REPRODUCTIVE HORMONE

TEST REQUESTING

Jeffrey BarronConsultant Chemical PathologistEpsom & St Helier University Hospitals

03.07.2007

EFFECTIVE REPRODUCTIVE HORMONE TEST REQUESTING EASY GUIDE

Jeffrey BarronChemical PathologistLabtests

Goodfellows 24.03.2112

Outline of Talk - Female• Laboratory role• Hypothalamic-Pituitary-Ovarian axis• Amenorrhoea: Secondary

– Oligo- & Amenorrhoea:• FSH interpretation• Prolactin Raised: Galactorrhoea • Testosterone raised:

–Polycystic Ovarian Syndrome –Hirsutism, Virilisation

• Menopause• Infertility - Subfertility • Recommendations for requesting

Laboratory Role: As You May See It

Specimen

Input Process

Lab

Output

Results

Productivity

Request

Laboratory Role: How We Add Value

Input

Clinical &ScientificExpertise

Process Output

ReasonRequest

Tests

Data Knowledge,Expert

Algorithms

ClinicalAdvice

Lab

Productivity

Value

Value Value

Hypothalamic-Pituitary-Ovarian axis

uterus

menses

Testosterone-theca cells/stroma

Amenorrhoea ?

Amenorrhoea

• Physiological– Prior to puberty – Pregnancy– Lactation– Menopause• Secondary– Gynaecological disorder – Systemic disease

FSH & LH levels vary

FSH levels vary

Amenorrhoea ?

Amenorrhoea ?

• Consider: - Pregnancy- Lactation

- Exercise- Weight loss / Coeliac disease- Severe illness

• If none of above request: - FSH, LH - Prolactin- Testosterone- Oestradiol to interpret FSH or guide Rx - Consider TSH

Oligo- & Amenorrhoea: SecondaryPreviously regular-None for 6 months

Amenorrhoea ?

• FSH high:Ovarian failure – early karyotype• FSH low to low normal:

- Pregnancy- Lactation

- Exercise- Weight loss- Severe illness- Stress- Contraceptive drugs- Hypothalamic/Pituitary disease

or masses•Uterine: Asherman’s syndrome

Oligo- & Amenorrhoea: Secondary

FSH

• Pregnancy• Lactation• Stress• Drugs: neuroleptics, SSRI, tricyclics, metoclopramide, domperidone, other• 1o hypothyroidism• Macroprolactin - prolactin~IgG• Pituitary adenoma

Oligo- & Amenorrhoea: Secondary

Prolactin raised

Galactorrhoea - 1

Juno holding her breast for Hercules in The birth of the Milky Way, Peter Paul Rubens1637

• Sample Collection: day 2 - 5, after midday: menses + diurnal rhythms

• Galactorrhoea &/or oligo-amenorrhoea + raised prolactin + correct sample + no medication + not macroprolactin+ not pregnant, lactation, hypothyroidism = possible prolactinoma

GalactorrhoeaProlactin raised

• Prolactin 500 - 800 mIU/L

- Suggest review medication

- Examine for galactorrhoea

- Repeat on day 2 – 5, after midday

• Repeat or > 800 mIU/L- Lab phone to review medication,

lactation, clinical- Exclude macroprolactin: prolactin~IgG

- Recommend: Repeat on day 2 – 5 Endocrine referral

Raised ProlactinNo Galactorrhoea or Amenorrhoea

Hirsutism

• PCOS - most common cause

• Hirsutism:mildsevere

• Virilisation

Oligo- & Amenorrhoea: SecondaryTestosterone raised

Ferriman-Gallwey hirsutism scoring system

Testosterone Total vs Hirsutism Score

Mayo Clinic specific testosterone assay

RS Legro et al, Total Testosterone Assays in Women with Polycystic Ovary Syndrome: Precision and Correlation with Hirsutism, J Clin Endocrinol Metab. 2010; 95: 5305–5313

