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Dr Andrea Robertson is an Osteopath, Naturopath, and Nutritionist. Georgie Beames is a Psychologist and Coach. The information shared in this podcast is for educational purposes only and does not constitute medical advice. Always consult your healthcare provider before making changes to your health regimen.

Show Notes

Episode Transcript

Ep 19 - What Blood Tests to Ask Your Doctor for During Perimenopause?

Andrea [00:00:00] Perimenopause is a hormonal transition, but the symptoms you feel are often coming from the systems that hormonal change touches, like your blood, your thyroid, your metabolism, your heart. And those are the things we can measure

Our sponsor today is Mineralite, an Australian electrolytes brand. And I have to tell you how I found them because this is a genuine story. Now, I'm really into paddle tennis, some may say obsessed , and a friend of mine introduced me to Mineralite to use for my hydration support during games. I was a little curious because I'd been recommending clients avoid those terrible sugary sports drinks for years, but I wasn't really sure what other options were available.

I now know that Mineralite is the option I'll recommend. It's unflavored and contains no sugar, no sweeteners, no artificial colors, no nasty additives. Just clean electrolyte support in drops you can add to your water or any hot or cold drink. And my paddle? It was noticeably different. My energy held, my focus held, and I even won some [00:01:00] games.

Mineralyte is now in my water every single day. Go and check them out at mineralite.com.au or find them in most pharmacies and health food stores throughout Australia and New Zealand

If you have ever walked out of your GP's office with some blood test results and the words, "Everything looks normal," when you feel anything but normal, this episode is for you. Often, women in perimenopause or menopause go to the doctor to ask for tests. They might be given one or two blood tests and then get told, "Your hormones are normal.

It's probably just stress." I have heard that story from hundreds of women in my clinic over the years, and almost every time, the answers were sitting in blood tests nobody had ordered. So today, I'm gonna give you the list, my favorite list.

I'm Dr. Andrea Robertson, osteopath, naturopath, and nutritionist. Here we nourish because food is medicine, and what you eat changes everything. We heal because the body has an extraordinary capacity to self-repair when [00:02:00] we remove what's blocking it, and we rise because feeling well isn't the destination, it's the foundation for living the life you truly desire.

This is Nourish, Heal, and Rise.

Before we begin, a quick and important note. Everything I share on this podcast is for educational purposes only. It's not personal medical advice, and it can't be, because in the context of this podcast, I don't know your health history, your medications, and what else is happening in your body. What I want this podcast to do is give you the knowledge to ask better questions, understand your body more deeply, and make more informed decisions in partnerships with the practitioners who do know you.

If something resonates and you wanna take action, please work with a qualified healthcare provider who knows your full picture

Andrea [00:03:00] Welcome back, my friend. Today's episode is a practical one. I want you to finish listening with a list you can take straight into your next GP appointment, and the confidence to ask for the tests on that list. Perimenopause is the time when so much shifts at once. Your periods change, your sleep changes, your energy, your moods, your weight, your cholesterol.

And so often, women go to their doctor, get given one or two hormone tests, get told they're all normal, and walk out with no more clarity than when they walked in. Today, we're gonna start with why a one-or-two hormone test picture can often mislead you in perimenopause, and when the hormone tests are actually useful.

Then I'm gonna take you through 10 blood tests grouped into five areas: your blood and iron, your thyroid, your heart, your blood sugar, and your vitamins, liver, and kidneys. For each one, I will tell you what the blood test measures, [00:04:00] and why it matters at this stage of life, and what to look out for. And we're gonna finish with exactly how to ask your doctor for these tests so you can walk out with exactly what you need.

Let's go.

To start with, I wanna share a story of one of my patients. I'm gonna call her Kate for privacy reasons. Kate came to see me at 46. She was exhausted in a way that sleep was not fixing. Her periods had become heavy, the kind of heavy where you planned your day around where the nearest bathroom is.

