2. Hormonal Assays Dr. Saleh Ahmed By
Ass. Prof. of Tumor Biology & Biochemistry
Faculty of Medicine
Umm Al Qura Univ. & Ain Shams Univ.

3. Some selected hormonal assays

4. Topics
PRL
TSH LH
FSH E2
ELISA Technique

5. PRL
Prolactin
Lactogenic hormone
Lactogen

6. PRL assay measure the concentration of the prolactin hormone in the blood.
PRL is a polypeptide hormone secreted by lactotrophs of the anterior pituitary gland, primarily for the development of mammary glands for lactation during pregnancy and for stimulating and maintaining lactation.
Reference values:
Premenopuasal: < 20 ng/ml
Postmenopausal: < 12 ng/ml

7. Conditions for PRL assay
Patient has to limit physical activity 12 hrs before test.
Fasting for 12 hrs before test.
Patient has to avoid stress, or stimulation for 30 minutes before test.
Sample drawn in the morning (3 - 4 hrs) after awakening.
Handle sample gently to prevent hemolysis.

8. PRL is under the complex regulatory system of estrogen, progesterone, dopamine, and thyrotropin-releasing hormone (TRH).
The function of PRL in males is unknown.

9. PRL levels are measured in the workup of galactorrhea, amenorrhea, infertility, impotence, and in cases of suspected pituitary tumor.
An elevated PRL classically presents with the syndrome of galactorrhea-amenorrhea in women, and the syndrome of infertility- impotence in men.
Men with elevated PRL typically have a low serum testosterone. However, testosterone replacement alone will not reverse the symptoms, the PRL must also be reduced.

10. Clinical significance of PRL level
Hypersecretion
Hyposecretion
Physiologic
Pharmacologic
Pathologic
Rare, if happened this may be due to pituitary necrosis or infarction

11. Causes of Hyperprolactinaemia
Pathologic
Pharmacologic
Physiologic
Hypothalamic disease
Methyldopa
Pregnancy
PRL secreting tumor
Reserpine
Lactation
Hpothyroidism
Cimetidine
Excerise
Addsion’s disease
Estrogen
Eating
Chronic renal failure
Morphine
Stress
Cirrhosis

12. PRL & Pituitary tumor ?? 60% pituitary tumor > 100 ng/ml
Modest elevation can be associated with pituitary tumor

13. Hyperprolactinemia may clinically present as:
Amenorrhea
Galactorrhea
Infertility
Osteoprosis
Impotence
Erectil dysfunction
Females
Males

14. PRL TSH  High (> 23 ng/ml) Normal (< 23 ng/ml) Normal High
MRI or CT
Hypothyroidism
Normal
hyperplasia
Microadenoma
Macroadenoma

15. TSH
Thyroid Stimulating Hormone
Thyrotropin

16. TSH Secreted by the thyrotrophic cells of the anterior pituitary.
It stimulates the growth of the thyroid follicular cells & step by step thyroid hormone synthesis

17. TSH value The best single test for the thyroid function
I Screening for thyroid dysfunction
a- TSH decreased with hyperthyroidism
b- TSH increased with hypothyroidism
II Monitoring thyroid replacement therapy (eg. Levothyroxine)
III Monitoring anti-thyroid therapy (eg.Propylthiouracil, methimazole or radioactive iodine)

18. TSH value
The ultra-sensitive assay in contrast to the older TSH assay which was unable to distinguish patient values in the normal range from those which were abnormally low.
It is the feeling of thyroid specialists that measurement of the TSH, complemented by FT4 measurement, represents the best and most efficient combination of blood tests for the diagnosis and follow- up of most patients with thyroid disorders.

19. TSH value
There has been a revolution in the approach to thyroid testing as the result of the development of ultra-sensitive TSH assays.
1st generation tests were able to measure levels of TSH to 1 IU/mL.
2nd generation tests were able to measure levels of TSH to 0.1IU/mL
3rd generation tests can measure TSH to 0.01IU/mL, a point at which hyperthyroidism may be diagnosed in ill patients.
4th generation assay able to measure TSH to IU/mL

20. Follow up patients on thyroxine supplementation (eg
Follow up patients on thyroxine supplementation (eg. Thyroxine or Synthroid) the TSH is an appropriate single test that can be followed and used to determine need for adjusting dosing.
 TSH is an indication to increase the thyroxine dose.
 TSH indicates a need to decrease the thyroxine dose.
Normal TSH range is the goal for patients on supplementation.

21. Clinical conditions associated with thyroid dysfunction
Amenorrhea
Oligomenorhea
Anovulation.
Inadequate corpus luteum.
Subfertility

22. Ultra-sensitive TSH  High Normal Low  FT4 Normal Thyroid FT4
Hypothyroidism
Normal
High
Hyperthyroidism
Subclinical
Hypothyroidism
Subclinical
Hyperthyroidism

23. LH & FSH

24. They are secreted by the anterior pituitary.
The alpha subunit is identical for all glycoprotein hormones (TSH, HCG, LH & FSH), but the beta subunit differs.
The peak of FSH is coincident with the peak of LH, but it is of lesser magnitude & briefer duration.
Following the mid-cycle surge of LH & FSH, there is drop in both.

