Are estrogen levels of 95, Follicle-Stimulating Hormone (FSH) levels of 3.6, progesterone levels of 8.7, testosterone levels of 19, and Sex Hormone-Binding Globulin (SHBG) levels of 19 within normal range for a 46-year-old female experiencing fatigue?

Hormone Levels Assessment in a Fatigued 46-Year-Old Female

Your SHBG level of 19 nmol/L is abnormally low and likely contributing to your fatigue, while your other hormone levels suggest you are in perimenopause with fluctuating ovarian function that requires further evaluation and monitoring.

Critical Finding: Low SHBG

• Your SHBG of 19 nmol/L is significantly below the normal range (typically 30-100 nmol/L for premenopausal women), which can profoundly impact how sex hormones function in your body 1, 2.
• Low SHBG is associated with increased free (bioavailable) testosterone and estrogen, which paradoxically can lead to symptoms of hormonal imbalance including fatigue, despite seemingly "normal" total hormone levels 3.
• This low SHBG warrants investigation for underlying metabolic conditions including insulin resistance, obesity, hypothyroidism, and polycystic ovary syndrome, all of which can cause or worsen fatigue 2, 4.

Estrogen and FSH: Perimenopausal Pattern

• Your estrogen level of 95 pg/mL with FSH of 3.6 mIU/mL suggests you are still having ovarian function but likely in perimenopause, as FSH levels fluctuate widely during this transition 5.
• FSH and estradiol should be interpreted in the context of your menstrual cycle timing and clinical symptoms, as these values vary dramatically throughout the cycle and between cycles during perimenopause 5, 6.
• A single FSH measurement of 3.6 mIU/mL is in the normal follicular phase range, but perimenopausal women can have normal FSH one month and elevated FSH the next 5.
• Serial measurements are needed if you're experiencing irregular cycles or vasomotor symptoms to better characterize your menopausal status 5.

Progesterone Interpretation

• Your progesterone level of 8.7 ng/mL suggests either mid-luteal phase of an ovulatory cycle or early luteal phase with suboptimal corpus luteum function 7.
• If this was drawn mid-luteal phase (approximately 7 days after ovulation), a level of 8.7 ng/mL is borderline low, as robust ovulation typically produces progesterone >10 ng/mL 7.
• Low progesterone relative to estrogen can contribute to fatigue, mood changes, and other symptoms commonly attributed to "estrogen dominance" 7.

Testosterone Assessment

• Your testosterone level of 19 ng/dL appears to be in the lower range for premenopausal women (normal range typically 15-70 ng/dL) 3.
• However, with your low SHBG of 19, your free testosterone is likely higher than expected, which requires calculation of the free androgen index (total testosterone/SHBG × 100) 3, 4.
• Your free androgen index would be approximately 100, which is actually elevated (normal <5-7), suggesting you may have relative androgen excess despite seemingly low total testosterone 4.

Clinical Implications for Your Fatigue

Your fatigue is unlikely to be solely explained by sex hormone deficiency; instead, the low SHBG pattern suggests metabolic dysfunction that requires comprehensive evaluation:

• Check fasting insulin, glucose, hemoglobin A1c, and thyroid function (TSH, free T4) to evaluate for insulin resistance and hypothyroidism, both common causes of low SHBG and fatigue 3.
• Evaluate for other causes of fatigue including anemia (complete blood count), vitamin D deficiency, vitamin B12 deficiency, and sleep disorders 5.
• Consider checking morning cortisol to rule out adrenal insufficiency, particularly if you have other symptoms like orthostatic hypotension or salt craving 3.

Recommended Next Steps

• Repeat FSH and estradiol on cycle day 2-4 (if you're still cycling) to better assess ovarian reserve and perimenopausal status 5.
• Measure free testosterone by equilibrium dialysis rather than relying on calculated values, as this is the gold standard 3.
• Address the low SHBG through lifestyle modifications including weight loss if overweight, exercise, and dietary changes to improve insulin sensitivity 3.
• If metabolic workup is normal and symptoms persist, consider trial of cyclic progesterone during luteal phase to address potential progesterone insufficiency 7.

Important Caveats

• Hormone levels represent a single snapshot in time and can vary significantly day-to-day during perimenopause 5, 6.
• SHBG levels can be influenced by oral estrogen therapy, liver disease, and thyroid disorders, so these must be excluded 2, 7.
• Do not initiate hormone replacement therapy based solely on these values without comprehensive evaluation of symptoms, menstrual pattern, and metabolic status 5.
• The relationship between SHBG and fatigue is complex and often mediated through metabolic dysfunction rather than direct hormonal effects 3.