What hormone levels would you expect to see in a woman who needs hormone replacement therapy (HRT)?

Hormone Levels Expected in Women Who Need HRT

Women who need hormone replacement therapy typically show FSH levels >30 IU/L, estradiol levels <20-30 pg/mL, and may have elevated LH levels, indicating declining ovarian function. 1

Diagnostic Hormone Patterns

Primary Indicators

• FSH (Follicle Stimulating Hormone):

  • Elevated levels >30 IU/L
  • Significant fluctuations during perimenopause
  • More consistently elevated in established menopause 1

• Estradiol:

  • Low levels <20-30 pg/mL
  • Declining but fluctuating levels during perimenopause
  • More consistently low in established menopause 1

• LH (Luteinizing Hormone):

  • Elevated levels, often paralleling FSH increases
  • Used to evaluate ovarian function 1

Secondary Indicators

• Anti-Müllerian Hormone (AMH):

  • Advantages over traditional markers:
    • Doesn't vary by menstrual day
    • Not affected by exogenous hormones
    • Correlates well with antral follicle count
  • Very low levels indicate ovarian insufficiency
  • May predict timing of menopause onset 1, 2

• Prolactin:

  • Should be normal (elevated levels suggest hyperprolactinemia as an alternative diagnosis) 1

• Thyroid Function (TSH):

  • Should be normal (thyroid dysfunction can mimic menopausal symptoms) 1

Hormone Patterns by Menopausal Stage

Perimenopause

• Wide hormonal fluctuations
• Irregular menstrual cycles
• FSH levels beginning to rise but fluctuating (10-30 IU/L)
• Estradiol levels fluctuating but trending downward
• Declining but not absent fertility 1, 2

Established Menopause

• Consistently elevated FSH (>30-40 IU/L)
• Consistently low estradiol (<20 pg/mL)
• Complete cessation of menses for ≥12 months 2

Premature Ovarian Insufficiency (POI)

• FSH >40 IU/L on two occasions 4-6 weeks apart
• Estradiol <20 pg/mL
• Occurring before age 40
• Often requiring higher doses of HRT than natural menopause 2

Clinical Correlation

The hormone level changes correlate with various symptoms requiring HRT:

• Vasomotor symptoms (hot flashes, night sweats) correlate with fluctuating and declining estrogen levels 2

• Bone density loss begins with declining estrogen, with 2% annual loss during the first 5 years post-menopause, followed by 1% annual loss thereafter 2

• Irregular bleeding patterns reflect the hormonal fluctuations of perimenopause 1

• Genitourinary symptoms (vaginal dryness, urinary symptoms) correlate with consistently low estrogen levels 1

Important Considerations

• Single hormone measurements may be misleading due to significant fluctuations during perimenopause 1

• Hormone levels should be interpreted alongside clinical symptoms 1

• Women with intact uterus require both estrogen and progestogen therapy to prevent endometrial hyperplasia 1, 3

• Transdermal estrogen administration may be preferable as it bypasses first-pass liver metabolism and reduces thromboembolism risk 2, 1

• Low-dose HRT (e.g., 25-50 μg/day transdermal 17β-estradiol) is often effective for symptom control while minimizing side effects 4, 5, 6

Hormone testing before initiating HRT helps confirm the diagnosis, rule out other conditions with similar presentations, and establish baseline levels for monitoring treatment effectiveness.