I run 14 tests on every menopausal patient who sits across from me, and based on my early medical training, I would have run only the first one.
I was taught menopause as an ending: use symptoms only to confirm what a woman already suspects, a prescription pad with one line on it if she qualifies, and a referral back to her regular doctor for anything that wasn’t a hot flash or a vaginal issue.
I know now that moment in a woman’s life is not a diagnosis to confirm and dismiss. It is the single best window medicine ever gets into her cardiometabolic vascular risk, bone trajectory, cognitive future, and sexual health for the next forty years, and most of us were trained to look away from almost all of it.
The biology of menopause is universal. The experience of it is not. Symptom severity, psychological load, and social context vary enormously between women, and most of what drives that variation is modifiable, if anyone is looking. Menopause research remains underfunded and under-taught, and a previous bad experience trying to get help is often what keeps a woman from trying again. Primary care, where most women actually ask these questions, still lacks the information and the confidence to prescribe hormone therapy with any authority. The result is a number that should embarrass the entire specialty: seventy-three to seventy-five percent of women who need treatment for menopause do not get it.
I believe that gap exists because medicine built its menopause model around fertility, and once fertility ends, so does most of the attention. We need a model built around healthspan that has decades more years of work to do, and that is the model I use.
1. The health maintenance bundle
Clinical exam, Pap smear, HPV testing, mammogram, and colonoscopy on their standard schedules. Unglamorous, and still the foundation everything else sits on top of.
2. Baseline hormone and metabolic serum panel
Estradiol, FSH, testosterone, a full thyroid panel with TPO antibodies, SHBG, a metabolic panel, fasting insulin, and HbA1c. Insulin resistance builds for years before glucose or HbA1c cross into a diagnostic range, and subclinical thyroid disease is more common in women than a TSH checked alone will catch. This tells me where you are in the transition, and what’s already shifting underneath it. More notes on estradiol and FSH here.
3. Advanced cardiovascular biomarkers
ApoB, hs-CRP, and lipoprotein(a) if you haven’t had it drawn once already before 45. Menopause is your second and final lifetime checkpoint for Lp(a), and cardiovascular risk accelerates fast once estrogen declines. I describe the full advanced panel in previous posts like this one.
4. Coronary artery calcium score
A baseline scan at 45, or at menopause if you arrive there first. It turns an abstract risk number into an actual picture of your arteries, years before a stress test would catch anything. A CT angiogram if we’re concerned about soft plaque. More here if you want the details.
In 2022, the North American Menopause Society reaffirmed hormone therapy as the most effective treatment available for hot flashes, night sweats, and the vaginal and urinary changes of menopause, with a favorable benefit-to-risk ratio for women under 60 or within ten years of their final period.[1]
The part fewer women hear: NAMS explicitly rejected arbitrary age-based stopping rules. There is no birthday that automatically ends a woman’s candidacy for hormone therapy. The standard is individualized decision-making, reevaluated periodically, quarterly to every six months in my practice. If a doctor has ever told you that you “aged out” of treatment, that instruction did not come from the evidence.
While this is not a blanket instruction to start or continue hormone therapy regardless of history, it is an instruction to stop treating 60, or 65, or 70 as an automatic stopping point when the guidance says otherwise. Your history, your risk profile, and your goals decide this, not your age alone.
Has a doctor ever told you that you were “too old” for hormone therapy, or too far past menopause to start? Tell me what they said. We need to address it.
For paid subscribers ready to go past the basics: bone and muscle status, nervous system load, and the hormone therapy conversation most women past sixty never get offered.
I had a patient last year, 63, who told me her previous doctor took her off hormone therapy the week she turned 60 because “that’s just the rule.” It is not the rule and it never was. I have written that exact prescription past 60 more times than I can count, because the evidence has never supported cutting a woman off on a birthday.
I was taught to hand a woman a stopping date along with her diagnosis. I know now the stopping date was never in the research. It was in our discomfort with treating a woman past the age we had stopped picturing her as needing anything from us.
I believe most of what follows gets skipped for the same reason. Once fertility ends, so does the appetite to keep investigating.
