Status and intended use
COMPASS v1.1.1 is a prevalidation framework, not a validated diagnostic instrument. Its scores are structured, hypothesis-generating prompts for differential review. They do not diagnose, exclude, or overturn a diagnosis; determine medication or level of care; or replace a clinical interview, medical evaluation, validated condition-specific instrument, or emergency protocol.
The current repository governance does not authorize clinical deployment. Any pilot involving people or records requires appropriate protocol, privacy, consent, safety, and oversight approval.
COMPASS is designed to reduce premature diagnostic closure by making temporal pattern, reproductive context, trauma and adversity, episode structure, medical contributors, and treatment response visible when considering PMS/PMDD, pregnancy/postpartum conditions, reproductive-transition presentations, PTSD/CPTSD, borderline personality disorder, bipolar-spectrum disorders, and thyroid or other medical contributors. Co-occurrence remains possible.
Administration workflow
- Explain that the tool organizes a differential and does not assign a diagnosis.
- Establish privacy, accessibility needs, and how urgent disclosures will be handled.
- Use Sections A–G for current reproductive, symptom, mood, safety, medical, and treatment context. The pregnancy/postpartum section may be marked not applicable. Sections H–L capture adversity and trauma context and generally need less frequent repetition.
- After submission, review raw safety answers first, then completeness, timing, reproductive context, longitudinal course, medical contributors, and calculated signals.
- Select validated follow-up instruments or diagnostic interviews and document uncertainty explicitly.
Do not interpret a LOW or zero result when a relevant section is incomplete. Most unanswered numeric items are currently treated as zero by the implementation.
Safety hierarchy
Raw safety responses supersede every score and care tier. Directly assess current suicidal thoughts, intent, plan, access to means, preparatory behavior, recent attempts or self-harm, intoxication, agitation, psychosis, mixed/manic symptoms, protective factors, and immediate environment. Use the organization’s emergency protocol and a recognized approach such as SAFE-T.
In the postpartum context, distinguish unwanted ego-dystonic infant-harm intrusions from desire, intent, planning, delusional belief, hallucinations, or impaired reality testing. Desire, intent, uncertainty about safety, inability to protect the infant, or possible postpartum psychosis requires immediate assessment. ACOG recommends immediate risk assessment after an affirmative self-harm response, bipolar screening before pharmacotherapy for depression or anxiety, and immediate medical attention for postpartum psychosis. ACOG implementation summary
Assess relationship violence privately and use patient-directed, trauma-informed procedures. Do not put information where an abusive person may access it.
Result key
| Output | Interpretation |
|---|---|
| LOW | The encoded pattern is not strongly represented. It does not exclude the condition. |
| MODERATE | Some programmed features are present and require clarification. |
| ELEVATED | Multiple programmed features align; conduct a condition-specific assessment. This is not a diagnosis. |
| INCOMPLETE | Required responses are missing; do not interpret the score. |
| NOT ASSESSED | The calculation was not performed for the recorded context. |
| NOT APPLICABLE | The section was intentionally skipped. |
| Red flag | Review the raw answer and act clinically regardless of the composite level. |
| Adjusted threshold | An experimental COMPASS attention modifier, not an accepted diagnostic cutoff. |
Scoring formulas
Weighted adversity (wACE)
Total = H1 + … + H10, each 0–3; range 0–30. ACE count is the number of H1–H10 items ≥1. Internal bands: 0–5 minimal, 6–10 mild, 11–17 moderate, 18–24 moderate-severe, 25–30 severe/critical. Total ≥15 modifies the reproductive-transition attention threshold. These proprietary bands are not conventional ACE cutoffs.
Cyclicity and symptom differential
CPI is HIGH when luteal onset, clear post-onset remission, and a noticeably better/symptom-free interval are all present; MODERATE when luteal onset and partial remission/improvement are present; LOW otherwise. Luteal total = C1…C14 and follicular total = C15…C28, each 0–42. LF differential = luteal − follicular. Differential ≥10 with HIGH CPI displays PMDD-compatible; ≥5 displays PMS or PMDD-with-comorbidity compatible; 0–4 reduces probability; <0 is strongly inconsistent with PMDD as the primary presentation. Confirm PMDD prospectively with daily ratings across at least two symptomatic cycles; retrospective COMPASS ratings are insufficient.
Trauma pattern
PTSD = P1…P6, 0–18; DSO = C1_i…C6_i, 0–18. Internal assignment: PTSD ≥8 and DSO ≥6 = C-PTSD pattern; PTSD ≥8 only = PTSD pattern; DSO ≥6 only = DSO-predominant; both ≥4 = elevated/subthreshold; otherwise below threshold. These are not validated diagnostic cutoffs. CPTSD is an ICD-11 diagnosis and is not separately defined in DSM-5.