Hirsutism Score

2.6 nmol/L

4.5

Testosterone

Ideal diagnostic test

Normal Disease

No false positives or negatives

Probability

No disease

Normal

Reference interval 95%

PCOS or Hirsutism

No

. of i

nd

ivid

ua

ls

Concentration

Testosterone in PCOS

False positivesFalse negatives

Hirsutism

Polycystic Ovarian Syndrome - 1

• Common, 5 – 10% young women• 21% NZ women, reproductive age

– ultrasound shows PCO• Presentation: ~ half patients

– Anovulatory infertility– Oligomenorrhoea– Hirsutism, acne, male type baldness

• Familial• Linked: type II diabetes

Hypothalamic-Pituitary-Ovarian axis

uterus

menses

Testosterone-theca cells/stroma

Hirsutism & Acne

Polycystic Ovarian Syndrome – 2

Diagnosis• Request: Testosterone, day 2 - 5

– Increased ~ 70% patients PCOS– Fulfills 1 of 3 criteria for diagnosis

• Other criteria:– Oligo- &/or anovulation– Ultrasound PCO

• FSH & LH NOT reliable criteria• Clinically Testosterone not necessary

Martin KA et al DIAGNOSIS AND EVALUATION OF WOMEN WITH PREMENOPAUSAL HIRSUTISM J Clin Endocrinol Metab: 93 (4), 1105-1120, 2008

Fritz M & Speroff L, Clinical Gynaecological Endocrinology & Infertility, 8th Ed, 2011.

Testosterone Total vs Hirsutism Score

Mayo Clinic specific testosterone assay

RS Legro et al, Total Testosterone Assays in Women with Polycystic Ovary Syndrome: Precision and Correlation with Hirsutism, J Clin Endocrinol Metab. 2010; 95: 5305–5313

Hirsutism Score

2.6 nmol/L

4.5

Testosterone

Diagnosis of Hirsutism

• Isolated mild - no request for testosterone• Moderate / severe, sudden onset, progressive

– Especially associated with: menstrual irregularity, infertility, central obesity, acanthosis nigricans, rapid progression, clitoromegaly

• Testosterone: day 2 - 5• Normal: no further tests• Rapid progression or virilisation:

– Consider androgen secreting tumour

Martin, Evaluation and treatment of hirsutism in premenopausal women. J Clin Endocrinol Metab: 93 (4), 1105-1120, 2008

Hirsutism, Amenorrhoea

• Hirsutism occurs most commonly with PCOS• Initial test:

– Testosterone total: day 2- 5, morning• Testosterone free

– adds no further diagnostic information– unnecessary test

Martin KA et al DIAGNOSIS AND EVALUATION OF WOMEN WITH PREMENOPAUSAL HIRSUTISM J Clin Endocrinol Metab: 93 (4), 1105-1120, 2008

Hirsutism, Amenorrhoea

High testosterone or progression

• If Testosterone total > 4.5 nmol/L– Lab request DHEAS, Testosterone free

• Or Rapid progression hirsutism, virilisation– Consider androgen secreting tumour– Request

• Testosterone free• DHEAS

Martin KA et al DIAGNOSIS AND EVALUATION OF WOMEN WITH PREMENOPAUSAL HIRSUTISM J Clin Endocrinol Metab: 93 (4), 1105-1120, 2008

Hirsutism, Virilisation, Amenorrhoea

Adult onset CAH is not an issue• Adult onset CAH, is NOT adrenal insufficiency,

normal cortisol• Consider if: early onset hirsutism or

ethnic origin is:– Mediterranean, Slavic, Ashkenazi Jewish

• If presenting with hirsutism alone– Anti-androgen therapy equivalent to

glucocorticoid therapy

• Diagnosis: day 2 – 5, morning

17 OH progesterone

Hirsutism, Virilisation, Amenorrhoea

Androstenedione is not necessary

• Commonly elevated• No diagnostic value over testosterone• Used: Diagnosis or management CAH

Androgen secreting tumours of adrenal or ovary

Ovarian Cycle

Progesterone

• Regular cycles: ovulation likely• Monitor pituitary-ovarian axis to confirm

ovulation: • Request: Midluteal progesterone on day 21

if 28 day cycle

• If midluteal progesterone: > 25 nmol/L:- Consistent with ovulation- No further hormone tests required

