What Labs Should You Get During Perimenopause?

I hear this from my patients in their late 30s, 40s and early 50s all the time: "My doctor said my labs are normal, so why do I feel like this?" These women often have trouble sleeping, low energy, dry skin, irregular cycles, moodiness and weight gain, to name a few. They just don't feel like themselves. Yet standard blood tests reveal absolutely nothing out of the ordinary, and as a result, there's no clear path for treatment.

During perimenopause, a period that can begin in our early 40s and last for 10 years or more, women's ovaries begin to decline in function. Hormone production fluctuates, so estrogen, progesterone and testosterone levels can vary widely. And these hormones play important roles in sleep, energy, mental focus, skin health, bone health, vaginal health, menstrual cycles, muscle tone and libido.

While there's not a single blood test that diagnoses perimenopause, which is dependent on a woman's age and her symptoms, there are incredibly valuable assessments of hormone balance, metabolic health, thyroid health, and nutrient absorption that you should measure. Let's talk about what those are, and what the numbers will tell you about your journey towards menopause.

1. Hormone balance panel

Hormone tests are often a starting point in working with patients in perimenopause—but there is a pretty big catch: Because hormone levels change throughout the menstrual cycle, one value alone does not always dictate where a patient stands in her menopause transition. That's why lab values should be used as a guide and followed over time for changes. (The ultimate "test" for menopause, however, is not a lab test: it's whether she has missed 12 months of cycles—but her lab numbers will likely reflect this.)

A hormone balance panel measures a woman's key hormones:

• Follicle-stimulating hormone (FSH)

  is produced in the pituitary gland. FSH signals the ovaries to produce estrogen. It is a negative feedback system, which means if the ovary does not respond, the FSH gets higher. When the ovary makes adequate estrogen, the FSH is lower. But FSH is more than a menopause marker. It is also an active metabolic driver of fat redistribution and a marker of cognitive decline and cardiovascular risk. In clinical studies, rising FSH has been linked to higher blood pressure, triglycerides and waist size, as well as thicker artery walls.

• Estradiol

  measures the most active form of estrogen in the body.

• Progesterone

  helps show whether ovulation likely happened in a woman's current cycle.

• Total and free testosterone

  help measure your baseline hormonal health.

How hormone replacement therapy (HRT) can help:

HRT gives back the hormones a woman is not fully producing any longer during perimenopause and menopause. This can be a game changer for a woman, offering her relief from hot flashes and sleepless nights and protecting bone density. Hormone therapy should be conducted only in the care of a healthcare provider and should be adjusted for age, personal risk, time in transition and symptoms. Healthy women starting therapy within 10 years of the start of their symptoms are generally the best candidates.

"Lab results and your individual symptoms are the most important drivers for treatment, whether through hormone replacement therapy (HRT), lifestyle or another course of treatment."

2. Thyroid test panel

The thyroid gland produces hormones that help to regulate our metabolism and energy. Thyroid problems can often produce symptoms similar to perimenopause, such as sleep problems, fatigue, and changes in weight, mood, menstrual cycle and hair health. The overlap is why thyroid testing is useful when symptoms are hard to explain. As we age, there is a higher risk for thyroid gland dysfunction. It is not unusual to discover an underactive thyroid in women while testing for perimenopause, and the symptoms can compound what a woman is already going through.

A complete thyroid panel includes:

• TSH (thyroid stimulating hormone),

  produced in the pituitary gland, works similar to FSH, signaling the thyroid to produce thyroid hormone. But if the thyroid is not functioning properly, the negative feedback system will elevate the TSH to encourage the thyroid to work better.

• Free T3 and free T4 levels

  reflect how well the thyroid gland is producing the thyroid hormone.

• Anti-TPO and anti-thyroglobulin

  are antibodies that can alter thyroid function, and their levels may add context when symptoms, family history, autoimmune history or abnormal thyroid labs are present. A patient can have a positive anti-TPO antibody test or antibody level and yet the thyroid gland is functioning in a normal range. She may have Hashimoto's, an autoimmune problem that may be present for years without disrupting the thyroid gland's function.

• Reverse T3

  is sometimes ordered in functional or integrative settings, since it has been implicated in interfering with T3's normal function.