Lifetime Adversity Index
Fourteen domains each equal occurrence 0–3 plus impact 0–3. Life/relational and occupational subtotals each range 0–42; LAI = both subtotals, range 0–84. Internal bands: 0–12 minimal, 13–25 mild, 26–38 moderate, 39–51 moderate-severe, 52–67 severe, 68–84 critical. LAI ≥40 modifies the reproductive-transition attention threshold. These bands are proprietary and prevalidation.
Pregnancy/postpartum pattern
PPD symptom total = PPD4…PPD13, range 0–30. ELEVATED requires core depressed mood or anhedonia ≥2, duration ≥2 weeks, moderate/severe impairment, and total ≥12. MODERATE requires total ≥8, a core symptom, or moderate/severe impairment. PPD15–PPD19 are separate safety/differential flags and add no points. Pregnancy is recorded as NOT ASSESSED for the postpartum-depression calculation; intentional skip is NOT APPLICABLE.
Reproductive-transition pattern (PPA)
The default software age is 40; it changes to 35 with wACE ≥15 or C-PTSD, to 38 with LAI ≥40, and to 18 with IPV-dominant adversity plus cycle irregularity. ELEVATED requires vasomotor symptoms plus the effective age condition, or an adversity modifier plus cycle irregularity. MODERATE requires the effective age plus cycle/vasomotor evidence, or meeting an adjusted age. These ages are experimental attention thresholds, not diagnostic criteria. The age-18 path is a prompt for medical/endocrine evaluation—not a perimenopause classification.
Differential signals and care tier
PMDD is ELEVATED with HIGH CPI, LF differential ≥10, and luteal total ≥10; MODERATE with non-LOW CPI, differential ≥5, and luteal total ≥8. PMS is MODERATE with non-LOW CPI and differential 5–9. Reproductive-transition mood is ELEVATED when PPA is ELEVATED and CPI is MODERATE/LOW; MODERATE for PPA MODERATE or PPA ELEVATED with HIGH CPI. BPD, bipolar, and CPTSD signals use internal point combinations of timing, triggers, duration, recovery, trauma, and treatment history; they are not diagnostic scales. The care tier is an organizational prompt and never overrides raw suicidality, infant-harm, psychosis, violence, or acute medical findings.
CSC-R
The exploratory CSC-R activates when reproductive-transition evidence, a specified lipophilic statin, inferred absence of hormonal exposure, and a cognitive/mood symptom signal all coexist. It is unvalidated and must not direct statin discontinuation, hormone prescribing, or another medication change.
Why trauma/CPTSD lowers the attention threshold
The modifier is intended to reduce missed inquiry and diagnostic overshadowing—not to assert that CPTSD causes menopause at 35. The evidence supports three cautious propositions:
- Hormonal sensitivity: early trauma may increase vulnerability to mood and trauma-symptom destabilization during reproductive-hormone fluctuation through stress-response, allopregnanolone/GABAergic, sleep, affect-regulation, and emotional-processing pathways. This is a mechanistic framework, not a patient-level causal test. 2024 review
- Greater symptom burden: adversity and PTSD have been associated with more severe menopausal symptoms, sleep disturbance, vasomotor symptoms, and vaginal symptoms. DREAMS study; PTSD and menopause symptoms
- Earlier transition evidence is mixed: one longitudinal cohort found severe childhood sexual abuse associated with more peri/postmenopausal classification at age 40, while other work found no association between ACEs/PTSD and earlier natural menopause; PTSD was associated with earlier menstrual cessation through gynecologic surgery in the Nurses’ Health Study II. New Zealand cohort; natural-menopause study; NHS II
Correct use: lower the threshold to ask about menstrual change, vasomotor symptoms, cognition, sleep, pain, genitourinary symptoms, and temporal worsening of trauma symptoms. Then stage reproductive aging independently. STRAW+10 principally uses bleeding-pattern criteria and is designed for application regardless of chronological age. STRAW+10
For patients younger than 40, consider pregnancy, thyroid and prolactin disorders, PCOS, hypothalamic amenorrhea, medication effects, eating disorders, chronic illness, treatment-induced ovarian dysfunction, and premature ovarian insufficiency rather than presuming typical perimenopause.
