The Hormone Panel Every Woman Over 38 Should Ask For
Day 22 of the 30-day Perimenopause Series.
The Panel You Have to Ask For
Most women in their forties have never had a full hormonal picture drawn. They have had a TSH, maybe a complete blood count at a physical, and a great deal of reassurance. Then they arrive at an appointment with two years of symptoms and are told everything looks fine.
Asking for a fuller panel is reasonable, and you should not have to apologize for it.
Estradiol. Progesterone. FSH. LH. Total and free testosterone. DHEA-S. SHBG. Ask for all of them. You are not being difficult. You are being thorough.
And then — this is the part that matters more than the list — know what each of those numbers can and cannot tell you. A panel you do not understand can be used against you as easily as for you.
First, the Honest Part
Perimenopause is diagnosed clinically — from your symptoms, your age, and the pattern of your cycles. It is not diagnosed by a blood test, and no number on a panel confirms or excludes it.
The reason is simple and it is the whole story of this transition: in perimenopause your hormones are not low, they are erratic. Estradiol can be higher than it ever was premenopausally one week and near the floor two weeks later. FSH climbs and then falls back. A blood draw captures a single hour of a system that is swinging violently. Draw it again on a different day and you may get a different picture entirely.
This is why major guidelines do not recommend routine FSH and estradiol testing to diagnose perimenopause in a woman over 45 with typical symptoms. I am telling you that plainly, because if you walk in demanding a panel without knowing it, you may be dismissed by someone who does.
So why ask at all? Because testing done for the right reasons still earns its place: to establish a baseline before treatment, to find the treatable conditions that imitate perimenopause, to answer specific questions like whether testosterone is worth discussing, and — in a younger woman — to catch something that genuinely changes the plan.
The Sex Hormones — and When to Draw Them
Timing changes what these numbers mean. A panel drawn on a random Tuesday is far less useful than the same panel drawn deliberately.
Estradiol and FSH. If you are still cycling, day two to four of your cycle is the conventional window, because it gives a comparable reference point. A rising FSH with a low estradiol is consistent with the transition — but a normal FSH means very little, since it fluctuates. These are most informative repeated over time, not as a single snapshot.
Progesterone. Only meaningful in the luteal phase — roughly seven days after ovulation, or about a week before your period is due. Drawn at the wrong point it will look low in a completely normal cycle. Its main use is confirming whether you ovulated at all, which is often the first thing to go.
Total and free testosterone, with SHBG. Draw in the morning, when levels are highest. SHBG is the carrier protein that binds sex hormones, so it determines how much testosterone is actually available to your tissues — which is why total testosterone alone can look reassuring while free testosterone is genuinely low. Oral estrogen and thyroid disease both raise SHBG. This trio belongs together or not at all.
DHEA-S. An adrenal androgen and a precursor to both testosterone and estrogen. It declines steadily with age, and it is worth knowing your number before anyone suggests supplementing it.
LH. Most useful alongside FSH, and particularly when the pattern is unusual — an LH-to-FSH ratio can point toward PCOS, which does not disappear in your forties and is regularly mistaken for perimenopause.
One practical note: if you are already on hormonal contraception, most of these results will reflect the contraception rather than your own ovarian activity. Say so before the draw, so nobody interprets the panel as though it were your baseline.
The Tests That Change Management More Often
If I could only order one set of labs on a forty-six-year-old woman who is exhausted, foggy, anxious, and not sleeping, it would not be the sex hormones. It would be these — because these find things that are treatable today.
A full thyroid panel — TSH with free T4, and free T3 and thyroid antibodies where the picture warrants it. Thyroid disease is common in midlife women and imitates almost every symptom in this series.
Ferritin and iron studies, with a complete blood count. Heavy perimenopausal bleeding depletes iron quietly, and low ferritin causes fatigue, brain fog, hair loss, restless legs and palpitations long before anemia shows up. Ask for ferritin specifically — a normal hemoglobin does not rule it out.
B12, folate, and vitamin D — all three produce fatigue and cognitive symptoms, and all three are straightforward to correct.