And she had brain fog, her hair was shedding in the shower, and she was getting breathless walking up the stairs at work. She'd been to her GP. She had been given a blood test for FSH and estradiol. Both came back within range, and she was told she was probably not in perimenopause yet, and to come back if things got worse.

So when she came to me, things had got worse. It was obvious she was really not well, and so we looked at the bigger [00:05:00] picture. Now, her ferritin, which are her iron stores, was nine. Nine. That is ridiculously low. And her thyroid antibodies were raised, and her LDL cholesterol had climbed quite a bit since her last check two years earlier.

Now, none of those results showed up on the hormone test she was given initially, but all of these things are treatable. So if she had had more extensive testing done, she would've been onto it well before she saw me. So within a few months of us working on Her iron, her thyroid, And her nutrition, Kate told me she felt like she had her brain back.

This is why this episode matters. Perimenopause is a hormonal transition, yes, but the symptoms you feel are often coming from the systems that hormonal change touches, like your blood, your thyroid, your metabolism, your heart. And those are the things we can measure.

So me being a dancer, [00:06:00] I've got a dancer analogy for you. Think of it like the tech run before the opening night of a show. Like, my dancer friends listening will relate. Anyone who has worked in a big stage production knows that before the curtain goes up, the crew checks every light, every cable, every cue.

The dancers check their shoes, their headdresses, their zippers. So nobody judges the whole show just by looking at one little spotlight or one tiny shoe on one of the dancers. Your range of different blood tests are that full technical run.

We need to look at everything. One hormone level is just that spotlight on that one shoe.

Now, I want to go a little deeper on hormone testing, because this is where so much confusion starts. The two tests most women over 40 are given are FSH and estradiol. FSH stands for follicle-stimulating hormone. It is the message your brain sends to your ovaries saying, "Come on, release an egg."

Follicle-stimulating hormone. Estradiol is the main form of [00:07:00] estrogen your ovaries make during your reproductive years. So they're the two main tests people often get sent for, FSH and estradiol or estrogen. As your ovaries age, they respond more slowly to that message from the brain saying, "Come on, ovaries, release an egg."

So your brain sends that message louder, the FSH, louder, louder, louder message, and FSH rises. Think of FSH as your brain turning up the volume on a speaker because the person in the next room has stopped answering. In theory, a high FSH tells us you are in perimenopause, and if we get two high FSHs in a row, then we can say you're at the tail end of perimenopause or into menopause.

However, in practice, perimenopause is defined by fluctuation. Your hormones do not decline in a nice, neat, straight line. They swing. In one cycle, your FSH can be high and your estradiol low. [00:08:00] In the next cycle, your ovaries rally together, and your estradiol can actually spike higher than it ever did in your 30s

Think of it like trying to judge the weather for a whole season from just a single afternoon. If you happen to test on a calm day, everything looks normal. If you test in the middle of a storm, the whole thing looks dramatic. Neither one tells you the whole story.

A 2023 review in the journal Cell, led by Professor Susan Davis from Monash University here in Melbourne, describes the physiology of the menopause transition as complex and still incompletely understood, and that matches what the major menopause guidelines say.

For women over 45 with typical symptoms like changing cycles, hot flushes, night sweats, and sleep disruption, perimenopause is diagnosed on your symptoms and your cycle history. A blood test is not required to make the diagnosis. So if your doctor tells you your hormones [00:09:00] are normal, please hear that as they were normal on the day we tested.

One test does not mean you are or are not in perimenopause. Now, that does not mean hormone tests are useless. There are some situations where they really help.

If you are under 45 and your cycles are changing, FSH testing can help your doctor work out what is going on. If you're under 40, it becomes even more important because we want to rule out premature ovarian insufficiency, which is where the ovaries stop working well much earlier than expected.

Hormone tests can also help if you no longer have periods to track. Say you've had a hysterectomy, but you've kept your ovaries, or you have a hormonal IUD like the Mirena that has stopped your bleeding. Without a cycle to watch and get the report from, a blood test gives your doctor another piece of the puzzle.