Twenty reproductive-transition signs and symptoms to recognize
This is a clinical recognition set, not a prevalence-ranked diagnostic checklist. Dr. Mary Claire Haver’s community symptom survey is included as a supplemental recognition source, while clinical interpretation is anchored in professional guidance and peer-reviewed evidence. Haver symptom overview; The Menopause Society
| # | Sign or symptom | Clinical clarification |
|---|---|---|
| 1 | Cycle-length or predictability change | Persistent shortening, lengthening, skipped cycles, or new variability. |
| 2 | Flow change | Heavier, lighter, prolonged, flooding, or intermenstrual bleeding; evaluate abnormal bleeding independently. |
| 3 | Hot flashes | May be described as heat, flushing, chills, sweating, panic, or an “adrenaline” surge. |
| 4 | Night sweats | Ask about awakenings and daytime consequences. |
| 5 | Sleep disruption | Sleep-onset difficulty, fragmentation, early waking, nocturia, or nonrestorative sleep—even without recognized sweats. |
| 6 | Brain fog/executive dysfunction | Word finding, working memory, concentration, sequencing, or processing speed. |
| 7 | Memory complaints | Rapid progression, disorientation, focal deficits, or major functional loss requires another evaluation. |
| 8 | Anxiety or panic | New somatic anxiety, dread, hypervigilance, or internal agitation. |
| 9 | Depression/anhedonia | Assess safety, bipolarity, trauma, thyroid, sleep, and psychosocial context. |
| 10 | Irritability or emotional lability | Separate cyclical/transition-linked change from brief reactivity and distinct manic episodes. |
| 11 | Palpitations | Also consider arrhythmia, anemia, thyroid disease, stimulants, and cardiac disease. |
| 12 | Headache, migraine change, or dizziness | Clarify aura and neurologic red flags. |
| 13 | Fatigue/reduced recovery | Review sleep, anemia, thyroid, nutrition, medication, cardiopulmonary and inflammatory causes. |
| 14 | Joint pain or stiffness | Assess distribution, swelling, inflammatory features, injury, and function. |
| 15 | Muscle pain, weakness, or lean-mass loss | Consider deconditioning, statin effects, neurologic disease, and vitamin or endocrine causes. |
| 16 | Tendon/ligament problems | Frozen shoulder, tendinopathy, heel pain, and recurrent soft-tissue injury require ordinary orthopedic/rheumatologic assessment too. |
| 17 | Body-composition/metabolic change | Central adiposity may change without large total-weight change. |
| 18 | Rising cholesterol | An objective sign, not a symptom; interpret through standard cardiovascular-risk assessment. |
| 19 | Genitourinary symptoms | Dryness, burning, dyspareunia, urgency, nocturia, recurrent UTI, dysuria, or incontinence. |
| 20 | Sexual, skin, hair, oral, eye, or sensory change | Libido/arousal/orgasm change, dry skin/eyes, hair thinning, brittle nails, burning mouth, altered taste/odor, paresthesia, or formication; evaluate alternatives as indicated. |
Musculoskeletal pain, analgesic exposure, and lipids
The 2024 review that introduced “musculoskeletal syndrome of menopause” describes arthralgia, muscle and bone loss, tendon/ligament injury, adhesive capsulitis, cartilage vulnerability, and osteoarthritis progression in the context of estrogen loss. It is a narrative review, not a treatment trial. Wright et al.
A systematic review and meta-analysis of 37 observational studies and 93,021 participants reported muscle or joint pain in 40% of premenopausal, 57% of perimenopausal, and 59% of postmenopausal participants. Heterogeneity was high and the evidence does not establish hormonal causation for every pain condition. Systematic review and meta-analysis
In 104,984 midlife women Veterans with chronic pain, 51% received long-term opioids, 13% high-dose long-term opioids, and 35% long-term opioids plus a CNS depressant; recorded menopausal symptoms were associated with 21% higher adjusted odds of long-term opioid prescribing. This cross-sectional study did not determine who would improve with estrogen. It supports including reproductive-transition assessment before escalating chronic analgesic treatment—not assuming that pain “just needs estrogen.” Veterans Health Administration study
In the WHI estrogen-alone trial’s post hoc analysis of 10,739 postmenopausal participants with prior hysterectomy, joint pain was modestly less frequent with estrogen than placebo at one year (76.3% vs 79.2%), while joint swelling was slightly more frequent. Pain alone is not an established primary indication for systemic menopausal hormone therapy. WHI analysis
SWAN found substantial increases in total cholesterol, LDL-C, and apolipoprotein B around the final menstrual period. Lipid change can be a reproductive-transition clue but neither diagnoses perimenopause nor replaces standard cardiovascular-risk assessment; MHT should not be prescribed solely to treat cholesterol or prevent cardiovascular disease. SWAN analysis
