Hormone Testing in Women Without a Uterus
In a woman without a uterus (post-hysterectomy), check FSH and estradiol as the primary hormone panel, with additional testing for LH, prolactin, and thyroid function (TSH) when clinically indicated. 1
Core Hormone Panel
FSH and estradiol form the essential diagnostic assessment for determining menopausal status in post-hysterectomy women, as these directly reflect ovarian function without the confounding factor of menstrual bleeding patterns. 1 Since you cannot rely on menstrual history to assess menopausal status in these women, hormone levels become particularly important. 2
- FSH: Primary marker that rises 10-15 fold after menopause 3
- Estradiol: Must be measured concurrently with FSH to provide context for ovarian function 1
- LH: Check when clinically indicated to provide additional information about ovarian status 1, 2
- Prolactin: Measure when indicated to exclude other causes of hormonal dysfunction 1, 2
Essential Additional Testing
Thyroid function tests are critical and should be checked in all women because thyroid disease commonly mimics menopausal symptoms and must be excluded before attributing symptoms solely to menopause. 3, 1 This is particularly important since you lack menstrual patterns as a clinical guide.
- TSH (and free T4 if abnormal): Essential for all symptomatic women 3, 1
- Anti-Müllerian hormone (AMH): May provide additional information on ovarian reserve, though it should not be used alone and normative data are limited 1, 2
Interpretation Criteria for Menopause
For women under age 60 who have had a hysterectomy, both FSH and estradiol must be in the postmenopausal range to confirm menopause. 3, 2 The specific criteria are:
- Age ≥60 years: Can be considered postmenopausal without testing 3
- Age <60 years: Requires FSH and estradiol both in postmenopausal range 3, 2
- Prior bilateral oophorectomy: Automatically postmenopausal regardless of hormone levels 3
Critical Caveats and Pitfalls
FSH is unreliable and cannot be interpreted accurately in several clinical scenarios that you must recognize:
- Women taking tamoxifen or toremifene 3, 1, 2
- Women receiving LHRH agonists or antagonists (menopausal status cannot be determined at all in these patients) 3, 1, 2
- Women with prior chemotherapy or pelvic radiation 3
Amenorrhea after chemotherapy does not confirm menopause, as ovarian function may resume despite absent menses—though this is less relevant in hysterectomy patients, it matters if they had chemotherapy before or after hysterectomy. 3, 1, 2
When to Perform Testing
Hormone testing should be performed in the following clinical scenarios:
- Vasomotor symptoms (hot flashes, night sweats) disrupting quality of life 1, 2
- Before initiating hormone therapy to establish baseline status 1, 2
- After chemotherapy or pelvic radiation to assess ovarian function 3, 1, 2
- When considering aromatase inhibitor therapy (requires confirmed postmenopausal status) 3
Expanded Testing for Specific Clinical Concerns
Consider additional hormone testing based on specific presentations:
- Testosterone and SHBG: When hirsutism, obesity, or polycystic ovary syndrome is suspected 1
- Calcium and phosphate: In women with osteoporosis risk or chronic liver disease 1
- 25-OH vitamin D: In women at high risk of deficiency or with chronic cholestasis 1
When to Refer
Refer to endocrinology or gynecology for:
- Persistently abnormal hormone levels requiring expert interpretation 1
- Confirmed hypogonadism requiring hormone replacement therapy 1
- Complex cases where hormone levels conflict with clinical presentation 1
Key Clinical Point
The absence of a uterus makes hormone testing MORE important, not less, because you cannot use menstrual patterns as a clinical guide to ovarian function. 2 However, remember that FSH levels can fluctuate significantly even in perimenopausal women, so a single elevated FSH does not definitively confirm menopause—both FSH and estradiol must be consistently in the postmenopausal range. 4, 5