You're 48 and You've Missed Four Periods. Your Doctor Has No Idea What's Wrong With You.
Menopause is a clinical diagnosis. It doesn't require a blood test. So why is your gynecologist ordering one?
She is pas 45. She has missed four periods. She is otherwise healthy. She makes an appointment with her gynecologist.
She sits on the exam table in a paper gown and says, “I’ve missed four periods. Something is off.”
Her gynecologist orders a pregnancy test. Negative. Then a TSH. Normal. Then a CBC. Normal. Then an FSH.
The FSH comes back at 38 mIU/L. The gynecologist calls her and says it’s “borderline.” Come back in three months. We’ll recheck it.
She hangs up the phone confused. She still has no diagnosis. She still has no explanation. She still has no treatment plan. She has a follow-up appointment twelve weeks away for a repeat blood test that will tell her gynecologist nothing useful.
Here is what should have happened.
Her gynecologist should have looked at a 48-year-old woman who has missed four periods and said: “You are in the menopausal transition. This is a clinical diagnosis. I don’t need a blood test to tell you that. Let me explain what is happening in your body and what your options are.”
That visit should have taken fifteen minutes. Instead it will take six months, two office visits, four blood draws, and a co-pay she shouldn’t have had to pay.
Menopause Is a Clinical Diagnosis. Full Stop.
The international gold standard for staging reproductive aging is the STRAW+10 system, published in 2012 by a multidisciplinary consensus group of scientists from five countries, sponsored by the National Institutes of Health, the North American Menopause Society (now The Menopause Society), the American Society for Reproductive Medicine, the International Menopause Society, and the Endocrine Society [1].
STRAW+10 defines the stages of reproductive aging based on menstrual cycle patterns. The criteria are straightforward:
The early menopausal transition (Stage -2) is defined by a persistent difference of seven or more days in the length of consecutive menstrual cycles. The late menopausal transition (Stage -1) is defined by an interval of amenorrhea of 60 days or more. Menopause itself (Stage 0) is defined retrospectively as 12 consecutive months without a menstrual period [1].
A 48-year-old woman who has missed four periods has, by definition, experienced at least 60 days of amenorrhea. She is in the late menopausal transition. This is not a matter of clinical judgment. It is not ambiguous. It is not borderline. It is the textbook definition of Stage -1.
STRAW+10 was designed to be applied regardless of age, ethnicity, body size, or lifestyle characteristics [1]. It is the Marshall-Tanner staging of reproductive aging. Every gynecologist in training should know it the way they know Bishop scores and Apgar scores.
Most don’t.
The FSH Test Your Doctor Ordered Is Useless
Here is something every patient should know and every physician was apparently never taught: FSH is not recommended for diagnosing menopause in women 45 and older.
The UK’s National Institute for Health and Care Excellence updated its menopause guideline in November 2024. The first quality statement reads: “Women aged 45 or over who present with menopausal symptoms are diagnosed with perimenopause or menopause based on their symptoms alone, without confirmatory laboratory tests” [2].
Not “consider” diagnosing without labs. Not “may” diagnose without labs. Diagnose. Without. Labs.
NICE explicitly instructs clinicians: “Do not use the following laboratory and imaging tests to identify perimenopause or menopause in people aged 45 or over” [2]. The list includes FSH, anti-Mullerian hormone, inhibin A and B, estradiol, and ovarian ultrasound.
Why? Because FSH fluctuates enormously during perimenopause. A single FSH value can be 15 one week and 55 the next in the same woman. As NICE states, hormone levels “fluctuate during the perimenopause” and “knowing these levels will not change management” [3]. ACOG agrees. The Menopause Society agrees. The British Menopause Society agrees.
When a 2017 paper in the Annals of Clinical Biochemistry reviewed the evidence behind the NICE guideline, the authors were blunt: “Reducing the number of unnecessary FSH tests in women over 45 is an area of care where considerable savings could be made through disinvestment” [4]. They weren’t talking about cutting corners. They were talking about eliminating a test that adds cost, delays diagnosis, and provides no clinically useful information.
