not to use for that purpose. Menopause itself is confirmed in hindsight, one year after your final period, as The Menopause Society’s perimenopause page notes.

Testing to set or “balance” your dose

Some clinics, particularly those offering custom-compounded hormones, use saliva, urine, or blood tests to set the dose and adjust it toward a target number. The Menopause Society’s 2022 hormone therapy position statement addresses this practice. It explains that using such testing to guide dosing “is considered unreliable” because hormones are absorbed differently from person to person, levels shift over the course of a day, and results vary both between women and within the same woman. Its key point on the subject reads, “Salivary and urine hormone testing to determine dosing are unreliable and not recommended. Serum hormone testing is rarely needed.”

In practice, the dose is adjusted to how your symptoms respond. The Society’s patient page on hormone therapy explains that “often a period of trial and error is required to arrive at the best dose and regimen for you,” and ACOG recommends revisiting the decision every year based on “your symptoms, risks, and benefits.” So if you have seen bioidentical hormones offered without a blood test, starting without a hormone level is consistent with this guidance for a woman in her mid-forties or older with typical symptoms, as long as she still gets a full evaluation of her history and symptoms.

When bloodwork does matter

A blood test is useful in the following situations.

Checking for something else

Several common perimenopause symptoms overlap with thyroid problems. MedlinePlus, the patient site of the National Library of Medicine, lists trouble tolerating heat, trouble sleeping, and mood swings among the symptoms of an overactive thyroid, and fatigue, depression, and heavy or irregular periods among the symptoms of an underactive one. The Endocrine Society notes that when the signs and symptoms are not classic, “evaluation for other causes of flushing may be needed, such as thyroid function testing to exclude hyperthyroidism.” The Menopause Society also lists thyroid dysfunction among the possible causes of abnormal bleeding, and its position statement says that hot flashes appearing many years after menopause need further evaluation, since they can come from other medical problems, an overactive thyroid among them.

Symptoms that start earlier than usual

Testing plays a larger role when symptoms begin before the mid-forties. NICE suggests considering a blood test for follicle-stimulating hormone (FSH) to confirm menopause in women aged 40 to 45 whose symptoms include a change in their cycle, and in women under 40 in whom menopause is suspected. For women under 40, it bases a diagnosis of premature ovarian insufficiency partly on elevated FSH in two blood samples taken 4 to 6 weeks apart, and advises against making that diagnosis on a single test. The Menopause Society notes that about three in 100 women go through menopause before 40 and recommends an examination by a healthcare professional when that happens. Hormonal birth control can make the picture harder to read as well, and NICE advises against using an FSH test to identify menopause in women taking combined estrogen and progestogen contraception.

Testosterone

With testosterone, blood levels are part of the treatment itself. A global consensus statement on testosterone therapy for women past menopause, endorsed by The Menopause Society (then the North American Menopause Society) and the Endocrine Society among others, says that “a blood total testosterone level should not be used to diagnose” low sexual desire that is causing distress. If a trial of testosterone is started, it recommends measuring a baseline level first, repeating it 3 to 6 weeks into treatment, and monitoring regularly after that, so that levels stay close to the normal range for women before menopause rather than climbing above it. That matches our earlier post on decreased libido, which notes that your provider should continue to monitor testosterone levels and side effects. The same post describes a broader hormonal evaluation for low desire that includes thyroid and prolactin levels, and our post on low libido in perimenopause covers where testosterone fits among the other causes.

Your overall health

Whether hormone therapy is a safe fit rests mainly on your health history rather than on a hormone level. ACOG advises deciding “based on your symptoms and your personal and family medical history.” The Menopause Society says that, in general, women with breast cancer, uterine cancer, unexplained uterine bleeding, liver disease, a history of blood clots, or cardiovascular disease should not use hormone therapy. Routine screening still matters at this age. ACOG’s guidance on the menopause years notes that heart disease risk factors such as high cholesterol and high blood pressure become more common in midlife, and it recommends a yearly visit “to have regular exams and tests.” If you are behind on that, it is worth catching up, since heart and clotting history is part of the hormone therapy decision.

What to expect from an evaluation

A thorough hormone therapy evaluation starts with a detailed history of your symptoms, your cycle, your medications, and your personal and family health, and it uses labs where they answer a specific question.

For any test, ours included, it is reasonable to ask what the result will change about your plan. A test to rule out a thyroid problem, or to keep testosterone within a safe range, has a clear answer to that question. If a provider proposes saliva testing to set your dose, ask how that fits with The Menopause Society’s position that it is unreliable for that purpose.

Not sure what testing you need?

If you are considering hormone therapy and are unsure what testing makes sense for you, that is a good question to bring to a consultation. Our board-certified physicians provide hormone therapy care through telehealth, with time set aside to take a full history and review what has already been done. Request a free consultation and bring any recent lab results you have. We would be happy to help you.