What hormones should a patient test for to assess ovarian function and hormonal balance?

Hormonal Testing to Assess Ovarian Function and Hormonal Balance

For comprehensive assessment of ovarian function and hormonal balance, measure FSH, LH, estradiol, and progesterone on cycle days 2-5 (early follicular phase), with mid-luteal progesterone (day 21 or 7 days post-ovulation) to confirm ovulation. 1, 2

Core Hormone Panel for Ovarian Function Assessment

Early Follicular Phase Testing (Days 2-5)

• FSH (Follicle-Stimulating Hormone): Essential baseline marker of ovarian reserve and function 1, 2

  • FSH >35 IU/L indicates ovarian failure 1, 2
  • Rising FSH with age reflects declining ovarian reserve even before menopause 3
  • Best measured on days 1-2 for optimal predictive value 4

• LH (Luteinizing Hormone): Critical for distinguishing ovarian dysfunction patterns 1, 2

  • LH >11 IU/L combined with elevated FSH confirms ovarian failure 1, 2
  • LH:FSH ratio >2 indicates polycystic ovary syndrome (PCOS) with ovarian hyperandrogenism 1, 2
  • LH <7 IU/mL suggests hypothalamic dysfunction 2

• Estradiol: Provides feedback status and ovarian estrogen production 1, 2

  • Suppressed FSH/LH with adequate estradiol indicates functional ovarian activity 1
  • Rising estradiol in older reproductive age women reflects compensatory mechanisms 4

Mid-Luteal Phase Testing (Day 21 or ~7 Days Post-Ovulation)

• Progesterone: The most reliable hormonal indicator of ovulation 2
  • Progesterone <6 nmol/L indicates anovulation 2
  • Must be timed correctly to mid-luteal phase for accurate interpretation 2

Additional Androgens for Complete Assessment

When Hyperandrogenism or PCOS is Suspected

• DHEA-S (Dehydroepiandrosterone Sulfate): Most reliable marker of adrenal androgen production 1

  • Exclusively produced by adrenal glands, distinguishes adrenal from ovarian androgen sources 1
  • Elevated DHEA-S (age-adjusted) indicates adrenal contribution to androgen pool 1
  • Normal/low DHEA-S with elevated testosterone suggests ovarian androgen production 1

• Total Testosterone: Best single biochemical marker for PCOS 5

  • Abnormal in 70% of PCOS cases, making it the most sensitive single test 5
  • Combined with DHEA-S, distinguishes ovarian versus adrenal hyperandrogenism 1

Critical Timing and Technical Considerations

Optimal Sample Collection

• Baseline measurements should be averaged from three samples taken 20 minutes apart for most accurate FSH and LH assessment 2
• Early follicular phase (days 2-5) provides baseline when hormones are least variable 2
• For irregular cycles, Anti-Müllerian Hormone (AMH) can be measured any time as it doesn't vary by cycle day 2

Common Pitfalls to Avoid

• Do not assess FSH/LH in women on hormonal contraceptives without stopping them at least 2 months prior 2
• Timing is critical: Mid-luteal progesterone must be measured approximately 7 days after suspected ovulation, not randomly 2
• In premenopausal women on aromatase inhibitors, FSH/LH can be paradoxically elevated due to stimulation of ovarian function; estradiol measurement is mandatory to confirm adequate suppression 6, 1
• Serial testing is required when assessing menopausal status after chemotherapy or during ovarian suppression therapy, as single measurements are unreliable 6

Algorithmic Interpretation Framework

Step 1: Assess Ovarian Function Status

• If FSH >35 IU/L AND LH >11 IU/L: Ovarian failure confirmed 1, 2
• If LH:FSH ratio >2: PCOS pattern with ovarian hyperandrogenism 1, 2
• If FSH and LH suppressed: Either adequate ovarian function or exogenous hormones 1

Step 2: Confirm Ovulation

• Mid-luteal progesterone <6 nmol/L: Anovulation confirmed 2
• Mid-luteal progesterone ≥6 nmol/L: Ovulation confirmed 2

Step 3: Determine Androgen Source (If Elevated)

• Elevated DHEA-S (age-adjusted): Adrenal contribution significant 1
• Normal/low DHEA-S with elevated testosterone: Ovarian source dominant 1
• Both elevated: Mixed adrenal and ovarian hyperandrogenism 1

Special Population Considerations

Premenopausal Women Post-Chemotherapy

• Cannot determine menopausal status while on ovarian suppression 6
• Serial assessment of LH, FSH, and estradiol is mandatory before considering aromatase inhibitor therapy 6
• Frequency of testing should be individualized but is essential to prevent treatment failure 6

Women Under Age 60 with Amenorrhea

• Monitor estradiol and FSH/LH if amenorrheic ≤12 months prior to endocrine therapy 6
• Test before each GnRH agonist dose, particularly in women under 45 years 6