Your gynecologist’s FSH order wasn’t cautious medicine. It was uninformed medicine.
Why Your Doctor Doesn’t Know This
The answer is simple and infuriating: nobody taught them.
A 2023 survey of 99 U.S. OB/GYN residency program directors found that only 31.3% reported having a menopause curriculum in their training program. Nearly all of them, 92.9%, agreed that residents nationwide should have access to a standardized menopause curriculum [5]. They know the gap exists. They endorse closing it. They haven’t closed it.
Only 20% of OB/GYN residencies offer dedicated menopause training [6]. One in five family medicine, internal medicine, and OB/GYN residents reported receiving zero menopause lectures during their entire residency [7]. And only 6.8% of residents felt adequately prepared to manage women experiencing menopause [7].
A global review published in Best Practice & Research Clinical Obstetrics & Gynaecology examined menopause medical education across countries and concluded that training on menopause management is “profoundly inadequate even nowadays” [8].
Think about what these numbers mean in practical terms. A woman who has completed medical school and a four-year OB/GYN residency, passed her board examinations, and hung a diploma on her wall may never have been taught how to diagnose menopause. Not the nuances of managing complex menopausal symptoms. Not the subtleties of hormone therapy prescribing. The diagnosis itself. The STRAW+10 criteria. The fact that it’s clinical. The fact that you don’t order an FSH.
She wasn’t taught it in medical school. She wasn’t taught it in residency. She wasn’t tested on it for boards. And now she is the physician sitting across from a 48-year-old woman who has missed four periods and doesn’t know what to say.
What This Costs Women
The consequences of this diagnostic incompetence are not abstract.
When a gynecologist cannot diagnose the menopausal transition, the patient leaves without answers. She Googles her symptoms at midnight. She finds terrifying articles about premature ovarian failure, thyroid disease, and early-onset dementia. She doesn’t sleep. She makes another appointment, this time with her primary care doctor, who orders the same labs again.
When a gynecologist cannot diagnose the menopausal transition, the patient doesn’t get treatment. She doesn’t learn that her hot flashes, her disrupted sleep, her joint pain, her vaginal dryness, her mood changes, and her irregular bleeding all have the same underlying cause. Each symptom gets its own workup, its own referral, its own medication. A sleep study for the insomnia. An antidepressant for the mood changes. A urology referral for the urinary symptoms. A rheumatology referral for the joint pain. None of these specialists diagnose the menopause transition either, because none of them were trained to.
When a gynecologist cannot diagnose the menopausal transition, the patient loses time. The average woman spends the late menopausal transition, the period between skipping cycles and her final menstrual period, in that stage for one to three years [1]. If her physician doesn’t recognize where she is in that trajectory, she spends those years undertreated or untreated entirely.
And when a gynecologist cannot diagnose the menopausal transition, the patient loses trust. She walked into the office of the physician who is supposed to be the expert on her reproductive health and that physician could not identify the single most predictable event in reproductive aging. Why would she trust that physician with anything else?
The Absurdity of the Situation
Let me put this in perspective.
If a 13-year-old girl walks into a pediatrician’s office and says she got her first period, no one orders a blood test to confirm it. No one checks her estradiol to make sure puberty is real. No one says, “Your menarche is borderline. Let’s recheck in three months.” The pediatrician says, “Congratulations, you’re going through puberty. Here’s what to expect.”
Menopause is the other bookend of reproductive life. It is equally universal, equally predictable, and equally diagnosable on clinical grounds. The STRAW+10 system was explicitly designed to be the reproductive aging equivalent of the Marshall-Tanner pubertal staging system [1]. Yet we treat one as obvious and the other as a diagnostic mystery requiring laboratory confirmation.
The difference is not scientific. The difference is that we invested in teaching physicians about the beginning of reproductive life and decided the end of it wasn’t worth their time.
What You Should Know
If you are 45 or older and your periods have become irregular, here is what the evidence supports:
You do not need an FSH test to know what is happening. If your cycles have become unpredictable, if you are skipping periods, if you have gone 60 or more days without bleeding, you are in the menopausal transition. This is a clinical diagnosis based on your menstrual pattern. Every major guideline in the world says the same thing [1, 2, 3].
