What causes elevated Follicle-Stimulating Hormone (FSH) levels?

Causes of Elevated FSH Levels

Elevated FSH most commonly indicates primary gonadal failure (ovarian or testicular dysfunction), but can also result from normal physiological aging, hypothalamic-pituitary dysfunction, or various pathological conditions affecting the reproductive axis.

Primary Gonadal Failure

In Women

• Primary ovarian insufficiency (POI) is defined as amenorrhea for ≥4 months with two elevated FSH levels in the menopausal range (typically >35 IU/L) occurring before age 40 years 1
• Advanced liver disease causes altered estrogen metabolism and disruption of the hypothalamic-pituitary axis, though this typically results in low FSH and LH, not elevated levels 1
• Unilateral ovariectomy causes pathologically elevated FSH levels due to reduced ovarian reserve 2

In Men

• Primary testicular failure presents with low testosterone, elevated FSH (typically >7.6 IU/L), and elevated LH 3, 4
• Non-obstructive azoospermia is characterized by testicular atrophy, elevated FSH (>7.6 IU/L), and absent or severely reduced sperm production 3
• FSH levels >7.5 IU/L in men are associated with five- to thirteen-fold higher risk of abnormal sperm concentration and morphology 4

Age-Related Reproductive Decline

Female Reproductive Aging

• Rising FSH in the early follicular phase is a characteristic hallmark of reproductive aging and indicates diminished ovarian oocyte reserve 2, 5
• Elevated basal FSH (>10 IU/L) reflects quantitative decline in ovarian reserve rather than poor oocyte quality, as fertilization rates remain normal despite elevated FSH 5
• Animal studies demonstrate that rising FSH levels actively accelerate female reproductive aging by increasing embryo-fetal resorption, independent of ovarian follicle depletion 6

Male Reproductive Aging

• Isolated FSH elevation with normal testosterone and LH in elderly men reflects selective age-related testicular changes where Sertoli cell function declines while Leydig cell function remains preserved 7
• This pattern indicates selective impairment of spermatogenesis with preserved Leydig cell function, which is common in aging and does not constitute hypogonadism requiring treatment 7

Polycystic Ovary Syndrome (PCOS)

• PCOS involves hypofunction of the FSH-granulosa cell axis, though the dominant hormonal pattern is elevated LH with LH/FSH ratio >2, not isolated FSH elevation 1
• FSH levels in PCOS are typically normal or low relative to LH 1

Hypothalamic-Pituitary Dysfunction

Recovery States

• Recovery from hypothalamic amenorrhea is associated with significant increases in FSH as the hypothalamic-pituitary-gonadal axis normalizes 2
• Hypothalamic amenorrhea itself causes low FSH and LH, but the recovery phase shows FSH elevation 1

Hyperprolactinemia

• Elevated prolactin can disrupt gonadotropin secretion and should be excluded when evaluating elevated FSH 1

Medication and Substance Effects

Hormonal Medications

• Drug-induced estrogen receptor blockade (clomiphene, tamoxifen, raloxifene) can elevate FSH by disrupting normal feedback mechanisms 3
• Aromatase inhibitors (letrozole, anastrozole, exemestane) may alter estrogen-mediated feedback on FSH secretion 3
• Oral contraceptive use can result in elevated FSH levels during certain phases 2

Gonadotoxic Exposures

• Excessive smoking is associated with pathologically elevated FSH levels 2
• Chemotherapy with alkylating agents (cyclophosphamide, busulfan, melphalan) and platinum agents causes dose-dependent ovarian damage with elevated FSH 1
• Radiation therapy to the pelvis or total body irradiation damages gonadal tissue, resulting in elevated FSH 1

Genetic and Congenital Causes

Chromosomal Abnormalities

• Klinefelter syndrome (47,XXY) and other karyotype abnormalities cause primary testicular failure with elevated FSH 3
• Y-chromosome microdeletions (AZFa, AZFb, AZFc regions) are associated with non-obstructive azoospermia and elevated FSH 3

Hereditary Conditions

• Hereditary dizygotic twinning is associated with elevated FSH levels 2

Physiological Variations

Normal Cyclical and Life Stage Variations

• FSH concentrations vary considerably due to hourly fluctuation, cycle day dependency, intercycle variation, and lifetime variation 2
• Puberty is associated with elevated FSH levels as the reproductive axis matures 2
• Lactation can produce elevated FSH levels 2

Assay and Technical Factors

• Intra-assay, inter-assay, and between-assay variation can cause FSH measurement differences 2
• Minor technical problems in hormone assays can cause variations in measured levels, necessitating repeat testing for confirmation 3

Metabolic and Endocrine Disorders

Thyroid Dysfunction

• Thyroid disorders commonly affect reproductive hormones and can disrupt the hypothalamic-pituitary-gonadal axis 3
• Hyperthyroidism causes specific reproductive changes including impaired spermatogenesis, which are reversible with treatment 3

Metabolic Stress

• Obesity (BMI >25) and metabolic syndrome can affect gonadotropin levels 3
• Metabolic stress and poor glycemic control in diabetes affect the hypothalamic-pituitary-gonadal axis 3

Critical Diagnostic Approach

Essential Workup

• Obtain complete hormonal panel including LH, testosterone, and prolactin to evaluate the entire hypothalamic-pituitary-gonadal axis 7, 3
• Check thyroid function (TSH, free T4) as thyroid disorders commonly affect reproductive hormones 3
• Repeat FSH measurement for confirmation to eliminate laboratory error and account for natural variation 3, 2

Pattern Recognition

• Primary gonadal failure: low testosterone/estrogen + elevated FSH + elevated LH 7, 3
• Secondary hypogonadism: low testosterone/estrogen + low or low-normal FSH + low or low-normal LH 3
• Isolated FSH elevation with normal LH and testosterone: selective Sertoli cell dysfunction or diminished ovarian reserve 7, 3