3. Metabolic tests

Insulin resistance, when the body's cells do not respond to insulin effectively, is the first metabolic signal to track in perimenopause. Insulin helps our bodies process glucose, but when the process doesn't work efficiently, insulin levels rise. This helps your body maintain normal sugar levels, but at a cost. Higher insulin leads to increased visceral fat, higher triglycerides, difficulty losing weight, lower HDL cholesterol, elevated blood pressure, fatty liver, and even an increased risk of heart disease—on top of the menopausal symptoms women are already dealing with.

These are the metabolic tests I typically order:

• Fasting glucose,

  the measure of sugar in your blood, is a common test, and it is used to watch for diabetes and prediabetes.

• Fasting insulin

  is a less common test, but incredibly useful. Fasting glucose can look completely normal on a standard panel, while fasting insulin is already rising, and that difference can be an early sign to intervene with nutrition, lifestyle changes and clinician-guided care before insulin resistance sets in. A clinical study of over 700 women also found higher fasting insulin levels early in perimenopause predicted earlier hot flashes (with longer duration) and night sweats among participants.

• HbA1C (hemoglobin A1c)

  measures the average glucose over a three-month period, and it is used alongside fasting insulin and fasting glucose to get a full picture of insulin resistance.

4. Cardiovascular tests

Estrogen is often framed in light of fertility, but it plays many more roles, including heart health protection. So when estrogen levels begin to dip, women tend to lose this protective effect. Studies have shown that the risk of heart disease is lower in premenopausal women than in men, but slightly higher in postmenopausal women than their male counterparts. Decreased ovarian function and lower estrogen levels can lead to weight gain, changes in lipids and lipoproteins, and poorer measures of vascular health.

Testing your risk markers early can give you time to make lifestyle and medical changes to keep your heart health in check. These are the cardiac tests most often ordered:

• Lipid panel and ApoB,

  because although a standard lipid panel is useful, a comprehensive lipid panel with ApoB can better reflect the number of artery-clogging fat particles in your blood.

• Lp(a)

  is a genetic marker that was not routinely tested in the past but is being measured more often to identify patients who may benefit from earlier heart disease prevention. Although Lp(a) is genetic, it appears to increase as estrogen levels decline.

• Hs-CRP and homocysteine

  also help determine cardiovascular risk. Hs-CRP measures your level of systemic inflammation, and homocysteine measures your risk for arterial plaque formation.

5. Nutrient deficiency tests

Nutrient deficiencies can cause common menopausal symptoms to feel worse, especially fatigue, low exercise tolerance, mood issues, muscle symptoms, and bone-health concerns. You'll want to look at:

• Vitamin D deficiency

  can contribute to the bone loss caused by estrogen decline. A 25-hydroxyvitamin D test can ensure adequate vitamin D3, which also help reduce the risk of many cancers and improve mood and memory.

• Iron and ferritin deficiency

  can contribute to hair loss and impaired hair growth, which is a major complaint among menopausal women.

• RBC (red blood count) magnesium

  is another important test. Women in perimenopause will want to steer clear of a magnesium deficiency that can lead to restless sleep patterns and headaches. These symptoms can worsen other common perimenopause discomforts.

• Omega-3 index

  measures the beneficial omega-3 fatty acids that help inhibit the inflammation related to insulin resistance, excess weight, and joint pain.

6. Bone density test

Bone loss is one of the telltale signs of menopause that often goes unnoticed. After all, no one "feels” osteopenia (when bone mineral density is lower than normal) or osteoporosis (a condition of severe bone loss) until a bone breaks. I remind my patients to make sure they are getting enough calcium and vitamin D3 daily and to practice weight-bearing exercise starting in their early 30s and 40s to help avoid the accelerated bone loss that occurs when estrogen drops.

• A DEXA scan

  is an easy, low-risk, bone mineral density scan that helps to determine a woman's bone fracture risk. The results can also determine if medication is needed to prevent further bone loss. It is recommended for all women 65 and over, and for those younger than 65 with at least one risk factor.

• A 25-hydroxyvitamin D test

  can identify the low vitamin D levels that can contribute to bone mineral loss.

7. Other specialty tests for perimenopause

These tests may be helpful for women in perimenopause, depending on their symptoms:

• Stool testing

  could be helpful for women experiencing gut or digestive concerns during perimenopause. Gut health and the gut microbiome have become the center of attention in recent years because of research pointing to their role in so many areas of health. All of our nutrients, hormones and inflammatory processes go through our gut. Stool testing detects the enzymes, bacteria, hormones and parasites that determine nutritional guidance and treatment plans.

