What is the approach to hormone testing and treatment in women?

Approach to Hormone Testing and Treatment in Women

Hormone testing and treatment in women should be guided by specific clinical presentations, with testing reserved for those with symptoms or risk factors indicating potential hormonal imbalances rather than as routine screening.

Initial Assessment and Indications for Testing

• Hormone testing should be targeted based on specific symptoms and clinical presentations rather than performed routinely 1, 2
• For menstrual irregularities, evaluate menstrual history, pregnancy history, and sexual difficulties or changes 1
• Primary amenorrhea evaluation should begin by age 15 if other pubertal development is normal, or by age 13 if no pubertal development is present 1
• Secondary amenorrhea warrants evaluation after 3 consecutive missed periods or 6-8 menses over 12 months 1
• In prepubertal survivors of childhood cancer, onset and tempo of puberty should be evaluated annually until sexual maturity 1

Specific Hormone Testing Recommendations

• For amenorrhea or irregular menses, test FSH, LH, estradiol, TSH, and prolactin as first-line laboratory evaluation 1
• For suspected hyperandrogenism, measure free and total testosterone, DHEA-S, and androstenedione 1
• Anti-Müllerian hormone (AMH) shows promise as a predictor of ovarian reserve and timing of menopause onset, especially in cancer survivors 1
• Bone mineral density testing should be considered for women with hypogonadism or amenorrhea lasting >6 months 1
• For women with clinical signs of PCOS, testing should include free and total testosterone, DHEA-S, androstenedione, LH, and FSH 1

Special Populations Requiring Hormone Testing

• Female athletes with amenorrhea should be evaluated for the female athlete triad (low energy availability, menstrual dysfunction, and low bone mineral density) 1
• Cancer survivors require monitoring of reproductive function with baseline LH, FSH, and estradiol levels by age 13 1
• Women with premature ovarian insufficiency (menopause before age 40) require comprehensive hormone evaluation and consideration for hormone replacement therapy 2
• Transgender women/transfeminine individuals undergoing gender-affirming hormone therapy require monitoring of testosterone (<50 ng/dL) and estradiol levels 1
• Women with acne and signs of hyperandrogenism warrant endocrinologic testing, particularly if accompanied by irregular menses, hirsutism, or other signs of androgen excess 1

Hormone Treatment Approaches

• For menopausal symptoms, hormone therapy decisions should be based on symptom severity, age, time since menopause, and individual risk factors 1, 2
• FDA-approved indications for hormone therapy in postmenopausal women are limited to treatment of menopausal symptoms and prevention of osteoporosis, not for primary prevention of chronic conditions 1
• Women with premature ovarian insufficiency should continue HRT until at least the average age of natural menopause to reduce osteoporosis risk 2
• For women with intact uterus, progestogen must be given with estrogen to protect the endometrium 2
• Transdermal estrogen administration should be considered for women with hypertension or increased thrombotic risk 2

Monitoring During Hormone Treatment

• Annual clinical review is recommended for women using hormone therapy 2
• For transgender hormone therapy, monitor for changes in body composition, hemoglobin levels, and development of secondary sex characteristics 1
• For women with amenorrhea due to hypothalamic dysfunction, monitor bone mineral density 1
• Women on combined estrogen-progestin therapy should be monitored for increased risk of breast cancer with longer duration of use 1
• Regular reassessment of risk-benefit ratio is mandatory for women on hormone therapy 2, 3

Common Pitfalls to Avoid

• Initiating hormone therapy solely for prevention of chronic conditions rather than symptom management 2
• Not considering transdermal estrogen for women with hypertension or increased thrombotic risk 2
• Failing to provide progesterone with estrogen in women with intact uterus 2
• Not discussing modest but real risks of hormone therapy, including potential for stroke, venous thromboembolism, and breast cancer with long-term use 2
• Overlooking the need for hormone therapy in women with premature ovarian insufficiency 2

Risk-Benefit Assessment for Hormone Therapy

• Benefits include relief of vasomotor symptoms, prevention of bone loss, and improved genitourinary symptoms 3
• Risks include small increased risk of stroke and breast cancer with long-term estrogen-progestin use 1, 3
• Healthy women who begin hormone therapy soon after menopause generally receive more benefit than harm 3
• Women with premature menopause who begin hormone therapy before age 50 appear to have significant advantages in terms of longevity 3
• Hormone therapy should be prescribed at the lowest effective dose for the shortest duration consistent with treatment goals and individual risk assessment 1