Hormone therapy is most effective for bothersome vasomotor symptoms and genitourinary syndrome and prevents bone loss/fracture in appropriately selected patients. Decisions require individualized assessment of indications, uterine status/endometrial protection, unexplained bleeding, formulation, route, timing, contraindications, and cardiovascular, thrombotic, and breast risk. 2022 Menopause Society position statement
Integrated differential review
| Pattern | Features increasing compatibility | Required clarification |
|---|---|---|
| PMDD | Predictable luteal onset, postmenstrual remission, symptom-free interval | Prospective daily ratings, impairment, persistent comorbidity |
| Pregnancy/postpartum depression | Perinatal onset, persistent core symptoms, impairment | Suicide, psychosis, bipolarity, anxiety/OCD, sleep, support, thyroid/medical causes |
| Reproductive transition | Bleeding change, vasomotor, sleep, cognition, pain, genitourinary and metabolic cluster | Pregnancy, medications, surgery, POI, thyroid, anemia, autoimmune and gynecologic causes |
| PTSD/CPTSD | Trauma reminders, re-experiencing, avoidance, threat, DSO | Whether reproductive fluctuation amplifies an enduring trauma disorder |
| BPD | Enduring pervasive cross-context pattern, identity/relationship instability | Trauma, neurodevelopmental factors, reproductive timing, and distinct mood episodes |
| Bipolar spectrum | Distinct days-long change in mood, energy, activity, sleep and function | Brief reactivity, trauma arousal, sleep deprivation, substances, antidepressant effects, cycle linkage |
| Thyroid/medical | Fatigue, cognition, temperature, bowel, weight, cardiac, pain, postpartum or exam/lab clues | COMPASS has no hypothyroidism score; conduct medical evaluation and testing as indicated |
Postpartum thyroiditis affects about 1 in 20 women in the first postpartum year and can produce hyperthyroid and/or hypothyroid symptoms that overlap psychiatric presentations. NIDDK
Known v1.1.1 limitations
- Most missing numeric answers default to zero; incomplete sections can look falsely LOW.
- A text-matching defect may fail to recognize one partial-remission response in CPI.
- Several intended treatment-response contributions and alerts are unreachable because stored response text does not match the calculation logic.
- Safety display state can persist after an answer is changed; verify current raw answers.
- Infant-harm and psychosis flags do not automatically force Tier 3.
- Adversity bands, differential point rules, care tiers, age modifiers, and CSC-R are proprietary prevalidation constructs.
- The CSC-R inference of progesterone/hormonal exposure is oversimplified; reconcile actual medication, formulation, route, dose, timing, and adherence.
- COMPASS calculates no separate hypothyroidism score and cannot perform a medical differential.
Documentation language
General: “COMPASS v1.1.1 was used as a prevalidation structured differential-review framework. It is not a validated diagnostic instrument. Results were interpreted with raw responses, completeness, reproductive timing, longitudinal course, trauma context, medical factors, functional impairment, and condition-specific assessment. No diagnosis or treatment decision was based on a COMPASS score alone.”
Early transition trigger: “COMPASS generated an earlier reproductive-transition attention signal because of the adversity/trauma profile. This lowers the threshold for inquiry; it does not diagnose perimenopause or establish earlier ovarian aging. Menstrual pattern, reproductive history, compatible multisystem symptoms, medical differential, and applicable staging criteria were reviewed independently.”
Incomplete: “Relevant sections were incomplete. Because unanswered numeric items may be represented as zero in the current build, low scores were not interpreted as negative findings.”
Patient debrief
“This result is not assigning you a diagnosis. It helps us see when symptoms occur and whether reproductive changes, trauma, medical factors, or distinct mood episodes may be contributing. More than one pattern can be present, so we will decide what needs a more specific assessment.”
Core clinical and evidence sources
- Practice guideline ACOG Clinical Practice Guideline No. 4: perinatal screening and diagnosis
- Practice guideline ACOG Clinical Practice Guideline No. 7: premenstrual disorders
- Consensus staging STRAW+10
- Position statement 2022 Menopause Society hormone-therapy statement
- Diagnostic standard WHO ICD-11 CDDR
- Government clinical resource VA National Center for PTSD: complex PTSD
- Government clinical resource NIMH: borderline personality disorder; NIMH: bipolar disorder
- Supplemental education Dr. Mary Claire Haver’s symptom overview—used for recognition breadth, not diagnostic criteria or prevalence authority.
Evidence types are labeled because association, mechanistic plausibility, diagnostic standards, and treatment recommendations are not interchangeable. Repository formulas control descriptions of what COMPASS calculates; external sources control statements about established clinical practice.