Screenings after early menopause

The main guidance

The European Society of Human Reproduction and Embryology (ESHRE), the American Society for Reproductive Medicine (ASRM), the Centre for Research Excellence in Women's Health in Reproductive Life (CRE-WHiRL) and the International Menopause Society (IMS) published a joint evidence-based guideline on POI in December 2024. It covers women under 40; it says early menopause (age 40 to 44) is outside its scope, but its evidence and recommendations may be relevant. (ESHRE/ASRM/IMS, 2024) In the UK, NICE guideline NG23 on menopause has a section on diagnosing and managing POI in people under 40. (NICE NG23) In the US, ACOG Committee Opinion 605 says that once POI is diagnosed, patients should be evaluated at least once a year, and that they should be counseled on the risk of related conditions and on possible genetic inheritance. (ACOG, 2014)

How it is confirmed

The ESHRE guideline recommends diagnosing POI with disordered periods for at least 4 months and an FSH blood level above 25 IU/l, repeating FSH after 4 to 6 weeks if the diagnosis is uncertain. It says women who had both ovaries removed before 40 have POI without further tests. (ESHRE/ASRM/IMS, 2024) NICE says to diagnose POI under 40 on menopause-associated symptoms and raised FSH on 2 blood samples taken 4 to 6 weeks apart, and not on a single blood test. Both say anti-Müllerian hormone (AMH) should not be the main or routine test. (NICE NG23)(ESHRE/ASRM/IMS, 2024)

Tests and checks the guidance lists

Tests for a cause: chromosomes, fragile X, thyroid and adrenal

For POI that was not caused by medical or surgical treatment, the ESHRE guideline recommends a chromosome test and an FMR1 premutation (fragile X gene) test for all women. It says the fragile X test must be ordered as a specific test, because multigene panels do not detect the premutation, and that age should not limit access to genetic testing. It recommends discussing what genetic testing means before it is done and considering referral for genetic counselling. (ESHRE/ASRM/IMS, 2024) MedlinePlus lists fragile X syndrome, Turner syndrome and autoimmune diseases such as thyroiditis and Addison disease among the known causes, and says the exact cause is unknown in about 90 percent of cases. (MedlinePlus) The ESHRE guideline recommends testing for 21-hydroxylase antibodies when the cause is unknown, with referral to an endocrinologist for adrenal function tests if positive; if negative, it says there is no need to retest later unless signs or symptoms of adrenal insufficiency develop. It recommends a TSH thyroid test at diagnosis, repeated every 5 years or when symptoms arise, and says thyroid peroxidase (TPO) antibodies should not be tested routinely. (ESHRE/ASRM/IMS, 2024) See who needs a thyroid test and screenings for people with Turner syndrome.

Bone density

The ESHRE guideline says POI is linked with weaker bone structure and lower bone density, and may raise the risk of osteoporosis and fracture later in life. It recommends a DXA bone density scan at diagnosis for all women where available, and repeat scans every 1 to 3 years, based on individual risk factors, for women with osteoporosis or low bone density. It says the value of a repeat scan within 5 years is low when bone density is normal and hormone therapy is taken as advised, and that osteoporosis risk factors should be checked at diagnosis and during ongoing care. (ESHRE/ASRM/IMS, 2024) See how often to have a bone density test and bone density test results.

Heart, blood pressure, cholesterol and diabetes

The ESHRE guideline says women with POI have a higher risk of cardiovascular disease, including coronary artery disease, heart failure and stroke. It recommends assessing cardiovascular risk at diagnosis, checking blood pressure, weight and smoking status at least once a year, and a lipid profile and diabetes screening at diagnosis, with later tests based on raised cholesterol, raised blood sugar and other risk factors. It also recommends checking heart, metabolic and thyroid health before a pregnancy. (ESHRE/ASRM/IMS, 2024) NICE says the population risk of cardiovascular disease is very low under 40 and rises with age. (NICE NG23) See blood pressure readings, cholesterol test by age and A1C and blood sugar results.

Relatives

The ESHRE guideline says sisters and daughters of women with POI not caused by treatment should be told they have a higher risk of POI, and that ovarian reserve testing may be helpful. It recommends genetic counselling and testing for relatives of women with an FMR1 premutation or another known genetic cause. (ESHRE/ASRM/IMS, 2024) MedlinePlus says having a mother or sister with POI makes it more likely. (MedlinePlus)

Routine age-based screening

These checks are added to, not instead of, the routine screenings for your age; see screenings by age and gender. For screenings after menopause at the usual age, see screenings after menopause.

Where they differ:

• How many FSH tests. The ESHRE guideline says one raised FSH above 25 IU/l, with disordered periods for at least 4 months, is enough, and repeats it only if the diagnosis is uncertain; NICE says 2 raised FSH samples 4 to 6 weeks apart and not a single blood test. (ESHRE/ASRM/IMS, 2024)(NICE NG23)
• Named tests and intervals. The ESHRE guideline names a chromosome test, a fragile X test, adrenal antibodies, TSH every 5 years, DXA at diagnosis and yearly blood pressure; NICE section 1.7 does not list these tests and asks for advice on bone and cardiovascular health and referral to experienced professionals. (ESHRE/ASRM/IMS, 2024)(NICE NG23)
• Age 40 to 44. The ESHRE guideline covers POI under 40 and says early menopause is outside its scope; the NHS describes higher bone and heart risks for anyone whose menopause starts before 45. (ESHRE/ASRM/IMS, 2024)(NHS)

Your doctor decides what your result means for you.

Questions people ask

What counts as early or premature menopause?

The NHS says early menopause is when regular periods stop before age 45 and premature menopause is when this happens before 40. The ESHRE guideline calls loss of ovarian activity before 40 premature ovarian insufficiency (POI) and periods stopping at 40 to 44 early menopause. (NHS) (ESHRE/ASRM/IMS, 2024)

Do I need a bone density scan?

The ESHRE guideline recommends a DXA bone density scan for all women at diagnosis of POI, where available. It says the scan should be repeated every 1 to 3 years for women with osteoporosis or low bone density. (ESHRE/ASRM/IMS, 2024)

Which blood tests look for a cause?

For POI that was not caused by surgery or cancer treatment, the ESHRE guideline recommends a chromosome test and a fragile X (FMR1) premutation test for all women. It recommends a 21-hydroxylase antibody test when the cause is unknown and a thyroid (TSH) test at diagnosis. (ESHRE/ASRM/IMS, 2024)

How often is my thyroid checked?

The ESHRE guideline says TSH should be measured at diagnosis and repeated every 5 years or when symptoms arise. (ESHRE/ASRM/IMS, 2024)

Should my sister or daughter be tested?

The ESHRE guideline says female relatives of women with POI not caused by treatment should be told they have a higher risk of POI, and that relatives of women with a fragile X premutation or another genetic cause should be offered genetic counselling and testing. (ESHRE/ASRM/IMS, 2024)

Related

• Screenings if you have had preeclampsia
• Screenings after menopause
• How often to have a bone density test
• Who needs a thyroid test
• Cholesterol test by age
• Screenings for people with Turner syndrome
• Screenings by age and gender
• Questions to ask your doctor