HRT Blood Tests: What Hormone Levels Are Measured and Why

Symptoms such as irregular periods, night sweats, vaginal dryness or mood swings can point to a shifting hormonal balance. A blood test helps map which hormone levels have dropped and whether other factors are playing a part. That makes it an important part of well-guided hormone therapy, even though blood is never the whole story.

In short

Around menopause and on hormone therapy, a blood test usually looks at FSH, estradiol, progesterone, testosterone (both total and free), SHBG and the thyroid (TSH, free T4, free T3), often supplemented with vitamin D and vitamin B12. At Menovia these form part of a broader panel of up to 36 values that also takes in your metabolism, blood sugar and vitamin status, tailored to your program. A blood test serves two purposes: at the start it maps which levels have dropped, and during treatment (at Menovia, every 12 weeks) it checks whether the dose still fits. The values give a snapshot of your hormonal system. They are valuable, but they do not tell the whole story: your symptoms and your history weigh at least as heavily. In practice we see that blood is one piece of a broader diagnostic puzzle, not the puzzle itself.

Two purposes: diagnosis and monitoring

Around menopause, a blood test has two separate functions that complement each other.

• At the start (diagnosis): we map where you stand. Which hormone levels have dropped? Are there other factors, such as the thyroid, vitamin D or blood sugar, that help explain your symptoms? This forms the basis for a treatment plan tailored to you.
• During treatment (monitoring): we check whether the intended values are being reached, whether the dose needs adjusting, and whether any unwanted effects are occurring. At Menovia we measure every 12 weeks, so your treatment keeps matching what your body needs at that point.

Which hormone values are measured, and what do they tell us?

Not every value measures the same thing. These are the markers that usually matter around menopause.

• FSH (follicle-stimulating hormone). Rises as the ovaries produce less estrogen. A raised FSH can point to menopause, but the value swings strongly from day to day, especially in perimenopause, so a single measurement says little. During hormone therapy FSH tells you even less, because the administered hormones affect the feedback loop; at that point estradiol and your symptoms are better guides.
• Estradiol (E2). The most important and most active form of estrogen in the fertile years. It declines gradually towards menopause. A fitting estradiol level relates to symptoms such as hot flashes and sleep problems, and plays a part in bone density and cardiovascular health. This value moves too, so a single snapshot does not give the full picture.
• Progesterone. Protects the lining of the womb in women who still have a uterus, and also plays a part in sleep and mood. At Menovia we work with bio-identical progesterone: molecularly identical to your own hormone.
• LH (luteinising hormone). Rises in parallel with FSH and gives additional information about how the ovaries are working.
• Testosterone, both total and free. Testosterone also plays a role in women, in energy, libido and maintaining muscle. Total testosterone alone does not tell the whole story: part of it is bound to protein and therefore not active.
• SHBG (sex hormone binding globulin). This protein binds sex hormones. The more SHBG, the less free (active) hormone is available. SHBG is needed to interpret the testosterone value properly.
• Prolactin. A raised prolactin level can mimic menopause-like symptoms. This value helps rule out other causes, such as a prolactinoma.
• DHEA-S. A precursor hormone to estrogen and testosterone. Low values can go together with fatigue and reduced vitality.

Why does the difference between free and total testosterone matter so much?

A hormone bound to protein is not available to your cells. Only the free portion is biologically active. As a result, someone can have a normal total testosterone while the free, working portion is low, for example because SHBG is high. If you look only at the total value, you miss that. That is why, for testosterone, we measure both total and free, together with SHBG, and read the values alongside your symptoms.

What does a thyroid test measure, and why does it belong here?

Thyroid symptoms and menopause symptoms closely resemble each other: fatigue, weight change, mood swings, brain fog. They are easily confused as a result. A thyroid check helps tell apart what comes from where, so a thyroid problem does not stay hidden behind the label “menopause”.

• TSH signals the thyroid and is the first screening value.
• Free T4 and free T3 show how much active thyroid hormone is actually available.

Thyroid problems are relatively common in women at this age: according to research in older populations, up to around 20% of women over 60 develop an underactive thyroid (Vanderpump, *The Lancet*, 2011). That makes the thyroid a logical part of the picture.

Why do vitamin D and B12 belong here too?

Vitamin D and B12 are not hormones in the classic sense, but a deficiency causes symptoms that are easily mistaken for menopause symptoms: fatigue, muscle and bone complaints, concentration problems.

• Vitamin D matters for bones and muscles, precisely in a phase when bone mass declines faster. Dutch public-health bodies (RIVM and the Gezondheidsraad) advise women aged 50 and over to take extra vitamin D daily.
• Vitamin B12 plays a part in energy and the nervous system. We prefer to measure the active fraction (holotranscobalamin), because it reflects how much B12 your body can actually use better than the total B12 value does.

More than hormones: why we also measure your metabolism and vitamin status

Hormones do not tell the whole story. How you feel during menopause is bound up with your thyroid, your blood sugar and your vitamin status, and in conventional care these are not always measured as standard. That is why we look at the full interplay, across three areas:

• Sex hormones and thyroid: estradiol, progesterone, testosterone (total and free), SHBG, LH, FSH, prolactin and DHEA-S, plus TSH, free T4 and free T3.
• Metabolism, blood sugar and cardiovascular health: including glucose and insulin (together a measure of insulin resistance), HbA1c (your average blood sugar over several months), the cholesterol profile and triglycerides, and inflammatory markers. A shifting hormonal balance can go together with a shifting metabolism, so these values help bring the broader picture into view.
• Nutrition, liver and kidneys: vitamin D, B12 and folate, ferritin (your iron stores), a full blood count, and liver and kidney values. Deficiencies or abnormalities here often produce symptoms that resemble menopause.

