When are hormone lab tests recommended for females and what tests are included?

Hormone Testing in Females: Clinical Indications and Recommended Panels

Hormone testing in females should be performed for specific clinical indications—menstrual irregularities, delayed puberty, signs of androgen excess, or suspected ovarian insufficiency—rather than as routine screening. 1, 2

When to Order Hormone Testing

Prepubertal and Adolescent Females

• Measure FSH and estradiol if no signs of puberty by age 13 years, as this represents the critical threshold requiring evaluation 1, 2
• Evaluate females age ≥11 years with delayed puberty who show early-onset body odor, axillary or pubic hair, accelerated growth, advanced bone age, or genital maturation 1, 2

Adult Females with Menstrual Irregularities

• Primary amenorrhea (no menses by age 16 years with other signs of puberty present) requires hormone testing 2
• Secondary amenorrhea (absence of menses for ≥4 months) warrants hormone evaluation 1, 2
• Oligomenorrhea (irregular cycles or cycle length >35 days) should be evaluated with hormone testing 1, 2

Signs of Androgen Excess

• Test postpubertal females presenting with hirsutism, androgenetic alopecia, infertility, polycystic ovaries, clitoromegaly, or truncal obesity 1
• Important historical features include onset and duration of androgen excess signs, menstrual history, medication use (including exogenous androgens), and family history of cardiovascular disease and diabetes 3
• Physical examination should assess for acne, balding, clitoromegaly, body hair distribution, ovarian enlargement, and signs of insulin resistance such as obesity or acanthosis nigricans 3

Recommended Hormone Panel

Core Reproductive Hormones

• FSH and estradiol should be measured during the early follicular phase (days 2-5) in women with oligomenorrhea 1, 2
• For women with amenorrhea, FSH and estradiol can be measured randomly 2
• LH is useful for evaluating the hypothalamic-pituitary-gonadal axis 1, 2

Essential Screening Tests

• TSH and free T4 should be measured to rule out thyroid dysfunction, as both hyperthyroidism and hypothyroidism can impair ovarian function 1, 2
• Prolactin level should be measured to exclude hyperprolactinemia 3

Androgen Assessment (When Indicated)

• Total testosterone or bioavailable/free testosterone levels should be measured when evaluating ovarian hyperandrogenism 3
• These tests help exclude androgen-secreting tumors, nonclassic congenital adrenal hyperplasia, and other causes of androgen excess 3

Metabolic Screening in PCOS

• All women with PCOS should undergo a two-hour oral glucose tolerance test (75-gram glucose load) due to increased risk of type 2 diabetes 3
• Fasting lipid profile including total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides should be measured, as women with PCOS frequently have dyslipidemia 3

Critical Timing and Preparation Considerations

Menstrual Cycle Timing

• Timing matters significantly: FSH and estradiol must be drawn during days 2-5 of the menstrual cycle for accurate interpretation in women with oligomenorrhea 1, 2
• Hormone markers vary throughout the menstrual cycle, affecting interpretation 1

Hormonal Contraceptive Use

• Women on hormonal contraceptives should discontinue them at least 2 months before testing if assessing baseline reproductive function 1
• Hormonal contraceptives and sex steroid replacement therapy significantly affect hormone marker levels 1

Age-Related Interpretation

• Normal hormone ranges vary throughout the lifespan, requiring age-appropriate interpretation 2
• AMH levels may fluctuate throughout the menstrual cycle, particularly in women under 25 years 2

Common Pitfalls to Avoid

• Do not perform routine hormone screening in asymptomatic women—testing should be driven by specific clinical indications 2
• Avoid testing during random cycle days when follicular phase timing is required, as this renders results uninterpretable 1, 2
• Do not overlook thyroid dysfunction, as it can mimic primary ovarian disorders and is a reversible cause of menstrual irregularities 3, 2
• Consider Cushing's syndrome in women with coexisting buffalo hump, moon facies, hypertension, abdominal striae, centripetal fat distribution, easy bruising, or proximal myopathies 3
• In women with acanthosis nigricans, consider associated insulinoma or malignancy, particularly gastric adenocarcinoma 3

When to Refer to Specialists

• Refer prepubertal females with no signs of puberty by age 13 years and elevated FSH levels to endocrinology or gynecology 1, 2
• Refer postpubertal females with menstrual dysfunction suggestive of premature ovarian insufficiency (POI) to endocrinology or gynecology 1, 2
• Consider referral for all patients diagnosed with POI for hormone replacement therapy consideration 1, 2
• Cancer survivors treated with alkylating agents or radiotherapy potentially exposing the ovaries should undergo hormone testing and specialist referral 2