What hormone tests should be ordered for females requesting hormone testing?

Hormone Testing for Females: A Structured Approach

When females request hormone testing, a targeted approach based on specific symptoms and clinical presentation is recommended rather than routine comprehensive hormone panels.

Initial Assessment

Determine the Clinical Context

• Evaluate for specific symptoms suggesting hormonal imbalance:
  • Menstrual irregularities (oligomenorrhea, amenorrhea)
  • Signs of hyperandrogenism (hirsutism, acne)
  • Menopausal symptoms
  • Fertility concerns
  • Bone health concerns

Key Hormonal Tests Based on Clinical Presentation

For Suspected PCOS

• LH and FSH levels (between days 3-6 of menstrual cycle) 1, 2
  • LH:FSH ratio >2 suggests PCOS
  • LH:FSH ratio ≤1 suggests functional hypothalamic amenorrhea
• Total testosterone or bioavailable/free testosterone levels 1
• Consider fasting glucose and lipid profile (due to associated metabolic risks) 1

For Suspected Primary Ovarian Insufficiency (POI)

• FSH and LH (elevated levels on two occasions 4-6 weeks apart) 2
• Estradiol (typically low) 2
• Consider anti-Müllerian hormone (AMH) to assess ovarian reserve

For Menopausal Symptoms

• FSH and estradiol to confirm menopause status 3
• Avoid routine testing in women over 45 with typical menopausal symptoms

For Suspected Thyroid Disorders

• TSH and free T4 1

For Suspected Hyperprolactinemia

• Prolactin level 1

Special Considerations

Bone Health Assessment

• For patients with risk factors for osteoporosis:
  • 25-hydroxyvitamin D level 1
  • Consider calcium levels 1
  • Consider bone density testing for high-risk individuals

Secondary Causes of Hormonal Imbalance

• For patients with suspected adrenal disorders:
  • Morning cortisol and ACTH 1
  • Consider ACTH stimulation testing for indeterminate results 1

Fertility Concerns

• For women with fertility issues:
  • Day 3 FSH, LH, estradiol
  • AMH for ovarian reserve assessment
  • Consider progesterone level in luteal phase

Common Pitfalls to Avoid

• Ordering comprehensive hormone panels without clinical indication: This can lead to incidental findings, unnecessary follow-up testing, and patient anxiety
• Failure to time hormone tests appropriately: Many reproductive hormones fluctuate throughout the menstrual cycle; testing at the wrong time can lead to misleading results
• Overlooking non-hormonal causes: Many symptoms attributed to hormonal imbalances may have other etiologies
• Not considering medication effects: Some medications can affect hormone levels and should be considered when interpreting results

Algorithm for Hormone Testing in Females

1. For irregular menstrual cycles:

   • First-line: LH, FSH, estradiol, testosterone, TSH, prolactin 1
   • Second-line (based on initial results): DHEAS, 17-hydroxyprogesterone, androstenedione

2. For menopausal symptoms:

   • Women >45 years with typical symptoms: Clinical diagnosis without testing
   • Women <45 years or atypical presentation: FSH, estradiol 3

3. For fertility assessment:

   • Day 3 FSH, LH, estradiol, AMH
   • Mid-luteal phase progesterone

4. For suspected endocrine disorders:

   • Targeted testing based on specific suspected condition
   • Consider referral to endocrinology for complex cases 1

By following this structured approach, clinicians can provide appropriate hormone testing that addresses patients' concerns while avoiding unnecessary testing.