When should hormone levels be ordered in a female patient?

When to Order Hormone Levels in Female Patients

Hormone levels should be ordered in female patients who present with specific clinical symptoms or signs of reproductive endocrine disorders, including menstrual irregularities, infertility, hirsutism, galactorrhea, or symptoms of premature ovarian insufficiency. 1

Clinical Indications for Hormone Testing

Menstrual Irregularities

• Order hormone levels when patients present with:
  • Polymenorrhea (cycles <23 days) 1
  • Oligomenorrhea (cycles >35 days) 1
  • Amenorrhea (no bleeding for >6 months) 1
  • Primary amenorrhea (no menarche by age 16) 1

Delayed or Abnormal Puberty

• Baseline LH, FSH, and estradiol levels should be assessed at age 13 years in at-risk patients 1
• Order hormone tests for:
  • Absence of breast development (Tanner stage 2) by age 13 1
  • Failure to progress in pubertal stage for ≥12 months 1
  • Accelerated puberty (before age 8 years) - requires FSH, LH, and estradiol testing 1

Infertility

• Order hormone levels after 12 months of regular unprotected intercourse without conception 1
• Testing should include:
  • LH and FSH (measured between days 3-6 of cycle) 1
  • Estradiol 1
  • Progesterone (mid-luteal phase) 1

Signs of Hyperandrogenism

• Order hormone levels for:
  • Hirsutism (male pattern hair growth) 1
  • Acne with menstrual irregularity 1
  • Testing should include:
    • Total testosterone (days 3-6 of cycle) 1
    • DHEAS (to rule out adrenal causes) 1
    • Androstenedione (if suspecting ovarian/adrenal tumor) 1

Galactorrhea

• Order prolactin levels for:
  • Spontaneous milk expression in non-lactating women 1
  • Crusting on nipples 1
  • Morning resting levels (not postictal) should be measured 1

Suspected Premature Ovarian Insufficiency (POI)

• Order hormone levels for:
  • Secondary amenorrhea in women under 40 years 1
  • Symptoms of estrogen deficiency (hot flashes, vaginal dryness) 1
  • History of gonadotoxic treatments (alkylating agents, radiation) 1
  • Testing should include:
    • FSH and estradiol (if amenorrheic, measure randomly; if oligomenorrheic, measure during early follicular phase) 1

Special Populations Requiring Hormone Testing

Cancer Survivors

• Order hormone levels in:
  • Female survivors treated with alkylating agents (especially cyclophosphamide, procarbazine) 1
  • Patients who received radiation to fields including the ovaries 1
  • Patients with cranial irradiation ≥30 Gy (risk of central hypogonadism) 1

Patients with Epilepsy

• Order hormone levels in:
  • Women with epilepsy who have menstrual irregularities 1
  • Patients on valproate therapy (increased risk of PCOS) 1
  • Testing should include LH/FSH ratio, testosterone, and prolactin 1

Perimenopausal Women

• Hormone testing generally not recommended for routine assessment of menopausal status 2
• Consider testing in:
  • Women with atypical symptoms or premature menopause (before age 40) 3
  • Women with severe vasomotor symptoms not responding to therapy 3

Specific Hormone Tests and Timing

For PCOS Evaluation

• LH, FSH (calculation based on average of three estimations taken 20 minutes apart between days 3-6 of cycle) 1
• Testosterone (day 3-6 of cycle) - most frequently abnormal marker (70% sensitivity) 4
• Androstenedione - second most useful marker (53% sensitivity) 4
• Glucose/insulin ratio (fasting, morning levels) 1

For Ovarian Reserve Assessment

• Anti-Müllerian hormone (AMH) - does not vary by menstrual day and is not affected by exogenous hormones 1
• FSH (early follicular phase) - increases years before clinical signs of approaching menopause 3
• Inhibin B - reflects decline in ovarian follicle numbers 3, 2

For Premature Ovarian Insufficiency

• FSH and estradiol measurements should be performed after stopping oral contraceptives/hormone replacement therapy, ideally after two months 1
• Diagnosis requires two elevated serum FSH levels in the menopausal range 1

Common Pitfalls to Avoid

• Relying solely on LH/FSH ratio for PCOS diagnosis (low sensitivity of 41-44%) 4
• Measuring hormone levels during use of hormonal contraceptives or HRT (may mask underlying abnormalities) 1
• Interpreting single hormone measurements during perimenopause (levels fluctuate markedly) 3, 2
• Failing to consider diurnal variations (testosterone should be measured in the morning) 1
• Assuming regular menstrual cycles indicate normal fertility in cancer survivors 1

Remember that hormone levels should be interpreted in the context of the clinical presentation, and normal ranges may vary between laboratories 1, 5.