An FSH level will not help you or your doctor. FSH swings wildly during perimenopause. A “normal” FSH does not mean you are not in the menopausal transition. An “elevated” FSH does not tell your doctor anything your menstrual history didn’t already say. If your physician orders an FSH when you are over 45 with irregular periods, your physician is not practicing evidence-based medicine.
You deserve a diagnosis at the first visit. A 48-year-old woman with four missed periods should leave her gynecologist’s office with a diagnosis, an explanation, and a plan. Not a lab slip and a follow-up in three months. If your physician cannot provide that, you have the right to ask why, and the right to find one who can.
“Too young” is not a medical assessment. The median age of menopause in the United States is 51, but the menopausal transition commonly begins in the mid-40s. The late menopausal transition, Stage -1, lasts one to three years before the final menstrual period [1]. A woman experiencing cycle changes at 45, 46, 47, or 48 is not “too young.” She is exactly on time.
Your symptoms are connected. The hot flashes, the sleep disruption, the mood changes, the vaginal dryness, the joint aches, the irregular bleeding: these are not separate problems requiring separate specialists. They are manifestations of a single hormonal transition. A physician who understands menopause can address them together. A physician who doesn’t will scatter you across the healthcare system chasing symptoms instead of treating causes.
This Is Our Failure
I am a gynecologist. I am writing this because this is our profession’s failure, and we need to own it.
Menopause is not a rare disease. It is not a niche interest. It is a universal biological event that every woman who lives long enough will experience. It affects bone density, cardiovascular risk, urogenital health, sexual function, sleep, mood, and cognition. It lasts, in its full symptomatic arc, for years.
And we graduate physicians who cannot diagnose it in a straightforward clinical presentation.
The STRAW+10 criteria have been published since 2012. The NICE guideline has said not to order FSH in women over 45 since 2015, and reaffirmed it in 2024. The Menopause Society has recommended clinical diagnosis for years. This is not new science waiting for translation. This is old science that the medical education system never bothered to teach.
Only 31% of OB/GYN residency programs have a menopause curriculum [5]. That means 69% are graduating gynecologists without structured training in a condition that affects 100% of their female patients.
We have no trouble teaching residents to diagnose preeclampsia. We have no trouble teaching them to manage postpartum hemorrhage. We have no trouble teaching them to stage cervical cancer. But the menopausal transition, the transition that every single one of their patients will go through, somehow didn’t make the cut.
Until residency programs require menopause education, until board exams weight it appropriately, until physicians are held accountable for knowing the diagnostic criteria for the most common endocrine transition in women’s health, women will keep sitting on exam tables in paper gowns, asking obvious questions, and getting blood draws instead of answers.
That is not a knowledge gap. That is a professional failure.
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References
Harlow SD, Gass M, Hall JE, et al. Executive summary of the Stages of Reproductive Aging Workshop +10: addressing the unfinished agenda of staging reproductive aging. J Clin Endocrinol Metab. 2012;97(4):1159-1168.
National Institute for Health and Care Excellence. Menopause: identification and management. NICE guideline [NG23]. Updated November 2024.
NICE Quality Standards. Quality statement 1: Diagnosing perimenopause and menopause. QS143. Updated 2024.
Davies M, Sarri G, Lumsden MA. Diagnosis of the menopause: NICE guidance and quality standards. Ann Clin Biochem. 2017;54(3):326-330.
Allen JT, et al. Needs assessment of menopause education in United States obstetrics and gynecology residency training programs. Menopause. 2023;30(10):999-1005.
Cuyuna Regional Medical Center. Addressing the Knowledge Gap: Menopause. January 2025.
The Menopause Society. Menopause Step-by-Step educational initiative; reported in The Flow Space, August 2024.
Armeni E, Paschou SA, Gkika I, et al. Menopause medical education around the world: the way forward to serve women’s health. Best Pract Res Clin Obstet Gynaecol. 2022;81:44-59.