Hemoglobin A1c, or fasting glucose with fasting insulin. Insulin resistance builds through this decade and drives the weight, the energy crashes, and a good deal of the mood volatility.
A lipid panel and a comprehensive metabolic panel. Cardiovascular risk changes across this transition, and heart disease remains the leading cause of death in women.
When Hormone Testing Genuinely Matters
If you are under 40 with menopausal symptoms or absent periods, this stops being optional. Primary ovarian insufficiency needs identifying — typically repeated FSH and estradiol several weeks apart, plus a broader workup — because it carries real bone and cardiovascular implications and it is treated differently.
Between 40 and 45, testing carries more weight than it does later, because the diagnosis is less obvious and other explanations deserve excluding.
If testosterone is being considered for low libido, a baseline total and free testosterone with SHBG is appropriate before starting and for monitoring afterward.
If your symptoms are atypical, if periods have stopped abruptly, if there is unexplained bleeding, or if you have had a hysterectomy and cannot use your cycle as a guide.
And as a baseline before starting hormone therapy, so that later you have something to compare against.
Do Not Let a Normal Panel End the Conversation
This is the single most important paragraph in this post, and it is the reason I want you to understand the panel rather than simply request it.
A normal FSH does not mean you are not perimenopausal. A normal estradiol does not mean your symptoms are imaginary. Levels that sit inside the reference range on the morning of your draw say almost nothing about the week you had. If someone hands you a printout and tells you your hormones are fine so this must be stress, that is not an interpretation — it is a misuse of the test.
The correct response is: my symptoms are the diagnosis, the labs were to rule things out and set a baseline, and I would like to talk about treatment. Perimenopause is treated on symptoms, not on numbers.
What I Would Not Spend Money On
Saliva hormone testing. It is not reliable for guiding treatment decisions, and the major menopause and endocrine societies do not endorse it. It is frequently the entry point to an expensive compounded prescription.
Direct-to-consumer panels sold with a proprietary interpretation and a matching supplement line. If the same company reads the result and sells the fix, treat that as a conflict.
Repeating a full sex hormone panel every few months while nothing about your plan depends on the result. Testing should answer a question. If nobody can tell you what would change based on the number, it is not worth the draw.
A Note to Your People
If she comes home from an appointment with a printout and the words everything is normal, and she is still exhausted — do not let that be the end of it either. Normal labs and a real problem coexist all the time. Help her get the next appointment.
Whole-Person Steps
Write the list down and take it with you: estradiol, progesterone, FSH, LH, total and free testosterone, DHEA-S, SHBG — plus thyroid, ferritin and iron studies, CBC, B12, folate, vitamin D, A1c or fasting insulin, lipids, and a metabolic panel.
Time the draw if you are still cycling: day two to four for FSH and estradiol, luteal phase for progesterone, morning for testosterone. Note your cycle day on the requisition.
Bring a symptom record, not just a request. Two months of tracking — cycles, sleep, mood, energy — does more to get you taken seriously than any single lab value.
Ask for your actual results, with the reference ranges, not a phone call saying everything is normal. You are entitled to them and you will want them later for comparison.
If you are under 40 with menopausal symptoms or your periods have stopped, do not wait. That warrants evaluation now.
If the panel comes back unremarkable and you still feel terrible, ask what the treatment plan is anyway. That question is the whole point of this post.
If You Are in Utah
At Integrative Mind Body Psychiatry, comprehensive lab work and interpretation are part of my functional medicine consultations — the whole picture rather than a single number, and an explanation of what each result actually means for you. Psychiatric care through insurance is available separately. Telehealth for adults, adolescents, and women in hormonal transitions across Utah. Insurance accepted through Headway. Learn more at integrativemindbodypsychiatry.com.
This post is general education, not medical advice. It does not create a provider-patient relationship and it is not a substitute for evaluation by a clinician who examines you. Which tests are appropriate for you depends on your age, history, and symptoms.
Tomorrow: Day 23 — Supplements That Actually Have Evidence (and the Ones That Do Not).
Respectfully, and with real care,
Beth Makar, RN, Dual-MSN, PMHNP-BC
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