But these blood tests have to be read with an understanding of the body that woman had or has [00:10:00] at the time of testing. And if your cycles are irregular or have stopped, your doctor may check prolactin and sometimes a pregnancy test. So yes, pregnancy is still possible in perimenopause. So if you don't want to fall pregnant, contraception is still needed until your doctor or practitioner tells you otherwise.

And one more, if you are on the combined oral contraceptive pill, your FSH and estradiol results , will not reflect your own ovaries because the pill is switching that conversation off. So blood testing, if you are taking the pill, tells you very little.

And finally, testosterone. A blood test cannot diagnose low libido. Where it does matter is if you and your doctor decide to try testosterone therapy, then you need a baseline level, and monitoring after that is part of using it safely. So hormone tests have their place. They are just not the whole picture.

Let's now chat about the tests that create the rest of the story. [00:11:00] We have the 10 tests, and area one is your blood and iron. So I want you to have a pen ready, or maybe actually just come back to the show notes afterwards, because you're really gonna wanna have notes on this one. In fact, I've got an even better idea.

I will create a one-page download for you with the notes in it. So you'll find the link for that in the show notes. Okay, test number one is to get a full blood count. This is the most basic blood test there is, and it is still one of the most useful. It looks at your red blood cells, your white blood cells, and your platelets.

The number we care most about here is hemoglobin and red cell count. Hemoglobin is the protein in your red blood cells that carries oxygen around the body. In perimenopause, periods often become heavier and closer together. More blood out with those heavier periods also means more iron out.

And when red cell count and hemoglobin drops, along with low ferritin, which is your [00:12:00] iron stores, you can get anemia, which shows up as tiredness, breathlessness, a racing heart, feeling the cold, and that heavy, foggy brain.

That leads us to test number two, iron studies, including ferritin. And this is the one I want you to definitely ask for, because a full blood count on its own can look perfectly normal even if your iron stores are running on empty.

Think of ferritin as the reserve tank for iron in your body. Hemoglobin is the fuel in the engine right now. Ferritin is what's in the jerry can in the boot or in the garden shed. Your body will drain the jerry can first to keep the engine running, so your hemoglobin can look fine for months while your ferritin quietly drops into single digits.

That's exactly what happened to Kate. Low ferritin, even without anemia, can show up as fatigue, hair shedding, restless legs, poor energy recovery, and low mood. [00:13:00] Now, the reference ranges. Many Australian labs set the lower limit for ferritin somewhere around 20 to 30 micrograms per liter. In my clinical experience, many women still feel flat and tired at levels in the 20s and 30s, and so I like to see it comfortably higher than 50 micrograms per liter.

One important catch, ferritin also rises when there is inflammation in the body, so a normal ferritin in someone with lots of inflammation can hide a real iron deficiency. That is why I like to see it alongside a marker called CRP, C-reactive protein, which is a general measure of inflammation. Think of CRP as the smoke alarm.

It doesn't tell you where the fire is, but it does tell you there's smoke. And please, if your periods are heavy enough that you are flooding, passing large clots, or bleeding for more than seven or eight days, tell your doctor. Heavy bleeding in perimenopause [00:14:00] is common, and it still needs to be looked into properly, sometimes with an ultrasound.

Our sponsor is Mineralite Liquid Electrolytes. And if you're still reaching for one of those sugary sports drinks when you need an energy hit, please stop. I say this with love, but they're full of sugar, artificial flavors, and things that are actively working against your health goals.

Mineralite is the alternative I actually recommend. Mineral-rich electrolyte hydration drops with no sugar, no sweeteners, no additives, nothing artificial. Add the unflavored drops to your water or any drink you're having, and you're supporting your energy, your focus, and your performance in a way that makes sense for your body.

I've got them in my drink bottle right now, so go and show them some love at mineralite.com.au or find them in most pharmacies and health food stores throughout Australia and New Zealand

Then we go to area three, which is your heart, and test number four is to do a fasting lipid panel.

