When should hormone testing be done for females?

When to Perform Hormone Testing in Females

Hormone testing in females should be performed when there are specific clinical indications of hormonal dysfunction, such as menstrual irregularities, symptoms of premature ovarian insufficiency, or signs of androgen excess, rather than as routine screening. 1

Indications for Hormone Testing in Prepubertal and Adolescent Females

• Failure to initiate puberty by age 13 years requires laboratory evaluation of FSH and estradiol levels 1
• Failure to progress through puberty normally or arrested puberty development warrants hormone testing 1
• Prepubertal females age ≥11 years with delayed puberty should undergo laboratory evaluation 1
• Early-onset body odor, axillary or pubic hair, accelerated growth, advanced bone age, and genital maturation in prepubertal children may indicate hormonal abnormalities requiring testing 1

Indications for Hormone Testing in Adult Females

Menstrual Irregularities

• Primary amenorrhea (no menses by age 16 years) in the presence of other evidence of puberty 1
• Secondary amenorrhea (absence of menses for ≥4 months) 1
• Oligomenorrhea (irregular cycles or cycle length >35 days) 1
• Persistent oligomenorrhea 2-3 years beyond menarche 2

Signs of Androgen Excess

• Hirsutism (excessive facial or body hair) 1, 2
• Severe or treatment-resistant acne 1
• Androgenetic alopecia (male pattern hair loss) 1, 2
• Virilization (clitoromegaly, deepening voice, increased muscle mass) 2

Fertility Assessment

• Women with infertility concerns 3
• Women who desire assessment of potential future fertility after gonadotoxic treatments 1

Special Populations

• Cancer survivors treated with alkylating agents and/or radiotherapy that potentially exposed the ovaries 1
• Women with suspected premature ovarian insufficiency (POI) 1
• Patients receiving immune checkpoint inhibitor therapy who develop symptoms of hypophysitis 1

Recommended Hormone Tests

Basic Hormone Panel

• Follicle-stimulating hormone (FSH) and estradiol - recommended for initial evaluation of ovarian function 1
• Luteinizing hormone (LH) - useful for evaluating hypothalamic-pituitary-gonadal axis 1, 3
• Thyroid-stimulating hormone (TSH) and free T4 - to rule out thyroid dysfunction 1

Additional Tests Based on Clinical Presentation

• Anti-Müllerian hormone (AMH) - useful marker of ovarian reserve, especially in women ≥25 years 1
• Total and free testosterone - for evaluation of hyperandrogenism (free testosterone is more sensitive) 1, 2
• Dehydroepiandrosterone sulfate (DHEA-S) - for assessment of adrenal androgen production 1, 2
• Prolactin - when amenorrhea or galactorrhea is present 3

Timing of Hormone Testing

• FSH and estradiol should be measured during the early follicular phase (days 2-5) of the menstrual cycle in women with oligomenorrhea 1
• For women with amenorrhea, FSH and estradiol can be measured randomly 1
• Hormone testing should be performed after discontinuing oral contraceptives or hormone replacement therapy for at least two months 1, 4

Important Considerations and Pitfalls

• Fluctuations in hormone levels: Hormone levels, particularly AMH, may fluctuate throughout the menstrual cycle, especially in young women under 25 years 1
• Limitations of testing during perimenopause: During the menopausal transition, hormone levels (especially FSH and estradiol) can vary markedly, making them unreliable guides to menopausal status 5, 4
• Age-related considerations: Interpretation of hormone tests should consider the patient's age, as normal ranges vary throughout the lifespan 1, 5
• Assay sensitivity: Free testosterone should ideally be determined through equilibrium dialysis techniques for accurate assessment of androgen excess 2
• Avoid routine testing: Routine microbiologic or endocrinologic testing is not recommended for the majority of patients without specific symptoms 1

When to Refer to Specialists

• Refer to endocrinology/gynecology when prepubertal females have no signs of puberty by age 13 years with elevated FSH levels 1
• Refer to gynecology, endocrinology, and/or reproductive endocrinology for postpubertal females with menstrual dysfunction suggestive of POI 1
• Consider referral for all patients diagnosed with POI for consideration of hormone replacement therapy 1
• Refer to specialists when fertility preservation is desired after gonadotoxic treatments 1