REPRODUCTIVE HORMONE TEST REQUESTING Jeffrey Barron Consultant Chemical Pathologist Epsom & St Helier University Hospitals EFFECTIVE REPRODUCTIVE HORMONE TEST REQUESTING EASY GUIDE Jeffrey Barron Chemical Pathologist Labtests Goodfellows

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 InputProcess Lab Output Results Productivity Request

Laboratory Role: How We Add Value Input Clinical & Scientific Expertise ProcessOutput Reason Request Tests DataKnowledge, Expert Algorithms Clinical Advice Lab Productivity 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 ?

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: Secondary Previously 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 1 o 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 Rubens 1637

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 Galactorrhoea Prolactin raised

Prolactin 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 Prolactin No Galactorrhoea or Amenorrhoea

Hirsutism

PCOS - most common cause Hirsutism:mild severe Virilisation Oligo- & Amenorrhoea: Secondary Testosterone 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 TestosteroneTestosterone

Ideal diagnostic test Normal Disease No false positives or negatives Probability

No disease Normal Reference interval 95% PCOS or Hirsutism No. of individuals Concentration Testosterone in PCOS False positives False 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 –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), , 2008 Fritz M & Speroff L, Clinical Gynaecological Endocrinology & Infertility, 8 th 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 TestosteroneTestosterone

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 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), , 2008

Hirsutism

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), , 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), , 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

> 45 years, with typical symptoms: No tests Atypical - Request FSH, LH on day 2 – 5 Perimenopause FSH > LH - FSH > 30 mIU/L FSH fluctuates perimenopause 40 mIU/L - on 2 occasions 8 weeks apart = ovulatory failure Oestradiol normal until perimenopause Menopausal Symptoms + Oligo- or Poly-Menorrhoea

Result: FSH > LH, FSH >30, Age <45 Biochemically consistent with premature ovarian failure Result: FSH > LH, FSH 10 – 30, Age >45 Consider early stage of perimenopause Result:FSH > LH, FSH 10 – 30, Age <45 Consider 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-Menorrhoea NO Menopausal Symptoms

The Toilet of Venus 1650 Venus - 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 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 Amenorrhoea Weight 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: Primary Failure 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 syn 46 XX Premature ovarian failure - Low: Constitutional delay Consider:anorexia exercise illness coeliac disease hypothalamic/pituitary - Intermediate: Anatomical - ultrasound Amenorrhoea: Primary Secondary sexual characteristics Absent 13y

Absent/abnormal then karyotype: - 46 XX Mullerian agenesis - 46 XY Androgen insensitivity Present + no outflow obstruction - As for 2 o amenorrhoea Amenorrhoea: Primary Secondary sexual characteristics Present by 16 years Ultrasound uterus