In total this comes to up to 36 values, tailored to your program (Basis, Plus or Compleet) and repeated every 12 weeks during your treatment. The full list of every value, and exactly what each program includes, is on our blood testing page.

How do timing and administration form affect the result?

For reliable results, the timing of the blood draw matters, especially during treatment. With transdermal administration (gel or patch) you preferably measure at a set point after applying, often in the morning, so you keep measuring comparable values. At Menovia we give exact instructions with every blood draw about the timing relative to your medication.

Transdermal administration also gives more stable hormone levels than tablets. That makes the blood values easier to interpret: there are fewer peaks and troughs, and the measurement is more representative of your average level over the day.

From measurement to action: adjusting the treatment plan

If blood values show that levels are too low or too high, or if you experience side effects, the dose or the administration form can be adjusted. That is not a sign of failure, but of well-guided care. In practice, hormone therapy calls for one or more adjustments in many women before the setting fits.

Do local symptoms persist while the general levels are fine? Then the treatment can be supplemented with local estrogen preparations for vaginal dryness or urinary leakage. These have negligible systemic absorption, which is why they are often added locally.

Why are blood values only one part of the story?

Blood gives a snapshot. It does not always say anything about what is happening at the cellular level, and hormone levels swing by day and by point in the cycle. On top of that, it is important to realise that blood values can fall within the “normal” reference range while you still do not feel well.

That is why we weigh three things alongside each other:

• Your blood values, as an objective snapshot.
• Your symptoms, systematically mapped. For this we use, among other things, the Menopause Rating Scale (MRS), so we see not only what your blood is doing but also how you actually feel.
• Your history, such as earlier conditions, medication and family history.

In short, blood values are one part of a broader diagnostic puzzle. Anyone who looks only at the lab misses half of it.

What does a GP often test, and what not?

In women over 45 with a recognisable pattern of symptoms, the diagnosis “menopause” is mainly a clinical one: the doctor makes it based on your symptoms and your cycle, not based on blood. The Dutch GP guideline on menopause (NHG-Standaard *De overgang*) therefore advises against routine hormone testing in that group, because the strong fluctuations mean the result adds little and does not change the diagnosis.

That is medically sound. It only means that a broader picture, think of free testosterone, SHBG, full thyroid function or the active B12 fraction, often stays out of view in the conventional setting. A clinic specialised in menopause does weigh those additional values, precisely so it can set a tailored dose and rule out other causes of your symptoms. Want to know exactly which values Menovia measures and when? See our blood testing page.

Frequently asked questions

Can a blood test tell me for certain whether I am in menopause?

Not with certainty from a single measurement. Hormone values such as FSH and estradiol fluctuate strongly, especially in perimenopause. The diagnosis rests mainly on your symptoms and your cycle; blood is supplementary.

Why does Menovia measure both free and total testosterone?

Because only the free portion, the part not bound to protein, is active. Together with SHBG that gives a more precise picture than the total value alone.

Why does the thyroid belong in a menopause work-up?

Thyroid symptoms and menopause symptoms closely resemble each other. Checking TSH, free T4 and free T3 helps tell apart where your symptoms come from.

Why does the timing of the blood draw matter during hormone therapy?

Especially with transdermal administration (gel or patch) you want to measure at a set point after applying. That keeps the values comparable and reliable to interpret. We give you exact instructions each time.

Do I need to fast for the blood test?

For our extensive test we advise fasting (water is fine, coffee is not), no heavy exertion in the 48 hours beforehand and no alcohol in the 24 hours beforehand. [FLAG - Freeha: confirm exact preparation instructions; the service page states 6h fasting specifically.]

Does my insurance reimburse a hormone test?

That depends on your policy and your situation. Testosterone and DHEA are not registered for women in the Netherlands; they are supplied via a compounding pharmacy and fall outside reimbursement. Always check this with your own insurer.

What if my blood values are normal but I do not feel well?

That happens. Reference values are averages and do not say everything about how you feel. That is why we always weigh your symptoms and history alongside the lab.

Summary

Around menopause and on hormone therapy, a blood test usually measures FSH, estradiol, progesterone, testosterone (total and free), SHBG and the thyroid (TSH, free T4, free T3), often supplemented with vitamin D and the active form of B12. At Menovia these belong to a broader panel of up to 36 values that also takes in your metabolism, blood sugar and vitamin status, tailored to your program and repeated every 12 weeks. The test serves two purposes: mapping at the start, and adjusting during treatment. The difference between free and total hormone determines how much is really active, and that is needed to interpret values properly. Timing and administration form affect the result. Blood remains a snapshot: it gains meaning only alongside your symptoms and your history. A GP often deliberately does not test hormones when the pattern of symptoms is recognisable, while a specialised clinic weighs a broader panel to set a tailored treatment.

This information is intended as an educational resource and does not replace medical advice, diagnosis or treatment. If you have symptoms or questions about your personal situation, we advise you to consult a doctor.