Pentagon expands hormone screening guidance to include female service members

The Defense Health Agency has explicitly established a hormone-screening pathway for female service members, directing providers to screen women annually for hormonal dysregulation and establishing clinical pathways for problems ranging from menstrual irregularities and fatigue to perimenopause and menopause.

The Sept. 2 guidance, signed by DHA Director Vice Adm. Darin Via, establishes clinical pathways for female hormonal optimization and lays out when a woman should receive additional evaluation, what conditions providers should consider and when treatment or referral is warranted.

A female Marine interviewed by Military Times said low testosterone can occur in women but can be harder to identify because women normally have much lower testosterone levels than men.

“Low testosterone isn’t really a problem that affects women the same way as it affects men,” the Marine said.

Unlike the mandatory testosterone blood testing for male service members aged 30 and older, the female pathway begins with an annual clinical screen for hormonal dysregulation during the Periodic Health Assessment, or PHA.

DHA identifies fatigue, musculoskeletal pain and changes in menstrual patterns, including cycles longer than 35 days, as signs that should prompt a targeted assessment for Relative Energy Deficiency in Sport, or RED-S.

DHA says military operational demands, fitness standards and occupational stressors can increase the risk of RED-S, a condition associated with low energy availability that can contribute to bone-stress injuries, impaired endocrine function and lost operational readiness.

If the initial assessment does not indicate concern for RED-S, no further evaluation is required under the DHA guidance. If concern remains, active-duty service members are referred to their primary care managers for further assessment and treatment.

The next step can include a validated screening tool such as the Low Energy Availability in Females Questionnaire, followed by the International Olympic Committee’s RED-S Clinical Assessment Tool Version 2. That assessment places service members into four risk categories, ranging from low risk, with unrestricted training and duties, to high risk, where limited duty, medical profiling or hospitalization may be necessary.

DHA also recognizes that one of the most visible indicators of RED-S can be obscured by treatment and notes that functional hypothalamic amenorrhea can be masked by hormonal contraception.

At the same time, menstrual-cycle and sex-hormone indicators are not scored in the RED-S assessment for women taking thyroid or sex-hormone-altering medications, including hormonal contraceptives.

When RED-S is suspected, clinicians can order blood tests including a complete blood count, comprehensive metabolic panel, ferritin, iron studies, vitamin B12 and thyroid-stimulating hormone. For women with prolonged or absent menstruation, pregnancy testing and additional hormone testing may be ordered when clinically indicated.

Treatment focuses first on correcting the underlying energy deficit, which can mean increasing dietary energy intake, reducing training volume or both. DHA also calls for attention to protein, carbohydrates, calcium and vitamin D, with psychological support when disordered eating, body-image concerns or performance pressures are involved.

Female service members aged 35 and older who report clinically significant symptoms of perimenopause or menopause are to be assessed for whether those symptoms affect operational duties or quality of life. If they do — or if the service member requests education or treatment — the provider is to refer her to a midlife-transition specialist.

That specialist could be an obstetrician-gynecologist, certified nurse midwife, women’s health nurse practitioner, endocrinologist or primary care provider trained in perimenopause and menopause care. If appropriate expertise is unavailable locally, DHA directs providers to its Midlife Telehealth Hub.

A Navy hospital corpsman interviewed by Military Times, says the military standard should remain the ability to perform the job.

“As long as they are fit for duty, any medically optional test they would like to have is fine for me personally,” she said. “If a testosterone treatment makes you fit for duty, then great, get in there.”

The DHA guidance addresses testosterone treatment for women within a narrow clinical context, citing the 2019 Global Consensus Position Statement on testosterone therapy, which identifies Hypoactive Sexual Desire Disorder, or HSDD, in postmenopausal women as the only evidence-based indication for testosterone therapy in women.

The guidance does not establish a testosterone blood-test threshold for diagnosing HSDD. Instead, it calls for a clinical assessment, consideration of other causes and shared decision-making between the patient and provider.

DHA says available evidence does not demonstrate a benefit from testosterone therapy for psychological well-being, depressive symptoms, cognitive performance, cardiovascular outcomes, bone mineral density, or muscle mass and performance. Evidence for treating HSDD with testosterone in perimenopausal women remains limited, according to the guidance.

For a postmenopausal service member with a distressing decline in sexual function, DHA recommends addressing other possible causes before considering testosterone. If treatment is chosen, it is off-label: The guidance recommends one-tenth of an FDA-approved male 1% testosterone cream or gel.

Those undergoing treatment will have their testosterone levels checked three to six weeks after treatment begins or after a dose increase, with the goal of keeping levels within the normal premenopausal female range.

DHA recommends stopping treatment after six months if there is no demonstrated benefit. For women who remain on treatment, the guidance calls for clinical evaluation and testosterone testing every four to six months.

The agency also cautions that safety data for physiologic testosterone treatment in women do not extend beyond 24 months and recommends caution for women with hormone-sensitive breast cancer or high cardiometabolic risk.

The guidance takes effect immediately and expires one year after its Sept. 2 signature unless DHA reissues or cancels it earlier.