We are all familiar with the binary result recorded doing a lateral flow test for COVID-19. You return a result which is negative or positive for COVID-19 antigen. The same principle applies for a pregnancy test where the early pregnancy hormone (beta human chorionic gonadotrophin) excreted in the urine will return either a positive or negative result.
These are examples of clinical tests where a binary result is sufficient. This approach is not suitable where quantification is required. For example, blood glucose monitoring provides a value for blood glucose concentration which is crucial in determining the dose of insulin required. The other challenge is where the clinical situation you are trying to assess may have a variable course. For example, perimenopause.
Perimenopause is the transition from having fully functioning female hormone networks, to menopause where the ovaries stop responding to hormone signals from the conductor of the hormone orchestra, the pituitary gland. This results in cessation of ovulation, drastic reduction of ovarian hormone production of oestradiol and progesterone and no further menstrual periods. The challenge for women is that this transition is not an on/off switch. Some menstrual cycles the ovaries may be working perfectly well, the female hormone network functioning beautifully with the hormones rising and falling in a biologically timed, co-ordinated manner. On the other hand, there may be some cycles where the ovaries are somewhat recalcitrant in their response to the control pituitary hormones, in particular follicle stimulating hormone (FSH). This is why consistently raised FSH over the cycle and over subsequent cycles can be a supportive piece of evidence for perimenopause. However, as outlined by the British Menopause Society, FSH is just one part of the picture when it comes to perimenopause.
The British Menopause Society are not in favour of performing an over-the-counter urine test for FSH as an indicator of transition to menopause[1]. In the first instance, this test returns a binary result of either high or low FSH. Although it is correct that high FSH in the cycle when not expected, can indicate reduced ovarian responsiveness, this is based on a quantified value from a blood test at a known time in the cycle. A one-off test showing a non-quantified “high” FSH level might simply reflect the rise before ovulation occurs, rather than a reduced ovarian response. As the timing of hormone release becomes more variable during perimenopause, this makes even quantified single time point FSH tests challenging to interpret. The urine test for FSH does not provide either quantification, or detail of timing.
The other major problem highlighted by the British Menopause Society is that any clinical test must be put in the clinical context of the individual. Perimenopause is characterised by change in the nature and regularity of menstrual periods and other symptoms. This is why interpretation of all clinical tests is performed by medical doctors who have received extensive clinical training. This can include specialised training from the British Menopause Society.
Ultimately, however accurate and specific a particular clinical test, the true value lies in the medical interpretation in the clinical context of the individual. This is especially important in the case of perimenopause where every woman has to be treated as an individual and a personalised approach to hormone health is vital[2].
When it comes to female hormones, as stated by the Vice President of the Royal College of Obstetrics and Gynaecology, it is crucial to “treat women as individuals, not statistics”[5]. Although the transition to menopause is normal physiology, every woman will follow a different path and experience this is in a different way. Providing personalised information and advice will empower women to make informed decisions for their quality of life and long-term health.
“Hormones, Health and Human Potential” is the title of the book I have written, which will be published in Autumn 2022 and will explore further the connections between hormones, health and lifestyle across the lifespan.
References
[1] BMS statement on over-the-counter menopause tests British Menopause Society10 June 2022
[2] Hamoda H, Mukherjee A, Morris E et al. Optimising the menopause transition: Joint position statement by the British Menopause Society, Royal College of Obstetricians and Gynaecologists and Society for Endocrinology on best practice recommendations for the care of women experiencing the menopause. Post Reproductive Health 2022, Vol. 0(0) 1–2 DOI: 10.1177/20533691221104882
[5] Rymer J, Brian K, Regan L. HRT and breast cancer risk British Medical Journal 2019; 367 doi: https://doi.org/10.1136/bmj.l5928
Dr Nicky Keay 