This measures your total cholesterol, your LDLs, your HDLs, and your triglycerides. Now, listen [00:15:00] in carefully here. Heart disease is the leading cause of death in women, not breast cancer, heart disease. A 2020 scientific statement from the American Heart Association, pulled together 20 years of research following women through the menopausal transition.

It found that the transition itself is a time of accelerating cardiovascular risk. LDL cholesterol tends to rise around the final menstrual period. Body fat shifts towards the abdomen, and blood vessels become less flexible. The author described midlife as a window for early prevention.

Think of estrogen as the internal maintenance crew for your blood vessels. It keeps them supple and helps your liver clear LDL cholesterol. As estrogen levels drop, that crew starts working fewer shifts. So if your last cholesterol test was five years ago, it is out of date.

Get a fresh baseline now and keep a track of it along the lines of looking after our [00:16:00] cardiovascular system, I want to mention test number five, lipoprotein A or Lp. This is the test I wish every woman knew about. Lipoprotein A is   a type of cholesterol particle whose level is largely set by your genes. Diet and exercise really don't change it. They barely move it. But a high level raises your risk of heart attack and stroke, even when the rest of your cholesterol looks good. A 2022 consensus statement from the European Atherosclerosis Society recommends that every adult has their Lpmeasured at least once in their lifetime.

Once. Because it barely changes. One test tells you what you need to know. If you have a family history of heart disease or stroke at a young age, this is really particularly important. In Australia, lipoprotein A is usually not covered by Medicare, so expect a small out-of-pocket cost. But knowledge is power.

So if you [00:17:00] find that yours is high, then you can take some positive action to do something about it.

Area four is your blood sugar. We're gonna look at test group six, HbA1c and fasting glucose. Fasting glucose is a snapshot of your blood sugar on the morning of the test. HbA1c is a longer view. Think of HbA1c as a three-month average. Sugar in your blood sticks to your red blood cells,

a bit like icing sugar dusting everything in a kitchen. Red blood cells live about three months, so HbA1c tells us how much sugar they have been exposed to across that time. An HbA1c of 6.5%, or 48 millimoles per mole, or above, is in the diabetes range. Between 6.0 and 6.4% is a warning zone. I like it to be under 5% for optimal health, though.

And a fasting glucose under 6.1 millimoles per liter is considered [00:18:00] normal, but I like this under five as well. And here is a connection that many people miss. Iron deficiency can push up HbA1c falsely. So if your iron is low, interpret your HbA1c with care, which is another reason to test your iron.

Then we go on to test seven, fasting insulin.

Glucose and HbA1c only rise once your body is already struggling. Insulin rises years earlier if there's a problem with it, of course. Think of insulin as the key that opens your cells so sugar can get in. When cells stop responding well, which we call insulin resistance, your pancreas makes more and more of those keys, more and more insulin, to get the same doors open.

Your blood sugar can look perfectly normal while your insulin is working overtime. That is often when the stubborn weight around the middle starts, and the energy starts to crash after meals [00:19:00] too Now, the test for fasting insulin is usually not covered by Medicare here in Australia, so there is often a small fee.

But for many women in perimenopause, it's the most useful early warning sign we have.

This is also the area where nutrition makes the biggest difference. My three-week inflammation detox program is designed to take you through a structured reset of what you eat. And my 12-week whole health solution program goes deeper into blood sugar, inflammation, and hormonal health in a supported and personalized way.

Now we go onto the final group of tests, your vitamins, liver, and kidneys. So our eighth test is vitamin D. Now, vitamin D works more like a hormone than a vitamin. It helps you absorb calcium for your bones, and it supports immune function and muscle strength. As estrogen falls, bone loss speeds up, so this matters more now than ever.

Think of vitamin D as the delivery driver that takes calcium from your gut to your bones. You can eat all the calcium you [00:20:00] like, but without the driver, it doesn't get delivered. In Australia, Medicare only covers vitamin D testing for people with specific risks, such as very limited sun exposure, darker skin, osteoporosis, or conditions affecting absorption.

