Hormone balance during menopause: which values change?

You have your hormones tested, and the result surprises you: your FSH is normal, while you have not felt like yourself for months. Two months later, urged on by a friend, you test again, and now that same FSH is raised. What is going on here?

This is the core of hormone balance in menopause: it is not a light switch that flips, but a process full of fluctuations. My position: a single hormone measurement in perimenopause says less than you think. The pattern, and the context of your complaints, says much more. Below you read which values change, in what order, and what a result does and does not mean.

Menopause in phases: not an on/off switch but a spectrum

What we call menopause actually consists of three phases that flow into one another:

• Perimenopause: the run-up, in which your hormones begin to fluctuate. This can start around age 40, sometimes earlier. Your cycle can become shorter or longer. This phase lasts an average of four to eight years.
• Menopause: the moment you have not menstruated for twelve consecutive months. Strictly speaking this is a single point in time, only established in retrospect.
• Postmenopause: all the years after menopause. Your hormone levels settle at a new, lower level. For most women, complaints gradually ease.

The average age for menopause in the Netherlands is 51, but the spread is wide. Read also about the average age of menopause.

Which hormones change, and in what order?

The hormones shift in a rough order, though it differs per woman. The table below lists the four most important, with the best time to measure.

FSH: the first measurable indicator

FSH (follicle-stimulating hormone) is produced by your pituitary gland and stimulates the ovaries. As your ovaries become less responsive, your pituitary makes more FSH. It is a feedback mechanism: the ovaries respond less, so the pituitary works harder. A rising FSH is therefore one of the earliest measurable signals.

FSH can fluctuate strongly, certainly in perimenopause. One month it can be raised, the next month normal again. The pattern over several measurements is often more informative than a single result.

Estradiol: the falling main hormone

Estradiol (E2) is the most active form of estrogen and influences your bone density, your heart and blood vessels, your skin, your mood and your sleep. In perimenopause estradiol begins to fluctuate, with peaks and dips. Those fluctuations can play a part in well-known complaints:

• Hot flushes and night sweats, possibly due to sudden falls that disrupt your heat regulation
• Sleep problems
• Mood swings
• Dry skin and mucous membranes
• Joint complaints

After menopause estradiol settles at a structurally lower level. That lower level belongs to postmenopause, but can play a part in your bone health and cardiovascular risk in the longer term.

Progesterone: often the first to fall

Progesterone is mainly produced after ovulation. When ovulation occurs less regularly, which can begin early in perimenopause, your progesterone production falls first. A relative shortage of progesterone compared with estrogen can cause complaints such as heavier menstruation, a bloated feeling, tender breasts, irritability and trouble staying asleep.

Measuring progesterone is most worthwhile in the luteal phase (around day 19-22 in a 28-day cycle). If your cycle is irregular, the timing is harder.

LH: partner of FSH

LH (luteinising hormone) works closely with FSH in driving the ovaries. During menopause LH rises gradually, like FSH, but often less pronounced. LH is rarely measured as the only marker, but it adds context in combination with FSH and estradiol.

What do fluctuating values mean?

One of the most confusing aspects of perimenopause is that your blood values can differ considerably from month to month. That does not mean your results are unreliable, but it does mean a snapshot does not always tell the full story. A few points of attention:

• A single measurement is a starting point, not a diagnosis
• The pattern over two or three measurements gives a more reliable picture
• Always combine blood values with your complaints and how you feel
• Reference values are based on broad populations and do not always account for your life stage

The Dutch GP guideline on menopause (NHG) emphasises that diagnosing menopausal complaints rests mainly on your story and your cycle, and that hormone tests have a limited, supporting role in this.

When to have your hormones tested?

There is no fixed protocol, but the following situations are good reasons:

• Your cycle becomes irregular: shorter, longer, skipped months or unexpectedly heavy bleeding
• You experience menopausal complaints such as hot flushes, sleep problems or mood swings
• You are under 45 and suspect an early menopause
• You are considering hormone therapy and want a baseline
• You want a baseline measurement around age 40

Note the timing of testing: if you still menstruate, days 2-5 are most suitable for FSH, LH and estradiol. Progesterone is best measured around day 19-22. The Menopause Check brings these values into view; if you want to look more broadly, there is the Women's Hormones panel. Want the full picture of menopause? Read our pillar on perimenopause, symptoms and solutions, and which hormones to test around menopause.

Frequently asked questions

Can I be in menopause at 38?

Yes, though it is unusual. An early menopause (premature ovarian insufficiency) is when ovarian function declines before age 40. The consequences go beyond fertility: early loss of estrogen can raise the risk of osteoporosis and cardiovascular disease. If you have menopause-like complaints under 40, discuss this with your GP.

How often to test hormones during menopause?

There is no fixed frequency. A first measurement can form a baseline. If you start hormone therapy or change your lifestyle, repeating after three to six months can be worthwhile. In postmenopause, routine testing is usually no longer needed.

What if my values are normal but I do not feel well?

A common, understandable frustration. Reference values are broad, and your hormones can fluctuate. Take your complaints seriously, even if the figures look fine, and discuss your results together with your symptoms with a doctor experienced in hormonal complaints in women.