• The DUTCH hormone test

  uses dried patches of urine to determine hormone levels. Saliva testing is another way to measure hormone levels. These tests may be helpful for measuring certain hormones more accurately, but as always, the patient and her symptoms are the most important indicator for treatment.

• Cortisol level testing

  may be helpful as well, as women in perimenopause may experience elevated stress levels.

What you need to know about labs for perimenopause

Perimenopause is not a straight line. Your healthcare provider should look at patterns, symptoms, age, cycle history and several body systems together. Here's what you need to know about testing as you enter this new chapter of your life:

• Why do my hormone labs come back normal, but I still have every symptom?

  Hormone levels rise and fall throughout the month. On any given day, we may see levels that are entirely different from five days prior. At age 30, the cycle may start at a certain baseline and have peaks and troughs. At 40, the baseline may be lower and the troughs deeper, yet still fall into a "normal range," and women can feel many symptoms. This is why diagnosis and treatment should be based on a woman's symptoms with bloodwork as a guide.

• What's the difference between a basic hormone panel and a comprehensive perimenopausal lab work?

  A basic hormone panel may only look at FSH, estradiol, progesterone and possibly testosterone. A comprehensive panel will include lipids, advanced cardiovascular markers, nutrients, thyroid studies, fasting glucose/insulin and HgBA1C, results that give your healthcare provider much more information to develop an individual and comprehensive treatment plan for you in perimenopause or menopause.

My advice? If you just don't feel like yourself anymore—or if you've reached your 45th birthday—get to know your numbers so you can start taking steps to start feeling better. If your doctor isn't ordering these tests, feel empowered to ask for them or order them yourself. Lab results and your individual symptoms are the most important drivers for treatment, whether through hormone replacement therapy (HRT), lifestyle or another course of treatment.

References

• "The 2022 Hormone Therapy Position Statement of The North American Menopause Society" Advisory Panel. "The 2022 hormone therapy position statement of The North American Menopause Society." Menopause. July 2022. https://pubmed.ncbi.nlm.nih.gov/35797481/
• Athar F, et al. "Insulin Levels Early in Perimenopause Inform Vasomotor Symptom Incidence Across the Menopausal Transition." The Journal of Clinical Endocrinology & Metabolism. January 2026. https://academic.oup.com/jcem/article/111/6/e1544/8413273
• Corral P, et al. "Lipoprotein(a) throughout life in women." Am J Prev Cardiol. October 2024. https://pmc.ncbi.nlm.nih.gov/articles/PMC11609252/
• El Khoudary SR, et al. "Menopause Transition and Cardiovascular Disease Risk: Implications for Timing of Early Prevention: A Scientific Statement From the American Heart Association." Circulation. December 2020. https://pubmed.ncbi.nlm.nih.gov/33251828/
• El Khoudary SR, et al. "Trajectories of estradiol and follicle-stimulating hormone over the menopause transition and early markers of atherosclerosis after menopause." Eur J Prev Cardiol. May 2016. https://pmc.ncbi.nlm.nih.gov/articles/PMC4816655/
• European Society of Endocrinology. "Evaluation and Management of Menopause and the Perimenopause." Guideline Central. October 2025. https://www.guidelinecentral.com/guideline/4969776/
• Karlamangla AS, et al. "Bone Health During the Menopause Transition and Beyond." Obstet Gynecol Clin North Am. December 2018. https://pmc.ncbi.nlm.nih.gov/articles/PMC6226267/
• US Preventive Services Task Force. "Screening for Osteoporosis to Prevent Fractures." JAMA. January 2025. https://jamanetwork.com/journals/jama/fullarticle/2829238
• Wylenzek F, et al. "A systematic review on the impact of nutrition and possible supplementation on the deficiency of vitamin complexes, iron, omega-3-fatty acids, and lycopene in relation to increased morbidity in women after menopause." Gynecology and Obstetrics. 2024. https://www.springermedicine.com/osteoporosis/osteoporosis/a-systematic-review-on-the-impact-of-nutrition-and-possible-supp/27264918
• Zhang C, et al. "Follicle-Stimulating Hormone Positively Associates with Metabolic Factors in Perimenopausal Women." Int J Endocrinol. November 2020. https://pmc.ncbi.nlm.nih.gov/articles/PMC7676929/