Urinary pregnanediol glucuronide and urinary follicle- stimulating hormone as biomarkers of the menopausal transition in Asian women: a systematic review

Background: The menopausal transition poses a significant diagnostic challenge in Asian women, who frequently experience burdensome vasomotor symptoms and sleep disturbances yet remain underdiagnosed due to reliance on invasive serum biomarkers and menstrual-based staging criteria. Urinary pregnanediol glucuronide (PdG), a non-invasive progesterone metabolite, has emerged as a promising indicator of ovarian ageing, but its utility in Asian populations has not been systematically evaluated. Methods: A systematic review and narrative synthesis were conducted in accordance with PRISMA 2020 guidelines and were prospectively registered with PROSPERO (CRD420261349771). PubMed, Web of Science, and Google Scholar were searched from inception to March 2026. Studies reporting urinary PdG and/or follicle-stimulating hormone (FSH) in Asian women during the menopausal transition were included. Methodological quality was assessed using the Newcastle–Ottawa Scale and evidence certainty was rated using the GRADE framework. Results: Eleven studies met the inclusion criteria, all derived from the Study of Women's Health Across the Nation (SWAN) cohort, comprising Chinese and Japanese participants. Longitudinal evidence demonstrated that declining urinary PdG trajectories preceded the final menstrual period by up to five years, with moderate certainty. Elevated urinary FSH and disrupted PdG patterns were consistently associated with vasomotor symptoms and sleep disturbance. Ethnic-specific hormonal profiles, including higher PdG and lower estrogen metabolites in Asian women compared to Caucasian counterparts, were identified across multiple studies. Conclusion: Urinary PdG is a reliable, non-invasive early indicator of perimenopause onset in Asian women and demonstrates clinically meaningful associations with vasomotor and sleep symptoms. Given the distinct hormonal profiles of Asian women, population-specific reference thresholds are needed. Further prospective validation across diverse Asian populations and integration with digital health tools are warranted.