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Why Regular Blood Testing for MHT is Bad Medicine

There is no good medical reason for regular blood (or urine or saliva) testing for sex hormone levels during perimenopause or menopause. Hormone levels vary wildly and unpredictably during perimenopause. In fact, it's one of the reasons that your symptoms are so severe. Once you're in menopause your hormone levels change very little so checking blood levels is a waste of time and money. Doctors following the evidence-based standard of care prescribe menopausal hormone therapy to treat certain symptoms of menopause, not to treat menopause itself or to restore your hormones to their reproductive age levels or to fix any other nonsense that folks selling supplements or hormones or testing, etc tout. Menopause is not a disease that needs to be cured any more than pregnancy or puberty.


Let's review how sex hormones fluctuate during a woman's lifetime. Before puberty, girls have stable, low levels of estrogen and progesterone. Puberty begins when the pituitary in their brains starts producing follicle-stimulating hormone (FSH) and luteinizing hormone (LH) and culminates when the girl starts to menstruate (menarche). During reproductive years, a woman's ~28-day menstrual cycle has 4 distinct parts (see graph below). The first, referred to as the follicular phase, sees a rise in estrogen and FSH. The estrogen that is produced by the follicles causes thickening of the uterus wall to prepare for fertilized egg implantation. And as its name suggests, FSH causes egg development in the ovary. By about day 14 of your cycle, the egg is mature. A woman's body produces LH in response to the rise in estrogen, which causes the egg to release (ovulation.) During the second half of your cycle (the luteal phase), the egg makes its way through the fallopian tube and into the uterus, and the follicle that released the egg becomes what's known as the corpus luteum. Progesterone levels rise as the corpus luteum starts pulsing it into a woman's body, and estrogen levels drop. If the egg is not fertilized and/or doesn't subsequently attach to the uterine wall, the corpus luteum will be resorbed by the ovary, levels of progesterone decrease as a result, and the uterine wall sheds through the vagina (menstruation.) If a woman gets pregnant, her body produces human chorionic gonadotropin (hCG) that helps maintain the corpus luteum and keeps the uterine lining thick. (Most pregnancy tests measure hCG.) Women have, on average, 450 menstrual cycles in their lifetimes.

The rise and fall of the different hormones account for symptoms such as bloating, breast swelling, pain, or tenderness, mood changes, headache, weight gain, changes in sexual desire, food cravings, irritability, tiredness, low back pain, trouble sleeping, and changes in color, texture, and amount of vaginal discharge. The rise of estrogen and testosterone in the follicular phase produces a boost of energy. Testosterone stimulates your libido; estrogen makes you feel more sociable and outgoing and suppresses your appetite. Those effects peak during ovulation. As progesterone starts to rise in the luteal phase, a woman will initially feel less anxious, more relaxed, and possibly sleep better. The second half of this phase, however, is notoriously difficult for many women - that's when premenstrual (PMS) symptoms appear. Cravings, particularly for breads and sweets, skyrocket. Bloating, breast tenderness, headaches, anxiety, and moodiness are common. Women might feel sluggish and prefer to stay on the couch instead of going for a run. (Graph reprinted from Harvard Women’s Health Watch, 1999)


During perimenopause, the hormone cycle described above gets disrupted (see graph). In some months, this disruption may cause an egg not to form or be released. In others, more than one egg may be released. As a result, the typical menstrual cycle symptoms get much worse (and perhaps different than you experienced previously), and you may have longer or shorter periods, irregular periods, and/or heavier or lighter bleeding. The longer you are in perimenopause, the more unwanted symptoms you may experience, and the less useful it is to use blood tests to evaluate treatment since your hormone levels are unpredictably from month-to-month, day-to-day, even hour-to-hour. If a doctor only used blood test levels to prescribe your treatment, they would undoubtedly get it wrong, high or low, since a snapshot of hormone blood levels are not a reliable measure.


Perimenopause continues through the time in which a woman no longer is producing eggs. One year following a woman's last period is referred to as menopause. At that time, hormone levels are low and basically unchanging. Blood testing for hormones is unnecessary to "diagnose" menopause (I put diagnose in quotes since diagnose implies that there is a problem, but menopause is no more a problem than puberty or pregnancy.) Further, low hormone levels are not a problem in and of themselves. There are plenty of menopausal women with low estrogen levels who have no symptoms and an equal number with higher estrogen levels who have severe symptoms. It would be needlessly risky for me to prescribe estrogen for a woman with no symptoms simply because her blood levels are low! Let me repeat - menopause is a natural experience that all women have if they are lucky enough to live that long. Hormone levels do not need to be kept at levels that you had when you were younger or at any other arbitrary number. Hormones do not need to be "replaced" or "balanced." Symptoms may warrant treatment.

The Menopause Society (formerly NAMS) and The Endocrine Society agree that menopause therapies should be driven by symptoms and their relief, and not by meaningless blood or urine or saliva levels of sex hormones. Both groups recommend that doctors use the lowest dose necessary to manage unwanted symptoms. Chasing the correct dose of MHT based on testing levels is an exercise in irresponsible medicine. There is zero evidence that "customizing" hormone dosages for a particular individual improves their symptoms or risks. If there are any advantages of "customization" (and as I said earlier, there are not), it would be offset by potential errors made in the preparation of the drugs at compounding pharmacies. One study showed that hormones obtained from 12 different compounding pharmacies contained doses of as much as 173% more than what had been prescribed and up to 40% less than what had been prescribed. In short, stick to FDA-approved drug formulations and insist that your doctor prescribe the lowest dose necessary to manage your symptoms - and only to manage your symptoms - primarily hot flashes, vaginal atrophy, and osteoporosis prevention. There is less data about the effectiveness of using MHT to treat mood disorders, sleep disturbance, and sexual desire concerns, but current evidence suggests that it may be helpful.


My advice is that you run from any healthcare professional (or pseudo-professional or social media influencer) who tells you that it is necessary for you to "replace" your sex hormones to your reproductive age levels to be healthy. Run even more quickly from those that tell you that the best way to manage that "replacement" is by regular blood/urine/saliva testing. Those people are almost certainly selling something, are unquestionably practicing medicine that is outside the standard of care, and may cause you harm.


So, what testing should menopausal women have done on a regular basis? Menopausal women are more prone to increased risk of cardiovascular disease, low levels of iron, disruptions to their thyroid function, diabetes, and deficiencies in vitamins B12 and D. Regular testing for markers of those conditions is prudent ,and your doctor can determine which tests are right for you. The USPS task force recommends routine testing (CBC, CMP, and lipid panel) every 3-5 years for women over 50 unless there are unexplained symptoms and/or risk factors for cardiovascular disease.


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