26. Conditions for the detection of LH & FSH
In female patients, indicate the phase of the menstrual cycle or duration of menopause on the lab request.
Medications containing estrogen and progesterone should be discontinued 4 weeks before test.

27. The clinical utility of testing LH & FSH levels, includes:
Evaluation of menstrual disorders.
Aids in the diagnosis and treatment of infertility
To evaluate ovarian reserve of egg supply in females
To evaluate low sperm count in males
Assists in the detection of ovulation and monitors therapy to induce ovulation
Evaluation of failure of sexual maturation in adolescence.

28. The clinical utility of testing LH levels, includes:
Assists in distinguishing between primary (ovarian or testicular) and secondary (pituitary or hypothalamic) gonadal failure or hypogonadism.
Evaluation of impotence in males.

29. E2
Estradiol-17 beta
Estrogen fraction
Serum Estradiol

30. Estrogens
More than 30 estrogens have been identified, only 3 estrogens are used in clinical practice: estrone (E1), estradiol (E2), estriol (E3).
E2 is the primary form of estrogen in women, and is responsible for development of secondary sexual characteristics.
E2 is produced by the ovaries in small basal amounts prior to the onset of puberty

31. Gonadotropin releasing hormone (GnRH) stimulates the pituitary to produce LH and FSH.
FSH stimulates ovarian follicle formation and estrogen secretion; LH triggers follicular rupture and ovulation.
E2 secretion cause changes in the cervical mucus secretion to optimize fertility.

32. Potential use of E2 measurement
Delayed Puberty
Precocious Puberty
Secondary Amenorrhea
Breast Cancer Risk
Infertility
Gynecomastia in males
Females

33. E2 range Conv. Units (pg/mL) Phase 20-150
Females (Adults) Early follicular
Females (Adults) Late follicular
Females (Adults) Midcycle peak
50-250
Females (Adults) Luteal
Up to 35,000
Females (Pregnant)
<50
Females (On OCPs)
<30
Females (Post-menopause)
30-280
Females (Pubertal)
<15
Females (Pre-puberty)
10-60
Males (Adults)
<10
Males (Prepubertal)

36. ELISA

37. ELISA Enzyme-Linked Immunosorbant Assay

38. ELISA Enzyme-Linked ImmunoSorbent Assay
Biochemical reaction to identify the presence of antigen or antibodies in a sample
Direct: Antigen detection
Indirect: Antibodies detection

39. Advantages of ELISA Non-radioactive High specificity
Color change or florescence allows to use photometric measurement.
Amplification of minute levels allows for high sensitivity
Qualitative and Quantitative

40. Direct ELISA: Antigen detection

41. Indirect ELISA: Antibodies detection

43. Micro-particle Enzyme Immuno Assay

44. MEIA

45. MEIA

46. ELISA assays Hormones Thyroid Stimulating Hormone (TSH)
Thyroxine (T4) & Triiodothyronine (T3)
Free Thyroxine (fT4) &Free Triiodothyronine (fT3)
Cortisol
Follicle-Stimulating Hormone (FSH)
Luteinizing Hormone (LH)
Prolactin
Estrogen
Progesterone
Testosterone
Human chorionic gonadotropin (hCG)

47. ELISA assays Cardiac Markers
Troponin I
Cardiac Markers
Myoglobin
Creatinine Kinase-MB (CK-MB)
B-type Natriuretic Peptide (BNP)
High Sensitivity CRP (hsCRP)

48. ELISA assays Hepatitis Markers HIV
Hepatitis A virus (HAV) and its antibodies
Hepatitis Markers
Hepatitis B virus (HBV) and its antibodies
Hepatitis C virus (HCV) and its antibodies
Hepatitis D virus (HDV) and its antibodies
Hepatitis E virus (HEV) and its antibodies
HIV-1
HIV
HIV-2

49. ELISA assays
(hCG)
Hormones
Tumor markers
Alpha Fetoprotein (AFP)
Carcinoembryonic Antigen (CEA) Prostate Specific Antigen (PSA)
Oncofetal Antigens
CA 15-3
CA 549
CA 27-29
CA 125
Carbohydrate Markers
CA 19-9
CA 50
CA 72-4
CA 242
Blood Group Antigens
Monoclonal IgA, Monoclonal IgG
Monoclonal IgM, B2-Microglobulin
Proteins

50. ELISA assays
Rub IgG and Rub IgM
Congenital Factors
Toxo IgG, Toxo IgM
CMV IgG, CMV IgM
Ferritin
Metabolic Tests
Vitamin B12
Folate

51. ELISA assays
Anti-CCP
(anti-cyclic citrullinated peptide antibody)
Specific Proteins
Apoliprotein A1 (Apo A1)
Apoliprotein B (Apo B)
Complement C3 & C4 (C3, C4)
Immunoglobulin G (IgG)
Prealbumin
Rheumatoid Factor (RF)

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