What is the initial approach to a female hormone workup?

Initial Approach to a Female Hormone Workup

A complete female hormone workup should include assessment of testosterone, free testosterone, estradiol, follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin, and thyroid-stimulating hormone (TSH), with timing of collection optimally performed between days 2-4 of the menstrual cycle for accurate assessment of ovarian reserve.

Core Hormonal Assessment

Baseline Hormonal Panel

• FSH and LH: Measure between days 2-4 of menstrual cycle

  • FSH >10 IU/L may indicate diminished ovarian reserve
  • FSH >40 IU/L is diagnostic of premature ovarian insufficiency (POI) or menopause 1
  • LH:FSH ratio >2 suggests PCOS, while ratio ≤1 may indicate functional hypothalamic amenorrhea 1

• Estradiol: Best assessed between days 9-11 of cycle for interindividual differences 2

  • Low levels may indicate ovarian insufficiency
  • High levels may suggest estrogen-producing tumors

• Testosterone and Free Testosterone: To evaluate hyperandrogenism

  • Elevated levels suggest PCOS or other androgen-excess disorders 1

• Prolactin: To rule out hyperprolactinemia

  • Elevated levels may indicate pituitary adenoma or medication effect

• TSH: To exclude thyroid dysfunction that can mimic reproductive disorders 1

Timing Considerations

• Hormone levels fluctuate throughout the menstrual cycle
• For accurate assessment of ovarian reserve, FSH should be measured between days 2-4 of the cycle 1
• Progesterone is best assessed between days 17-21 (mid-luteal phase) 2
• For women with irregular cycles, random sampling may be necessary, but interpretation should consider cycle irregularity

Additional Evaluations Based on Clinical Presentation

For Suspected PCOS

• Complete metabolic panel including glucose tolerance test and lipid profile
• Transvaginal ultrasound to assess ovarian morphology (≥12 follicles measuring 2-9mm in diameter) 1

For Suspected Premature Ovarian Insufficiency

• Anti-Müllerian Hormone (AMH) to assess ovarian reserve
  • AMH correlates well with antral follicle count and is better than age, basal FSH, estradiol, and inhibin B 3
  • AMH generally doesn't vary by menstrual day or use of exogenous hormones

For Suspected Adrenal Disorders

• Morning cortisol and ACTH levels
• Consider standard dose ACTH stimulation test for indeterminate results 3

Clinical Assessment Components

History

• Menstrual history (age at menarche, regularity, duration, flow)
• Pregnancy history (gravidity, parity)
• Symptoms of hormone imbalance (hot flashes, vaginal dryness, hirsutism, acne)
• Medication history (including hormonal contraceptives)
• Family history of reproductive or endocrine disorders

Physical Examination

• BMI calculation
• Vital signs including blood pressure
• Assessment for hirsutism, acne, male-pattern baldness
• Breast examination
• Pelvic examination when indicated

Imaging Studies

When Indicated

• Transvaginal ultrasound: For assessment of ovarian morphology, endometrial thickness, and to rule out structural abnormalities
• Pelvic MRI: For further evaluation of suspected pituitary or adrenal abnormalities
• Bone mineral density testing: For patients with suspected hypogonadism 3

Common Pitfalls and Caveats

1. Timing errors: Incorrect cycle day for hormone measurement can lead to misinterpretation

   • FSH should be measured on days 2-4 of cycle for accurate assessment 1
   • Progesterone should be measured mid-luteal phase (days 17-21) 2

2. Contraceptive influence: Hormonal contraceptives alter endogenous hormone levels

   • Discontinue hormonal contraceptives for at least one month before testing
   • Document type and duration of hormonal contraceptive use 3

3. Stress effects: Acute stress can alter hormone levels

   • Consider repeat testing if results are inconsistent with clinical presentation

4. Interpretation without clinical context: Hormone levels should always be interpreted in the context of symptoms and clinical findings

   • Isolated abnormal values may not be clinically significant

Referral Considerations

• Refer to endocrinology for delayed puberty, persistently abnormal hormone levels, or hypogonadism 3
• Refer to reproductive endocrinology for infertility evaluation and consultation on assisted reproduction 3
• Consider gynecology referral for structural abnormalities or complex hormonal issues

By following this systematic approach to female hormone workup, clinicians can accurately diagnose and manage various reproductive and endocrine disorders affecting women's health.