• Irregular cycles – repeat progesterone weekly• Require progesterone,

7 days pre onset menses

Infertility or Subfertility - 1

• If day 21 progesterone < 25 nmol/L

• Then repeat twice:- Midluteal progesterone - on day 21 if a 28 day cycle

Infertility or Subfertility - 2

Infertility or Subfertility – 3

• If Progesterone < 25 nmol/L after 3 cycles

• Request on day 2 - 5: – FSH, LH– Prolactin– Testosterone– Oestradiol– Consider TSH

Use of Serum Progesterone

• To determine– If ovulating – Specialist use if possible risk

• Miscarriage• Ectopic pregnancy

Thought to be Post Menopausal. Now pregnant

FSH & LH levels vary

Menopausal Symptoms + Oligo- or Poly-Menorrhoea

• Result: FSH > LH, FSH >30, Age <45Biochemically consistent with premature ovarian failure

• Result: FSH > LH, FSH 10 – 30, Age >45Consider early stage of perimenopause

• Result: FSH > LH, FSH 10 – 30, Age <45Consider early stage of premature ovarian failure

Menopausal Symptoms + Oligo- or Poly-Menorrhoea

Peri-Menopause - 1

• FSH fluctuates markedly • History basis of diagnosis. • Therapeutic trial HRT• No place assays: oestradiol, progesterone

• Thyroid disease symptoms may mimic

menopausal symptoms

Peri-Menopause – 2

Request FSH if• Not on HRT, oestrogen pill• Hysterectomy with ovarian conservation• Menstrual bleeding

• FSH on day 2 – 5–FSH > LH–Raised > 10 mIU/L–Indicates diminished ovarian response

• Request:- FSH, LH- Prolactin- Testosterone- Oestradiol

Oligo- or Poly-MenorrhoeaNO Menopausal Symptoms

The Toilet of Venus 1650Venus -

Diego Velazquez

Recommendations for requesting - 1

• Primary Amenorrhoea:– FSH, LH

• Secondary Oligo-, Poly-, A-menorrhoea :

– FSH, LH, Prolactin, Testosterone total, Oestradiol

• Hirsutism, Polycystic Ovarian Syndrome:– Testosterone total on day 2 - 5

• Menopause atypical:– FSH, LH on day 2 - 5

Recommendations for requesting - 2

• Galactorrhoea– Prolactin on day 2 - 5, after 12 midday

• Infertility:– Progesterone day 21

Dysfunctional Uterine Bleeding• Menorrhagia• Intermenstrual or post coital • Abdominal and pelvic examination • FBC: exclude anaemia• HCG: Exclude pregnancy / trophoblast• Consider TSH if symptoms or signs• No other hormone investigations• History: consider clotting disorder

Dysmenorrhoea: Laboratory tests not necessary

Post Pill AmenorrhoeaWeight Loss

Hypopituitarism

• Low– LH, FSH– Oestradiol

Libido Loss• Common• Tests only if indicated by history &

examination• Weak correlation with testosterone,

DHEAS, androstenedione, oestradiol, FSH, prolactin

• Rare causes consider: acromegaly, Cushing's syndrome, CAH, adrenal insufficiency

Hypothyroidism increases Prolactin

Amenorrhoea: PrimaryFailure to establish menstruation

• Absent by 13 years- Without secondary sexual development• Absent by 16 years

- With secondary sexual characteristics

• Family history: Consider watchful waiting• Request: FSH, LH

- Raised: Karyotype: 45 XO Turner syn46 XX Premature ovarian failure

- Low: Constitutional delayConsider: anorexia

exerciseillnesscoeliac diseasehypothalamic/pituitary

- Intermediate: Anatomical - ultrasound

Amenorrhoea: Primary

Secondary sexual characteristicsAbsent 13y

• Absent/abnormal then karyotype:- 46 XX Mullerian agenesis- 46 XY Androgen insensitivity

• Present + no outflow obstruction- As for 2o amenorrhoea

Amenorrhoea: Primary

Secondary sexual characteristics Present by 16 yearsUltrasound uterus