FSH Testing for Menopause and Contraception

MENOPAUSE REFERRALS AND ADVICE QUERIES SHOULD BE DIRECTED TO THE MENOPAUSE CLINIC AT CHALMERS VIA SCI GATEWAY.

THE LABORATORY INVESTIGATION OF PERI/MENOPAUSE AND ASSESSING CONTRACEPTIVE NEEDS

1. Use of serum FSH to diagnose perimenopausal/menopause

Serum FSH should be checked if:

• A woman aged <40 years has symptoms or a change in menstrual cycle that could indicate premature ovarian insufficiency (if using combined hormonal contraception or HRT see note below)

Serum FSH should be considered if:

• A woman aged 40-45 has symptoms or a change in menstrual cycle that could indicate early menopause (if using combined hormonal contraception or HRT see note below)

Interpreting the FSH result A single raised FSH level (> 30 U/L) indicates a degree of ovarian insufficiency consistent with perimenopause/menopause. There is no need to repeat this test. An FSH of <30 U/L does not exclude perimenopause. Levels can fluctuate widely during the perimenopause.

Serum FSH should not be checked in:

• Women aged > 45 years.
• Women using combined estrogen and progestogen contraception or HRT

Why not? In otherwise healthy women over 45 years who have menopausal symptoms and/or change in menstrual cycle, perimenopause can be diagnosed. Menopause management is not altered by an FSH test. By not testing these women we reduce the use of laboratory and phlebotomy resources, we avoid follow up consultation to discuss the result and we limit delay in starting any treatment required. FSH levels are not useful in diagnosing perimenopause/menopause in people using combined hormonal contraception or HRT because the exogenous hormone suppresses serum FSH and estradiol.

2. Use of serum FSH measurement in assessing requirement for contraception

PLEASE NOTE THAT SERUM FSH >30 U/L DOES NOT CONFIRM THAT CONTRACEPTION CAN BE STOPPED IMMEDIATELY.

Serum FSH testing is not required prior to stopping contraception in:-

• Women aged 55 years or over. These individuals can stop contraception.
• Women aged 51 or over who have been NATURALLY amenorrhoeic for over a year. These individuals can stop contraception. This does NOT apply to individuals who are amenorrhoeic while using hormonal contraception or HRT.

Serum FSH measurement can be considered to guide ongoing requirement for contraception in women aged 50 or over who wish to stop contraception. (Alternatively, suitable progestogen-only contraception can be continued until age 55 years and then stopped).

Note that serum FSH is not useful during use of combined hormonal contraception or HRT (see guidance below).

Managing the FSH result If a woman aged over 50 years has a single serum FSH of >30 U/L (even if using progestogen-only contraception) they can stop contraception after one more year. There is no benefit in checking FSH after the person’s 54th birthday as contraception can be stopped at age 55 in any case. If the FSH result is <30 U/L the person can continue suitable progestogen-only or non-hormonal contraception until age 55. Alternatively, the serum FSH can be repeated after 1 year.

FSH testing should not generally be used under age 50 to guide stopping contraception. Women under age 50 years should, in general, continue contraception to age 50 years then follow the advice above. 

Why? In younger individuals (even those with elevated FSH and a period of amenorrhoea) future ovulation is not uncommon, and it is generally recommended that contraception should be continued at least until age 50.

3. Notes on contraception in the perimenopause

• Women using a copper IUD (Cu-IUD) that was inserted after age 40 years can use the device for contraception until age 55 years when contraception can be stopped. If they are amenorrhoeic for a year after age 50, the Cu-IUD can be removed.

• Women using the progestogen-only pill (POP), etonogestrel implant (IMP) or any levonorgestrel IUD (LNG-IUD) can continue the contraception until age 55 years and then stop. These progestogen-only contraceptives can be used alongside HRT, but ONLY the 52mg LNG-IUD can be used for endometrial protection as part of HRT (for 5 years after insertion). Note that a 52mg LNG-IUD like Mirena or Levosert inserted after age 45 years can be used FOR CONTRACEPTION until age 55 years (but is effective for only 5 years for endometrial protection as part of HRT).

If they wish to discontinue contraception, women aged over 50 years who are amenorrhoeic using POP, IMP or an LNG-IUD can have a serum FSH checked. If the result is >30 U/L, they should continue contraception for 1 year and then stop (there is no need to repeat this test). If the result is <30 U/L, they should continue the contraception and recheck FSH after 1 year.

• Combined hormonal contraception (CHC) -ethinylestradiol with a progestogen – is not recommended for use after age 50 because of the associated increased risk of venous thromboembolism.

Women aged 50 years or over who are using CHC and who wish to continue contraception should switch to the POP, IMP or LNG-IUD or non-hormonal contraception and continue until age 55 years.

Women aged 50 years or over who are using CHC and wish to consider stopping contraception should switch to the POP for at least 6 weeks, then follow advice for POP as above.

CHC should not be used in addition to HRT.

Eligible individuals aged under age 50 years could consider using CHC instead of HRT for symptom management and bone protection as well as contraception. HRT is, however, generally more effective for symptom control and bone protection and has a smaller effect on thrombotic risk (especially if the HRT contains transdermal – rather than oral – estradiol).

• Contraceptive alternatives to depot medroxyprogesterone acetate (DMPA) are recommended after age 40 because of the adverse effect of Depo Provera and Sayana Press on bone mineral density. DMPA may suppress FSH levels. An FSH of >30 U/L during DMPA use can be confidently attributed to peri-menopause, however a result of <30 U/L cannot exclude it. The optimum time to measure FSH levels in a woman using DMPA is just before a repeat DMPA is administered.