If you do not meet those criteria, you may pay a small fee. Most Australian guidance considers 50 nanomoles per liter or higher to be adequate. Many doctors do aim a bit higher, especially at the end of the winter. However, for optimal health though, I like vitamin D to be around 100 to 120. And while we're on the bones, a blood test cannot tell you your bone density.

That needs a DEXA scan. If you have risk factors like early menopause, a family history of osteoporosis, or a past fracture, ask your doctor to get one done. Now, test nine, vitamin B12 and folate. B12 is essential for energy, nerve function, and mood. [00:21:00] Low B12 can cause tingling in your hands and feet, fatigue, poor memory, and low mood, all kind of more overlapping symptoms.

You are at greater risk if you eat little or no animal food, if you're celiac, or if you take medications that reduce stomach acid or metformin. And while you're asking for B12 and folate, I want you to add one more marker to that same line on the form, which is homocysteine. Homocysteine is an amino acid your body makes when it is breaking down methionine, a protein building block found in meat, eggs, and dairy.

In a healthy system, it does not hang around for long. Your body recycles it straight back into useful compounds. And to do that recycling, it needs folate, vitamin B12, and vitamin B6 Think of homocysteine as the rubbish bin in your kitchen. The bin is filling up as normal. That's what happens when you cook.

But the trouble starts when nobody empties the bin. B12, folate, and B6 are the ones that take the bins out, and if [00:22:00] any of them do not turn up for work in the kitchen, the rubbish piles up. So why does this matter in perimenopause? Raised homocysteine is linked with damage to the lining of your blood vessels, with heart disease and stroke, and with changes in memory and thinking.

That last one matters to so many of you listening because brain fog is often the symptom that frightens women most. In 2018, an international group of researchers led by Professor David Smith from the University of Oxford published a consensus statement in the Journal of Alzheimer's Disease.

They concluded that raised homocysteine is a modifiable risk factor for cognitive decline and dementia in older people. Modifiable, something that you can do something about. Now, I wanna give you the full picture on the heart side, too. A 2017 Cochrane review found that lowering homocysteine with B vitamins did not reduce heart attacks, although it may slightly reduce [00:23:00] the risk of stroke.

So I treat homocysteine when it's high as a flag, and a raised result tells me to look harder at your B12 and folate, at your kidney function and your thyroid, and at the rest of your heart picture, including your lipids and your lipoprotein.

So what pushes homocysteine up? Low B12, low folate, and low B6. Eating little or no animal food. Smoking and a higher alcohol intake. An underactive thyroid, reduced kidney function, and medications like metformin And acid-reducing medications through their effect on B12.

And a common gene variation called MTHFR, which affects how well you process folate, and I've got a whole episode of its own coming on that, so stay tuned for that one. Most Australian labs flag homocysteine above about 15 micromoles per liter as a problem. For optimal health, I like to see this under about 8 to 10.

This test is usually not covered by Medicare, so expect a small out-of-pocket cost, and it is [00:24:00] best done fasted in the mornings. Now, test 10 is liver and kidney function. These are routine tests, and they give your doctor a lovely baseline. Liver function tests show how your liver is coping, and your liver has a very big job in mid-life. It processes hormones, cholesterol, alcohol, and medications. Kidney function, often written as EUC or eGFR on the form, along with your electrolytes, tells us how well your kidneys are filtering.

Think of these two as the cleaning and recycling depot of your body. Before you add anything new, menopause hormone therapy, a new supplement, a new medication, it is useful to know that the depot is running well.

So that's my list of starting tests that I think every woman over 40 should ask their doctor for on an annual basis. Remember, you can download that one-page handout with the full list via the link in the episode show notes.

And finally, I want to take you through how to ask for these tests, because knowing the list is one thing, walking out of the appointment with the right [00:25:00] form from your doctor is another. In 2024, The Lancet published a series on menopause, and the first paper, led by Professor Martha Hickey from the University of Melbourne, argued for what they called an empowerment model.

