What tests should be ordered to assess a female's hormone levels?

Hormone Testing for Female Patients

For female patients requiring hormone level assessment, a comprehensive panel should include luteinizing hormone (LH), follicle-stimulating hormone (FSH), estradiol, and prolactin as the core tests, with additional specialized testing based on specific clinical presentations. 1

Core Hormone Tests

• Luteinizing Hormone (LH) and Follicle-Stimulating Hormone (FSH): These gonadotropins should be measured between days 3-6 of the menstrual cycle for most accurate baseline assessment 1
• Estradiol: Should be measured alongside LH and FSH to evaluate ovarian function 1
• Prolactin: Essential for ruling out hyperprolactinemia, especially in patients with galactorrhea or irregular menses 2, 1

Clinical Indications for Hormone Testing

• Menstrual Irregularities: Order hormone levels for patients with polymenorrhea, oligomenorrhea, or amenorrhea 1
• Primary Amenorrhea: Comprehensive hormone panel needed if no menarche by age 16 1
• Secondary Amenorrhea: FSH, LH, estradiol, and prolactin should be ordered after 3 months without menses 2, 1
• Infertility Evaluation: Hormone testing recommended after 12 months of regular unprotected intercourse without conception 1
• Hyperandrogenism Signs: Total testosterone should be ordered for patients with hirsutism or acne with menstrual irregularity, as it's the most frequently abnormal biochemical marker (70%) in PCOS 1, 3
• Suspected Premature Ovarian Insufficiency: FSH and estradiol measurements required for women under 40 with menopausal symptoms 2, 1

Specialized Testing Based on Clinical Presentation

For PCOS Evaluation:

• Total Testosterone: Most sensitive single hormone test for PCOS diagnosis 3
• Androstenedione: Elevated in 53% of PCOS cases 3
• LH/FSH Ratio: Although traditionally used, this has low sensitivity (41-44%) and should not be used as the sole diagnostic criterion 3
• Sex Hormone Binding Globulin (SHBG): May be decreased in PCOS, particularly in patients with higher BMI 3

For Ovarian Reserve Assessment:

• Anti-Müllerian Hormone (AMH): Can be measured at any time during the cycle as it doesn't vary by menstrual day or with exogenous hormones 2, 1
• Inhibin B: May provide additional information on ovarian status in certain populations 2

For Suspected Pituitary Disorders:

• Prolactin: Should be measured in patients with low testosterone and low/normal LH levels 2
• Pituitary MRI: Consider for patients with significantly elevated prolactin or very low hormone levels 2

Special Populations

• Cancer Survivors: Regular hormone monitoring recommended for those treated with alkylating agents or radiation 2, 1
• Adolescents: Baseline LH, FSH, and estradiol levels should be assessed at age 13 years in at-risk patients 2, 1
• Perimenopausal Women: FSH and estradiol measurements help determine menopausal status 2

Common Pitfalls to Avoid

• Timing Issues: Hormone levels fluctuate throughout the menstrual cycle; inappropriate timing can lead to misinterpretation 1, 4
• Hormonal Contraceptive Use: Measuring hormone levels during use of hormonal contraceptives may mask underlying abnormalities 2, 1
• Assay Variability: Different assay methods can yield significantly different absolute values for the same hormones 3, 4
• Isolated Testing: Using single hormone tests (especially LH/FSH ratio) without clinical context can lead to misdiagnosis 3
• Failure to Consider Age: Normal hormone levels change with age; FSH begins to rise significantly after approximately age 43 5

Test Interpretation Guidelines

• For PCOS diagnosis, a combination of testosterone, androstenedione, and LH testing provides the highest sensitivity (86%) 3
• Two elevated FSH levels in the menopausal range are required for diagnosis of premature ovarian insufficiency 1
• Morning testosterone measurements are preferred due to diurnal variations 1
• Estradiol levels below 20 pg/mL with elevated FSH suggest ovarian insufficiency 2