What tests are ordered to check hormone levels in women?

Hormone Level Testing for Women

For comprehensive hormone level assessment in women, order serum luteinizing hormone (LH), follicle-stimulating hormone (FSH), estradiol, progesterone, prolactin, and testosterone with sex hormone binding globulin (SHBG). These tests should be timed appropriately based on the menstrual cycle and clinical presentation to ensure accurate interpretation.

Core Hormone Panel

Essential Tests

• LH and FSH: Measure between days 3-6 of the menstrual cycle 1

  • Ratio of LH/FSH >2 may indicate PCOS
  • FSH >35 IU/L with LH >11 IU/L suggests ovarian failure

• Estradiol: Measure between days 3-6 of the cycle 1, 2

  • LC-MS/MS methods provide more accurate measurements than older immunoassays
  • Levels peak at midcycle and remain elevated in mid-luteal phase

• Progesterone: Measure during mid-luteal phase (7 days before expected menses) 1

  • Levels <6 nmol/L indicate anovulation
  • Critical for confirming ovulation

• Prolactin: Measure morning resting levels (not post-ictal) 1

  • Values >20 μg/L are abnormal
  • May be mildly elevated in patients with epilepsy

Additional Important Tests

• Testosterone and SHBG: Measure between days 3-6 of the cycle 1
  • Free testosterone index (total testosterone/SHBG) <0.3 indicates hypogonadism
  • Morning samples are preferred due to diurnal variation 1
  • Testosterone >2.5 nmol/L may indicate PCOS or other androgen excess disorders

Specialized Testing Based on Clinical Presentation

For Suspected PCOS

• Androstenedione: Values >10.0 nmol/L warrant investigation for adrenal/ovarian tumors 1
• DHEAS: Elevated levels may indicate adrenal hyperplasia 1
• Fasting glucose/insulin ratio: Values >4 suggest insulin resistance 1
• Anti-Müllerian Hormone (AMH): Elevated in PCOS, with diagnostic thresholds varying by laboratory 1
  • Values >30 pmol/L have good sensitivity and specificity for PCOS diagnosis

For Suspected Thyroid Dysfunction

• Thyroid function tests: Important when evaluating reproductive disorders 1

For Suspected Vitamin D Deficiency

• 25-OH vitamin D: Particularly important in patients with chronic liver disease 1

Timing Considerations

1. Follicular Phase Testing (Days 3-6 of cycle):

   • LH, FSH, estradiol, testosterone, SHBG, androstenedione, DHEAS

2. Mid-Luteal Phase Testing (7 days before expected menses):

   • Progesterone (to confirm ovulation)

3. Any Time Testing (not cycle-dependent):

   • Prolactin, thyroid function tests, 25-OH vitamin D

Imaging Considerations

• Pelvic Ultrasound: Transvaginal preferred over transabdominal, performed between days 3-9 of cycle 1

  • 10 peripheral cysts (2-8mm) in one plane with ovarian stromal thickening suggests polycystic ovaries

• Pituitary MRI: Consider when prolactin is persistently elevated or with symptoms of pituitary dysfunction 1

Common Pitfalls to Avoid

1. Incorrect Timing: Hormone levels fluctuate throughout the menstrual cycle; incorrect timing leads to misinterpretation 3

2. Using Screening Questionnaires: These are not appropriate substitutes for laboratory testing 1

3. Relying on Single Measurements: Testosterone should be measured at least twice in early morning samples 1

4. Ignoring SHBG: Total testosterone alone is insufficient; SHBG must be considered for accurate assessment 1

5. Post-Ictal Prolactin Measurement: Can lead to falsely elevated results 1

6. Using Outdated Assay Methods: LC-MS/MS provides more accurate measurements than immunoassays, especially at low hormone levels 2

By following this structured approach to hormone testing in women, clinicians can accurately diagnose and manage conditions such as PCOS, premature ovarian failure, hyperprolactinemia, and other reproductive endocrine disorders.