The idea is that you are the expert in your own experience, and your health professional is your partner in decisions about your care. I love that. And being an equal partner starts with you walking in prepared. So here is what I want you to do. Step one, book a long appointment next time you see your GP.

A standard 10-minute consult is not enough time to talk through perimenopause properly. Ask the receptionist for a long consult and tell them it's about perimenopause and blood tests.

Step two, write down your symptoms before you go. Your cycle changes, your sleep, your energy, your moods, your hair, your weight, any heavy bleeding. Keep a symptom and cycle diary for one to three months if you [00:26:00] can, because your symptoms are what will justify your doctor being able to give you the tests.

Then step three, bring your list of what you want and explain the reasons. So rather than reading out 10 tests and saying, "My naturopath told me to get these on a podcast I was listening to," rather link each one of these to what you're experiencing. For example, "My periods have become very heavy and I'm exhausted.

Could we check my iron studies and ferritin?" Or my mom had a heart attack at 58. Could we check my lipids and lipoprotein A?" That gives your doctor the clinical reason they need, and it makes the conversation easy. Step four, ask about timing and fasting. Lipids, glucose, insulin, and homocysteine are best done fasting, so book an early morning collection and only drink water beforehand.

Also, make sure you don't exercise on the morning before a blood test. If your doctor does order hormone tests, ask which day of the cycle to have them done. Progesterone is typically done on day [00:27:00] 21, and LH and FSH on days two or three. Step five, ask for copies of your results every single time. Keep them in a lovely folder or on a note on your phone or in a folder on your computer.

Your blood tests become far more useful as a trend over the years than as a single snapshot. And that way, normal becomes something because you know what normal is for you. Step six, book the follow-up. Ask when you should recheck. Iron might need rechecking in about three months if you're treating it.

Lipids and HbA1c might be yearly. Whatever your doctor suggests, put it in your diary before you leave. And if you ask for testing and you're dismissed, you are allowed to ask why. You are allowed to ask for a second opinion. You are allowed to see a GP with a special interest in women's health or menopause if you don't get the answers and the support you need from your regular doctor.

You can also order lots of these tests with guidance from natural medicine practitioners like myself [00:28:00] via online ordering systems such as Instant Scripts, Vively, and Aussie Scripts here in Australia, and at Fullscripts in America.

So a summary of those six steps: book a long appointment, write down your symptoms, link each test to a reason, ask about fasting and timing, get copies of your results, and book your follow-up. When you have the information from these tests, things can change. Women like Kate stop wondering whether it's all in their head.

You find the iron deficiency that has been flattening you for two years. You catch the thyroid early. You see your cholesterol starting to climb while there is still plenty of time to act on it. And instead of being told you're fine while feeling anything but, you have real numbers to work with alongside a practitioner who is working with you.

That is the foundation. Once you can see what is going on, you can start to really understand your body better, and then nourish, heal, and [00:29:00] rise.

Next episode is landing on my 50th birthday, so I wanna have a special episode that you do not wanna miss. I'm gonna share 50 things I find fascinating or amazing or incredible about the human body, health, and wellness.

Make sure you look out for that one. So please hit subscribe or follow the show on whatever platform you're listening on right now, because you do not wanna miss a single episode. And if someone in your life needs to hear this too, please share it with them, because the more women who have access to this kind of information, the better.

Just a little note, all of my free resources, my three-week inflammation detox, and my 12-week whole health solution program can be found at andrearobertson.health. Everything you need is right there waiting for you. If you loved today's episode, please take 30 seconds to leave a review on Apple Podcasts, Spotify, or wherever you listen to your podcasts.

It genuinely helps more women find the show so they can nourish, heal, and rise too. Until next week, nourish your [00:30:00] body, keep healing, and never stop rising. I'm Dr. Andrea Robertson, and this has been Nourish, Heal, and Rise.