Pentagon expands hormone screening guidance to include female service members

The Defense Health Agency (DHA) has formally established a hormone-screening pathway for female service members, directing providers to conduct annual screenings for hormonal dysregulation and creating clinical pathways for conditions ranging from menstrual irregularities and fatigue to perimenopause and menopause.

New Clinical Guidelines

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

Screening Process

Unlike the mandatory testosterone blood testing required 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 (PHA).

A female Marine interviewed by Military Times noted that low testosterone can occur in women but is harder to identify because women naturally 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.

RED-S Identification and Assessment

DHA identifies the following signs that should prompt a targeted assessment for Relative Energy Deficiency in Sport (RED-S):

• Fatigue
• Musculoskeletal pain
• Changes in menstrual patterns, including cycles longer than 35 days

DHA states that military operational demands, fitness standards, and occupational stressors can increase the risk of RED-S. This condition is associated with low energy availability and can contribute to:

• Bone-stress injuries
• Impaired endocrine function
• Lost operational readiness

Assessment Protocol

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

The next step may 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. This assessment places service members into four risk categories:

| Risk Category | Action | |---------------|--------| | Low risk | Unrestricted training and duties | | High risk | Limited duty, medical profiling, or possible hospitalization |

DHA also recognizes that one of the most visible indicators of RED-S—functional hypothalamic amenorrhea—can be masked by hormonal contraception. Additionally, 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.

Diagnostic Testing

When RED-S is suspected, clinicians may order blood tests including:

• Complete blood count
• Comprehensive metabolic panel
• Ferritin
• Iron studies
• Vitamin B12
• Thyroid-stimulating hormone

For women with prolonged or absent menstruation, pregnancy testing and additional hormone testing may be ordered when clinically indicated.

Treatment Approach

Treatment focuses first on correcting the underlying energy deficit, which may involve:

• Increasing dietary energy intake
• Reducing training volume, or both

DHA also calls for attention to:

• Protein
• Carbohydrates
• Calcium
• Vitamin D

Psychological support is recommended when disordered eating, body-image concerns, or performance pressures are involved.

Perimenopause and Menopause Care

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.

Qualified specialists include:

• Obstetrician-gynecologists
• Certified nurse midwives
• Women's health nurse practitioners
• Endocrinologists
• Primary care providers trained in perimenopause and menopause care

If appropriate expertise is unavailable locally, DHA directs providers to its Midlife Telehealth Hub.