Checking Estrogen and Testosterone Levels in a 65-Year-Old Woman with Severe Fatigue
Checking estrogen levels is not recommended in postmenopausal women with fatigue, as estrogen levels are universally low after menopause and do not correlate with symptoms or guide treatment decisions. 1, 2 Testosterone levels should also not be routinely checked in women presenting with fatigue, as there is no well-defined androgen deficiency syndrome in women, and androgen levels do not correlate with specific symptoms like fatigue. 3, 2
Why Estrogen Testing Is Not Indicated
Estrogen levels are universally low in all postmenopausal women and show high variability that does not predict symptoms or response to therapy. 4 Measuring estrogen in a 65-year-old woman provides no actionable clinical information.
The Endocrine Society explicitly recommends against diagnosing androgen deficiency syndrome in healthy women because there is a lack of a well-defined syndrome and no data correlating hormone levels with specific signs or symptoms like fatigue. 2
The U.S. Preventive Services Task Force does not recommend hormone replacement therapy for chronic disease prevention in postmenopausal women, as risks outweigh benefits for most indications beyond menopausal symptom management. 3
Why Testosterone Testing Is Not Indicated in Women
The Infectious Diseases Society of America and HIV Medicine Association explicitly state that obtaining testosterone levels in women in nonresearch settings is not recommended. 3 This applies to general clinical practice.
The Endocrine Society's 2014 guideline emphasizes that there is no validated androgen deficiency syndrome in women, and testosterone levels do not predict response to therapy even when sexual dysfunction is present. 2
Research shows that cognitive fatigue in postmenopausal women is not associated with sex hormone levels, and testosterone/estrogen replacement had no significant effect on fatigue symptoms. 5
What Should Be Done Instead
The appropriate workup for severe fatigue in a 65-year-old woman should include: 6
- Complete blood count (to evaluate for anemia) 6
- Comprehensive metabolic panel (electrolytes, renal function, liver function) 6
- Thyroid-stimulating hormone (TSH) 6
- Fasting glucose or HbA1c 6
- Assessment for depression, sleep disorders, medications causing fatigue, and cardiac disease 3, 6
Important Context from Oncology Guidelines
The only clinical scenarios where sex hormone testing might be considered in women with fatigue are highly specific situations:
In premenopausal women with suspected hypophysitis (pituitary dysfunction) who present with fatigue, loss of libido, mood changes, or oligomenorrhea, measuring FSH and estrogen may be appropriate to diagnose central hypogonadism. 3
This does not apply to a 65-year-old postmenopausal woman, where low estrogen is physiologically expected and not pathologic. 3
Common Pitfalls to Avoid
Do not order hormone levels based on nonspecific symptoms alone in postmenopausal women—fatigue has numerous other causes that should be systematically evaluated first. 3, 6, 2
Do not assume that low testosterone or estrogen levels in postmenopausal women require treatment—these are normal physiologic findings, and replacement therapy is not indicated for fatigue. 2
Focus the workup on treatable causes of fatigue including thyroid disease, anemia, diabetes, sleep disorders, depression, medication effects, and cardiac disease rather than sex hormones. 3, 6