1. REPRODUCTIVE HORMONE TEST REQUESTING Jeffrey Barron Consultant Chemical Pathologist Epsom & St Helier University Hospitals 03.07.2007 EFFECTIVE REPRODUCTIVE HORMONE TEST REQUESTING EASY GUIDE Jeffrey Barron Chemical Pathologist Labtests Goodfellows 24.03.2112

2. 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

3. Laboratory Role: As You May See It Specimen InputProcess Lab Output Results Productivity Request

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

5. Hypothalamic-Pituitary-Ovarian axis uterus menses Testosterone-theca cells/stroma

6. Amenorrhoea ?

7. Amenorrhoea Physiological –Prior to puberty –Pregnancy –Lactation –Menopause Secondary –Gynaecological disorder –Systemic disease

8. FSH & LH levels vary

9. FSH levels vary

10. Amenorrhoea ?

12. 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

13. Amenorrhoea ?

14. 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

15. Pregnancy Lactation Stress Drugs: neuroleptics, SSRI, tricyclics, metoclopramide, domperidone, other 1 o hypothyroidism Macroprolactin - prolactin~IgG Pituitary adenoma Oligo- & Amenorrhoea: Secondary Prolactin raised

16. Galactorrhoea - 1 Juno holding her breast for Hercules in The birth of the Milky Way, Peter Paul Rubens 1637

17. 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

18. 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 Prolactin No Galactorrhoea or Amenorrhoea

19. Hirsutism

20. PCOS - most common cause Hirsutism:mild severe Virilisation Oligo- & Amenorrhoea: Secondary Testosterone raised

21. Ferriman-Gallwey hirsutism scoring system

22. 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

23. Ideal diagnostic test Normal Disease No false positives or negatives Probability

24. No disease Normal Reference interval 95% PCOS or Hirsutism No. of individuals Concentration Testosterone in PCOS False positives False negatives

25. Hirsutism

26. 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

27. Hypothalamic-Pituitary-Ovarian axis uterus menses Testosterone-theca cells/stroma

28. Hirsutism & Acne

29. 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, 8 th Ed, 2011.

30. 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

31. 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

32. Hirsutism

33. 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

34. 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

35. 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

36. 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

38. Ovarian Cycle Progesterone

39. 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

40. If day 21 progesterone < 25 nmol/L Then repeat twice: - Midluteal progesterone - on day 21 if a 28 day cycle Infertility or Subfertility - 2

41. Infertility or Subfertility – 3 If Progesterone < 25 nmol/L after 3 cycles Request on day 2 - 5: –FSH, LH –Prolactin –Testosterone –Oestradiol –Consider TSH

42. Use of Serum Progesterone To determine –If ovulating –Specialist use if possible risk Miscarriage Ectopic pregnancy

43. Thought to be Post Menopausal. Now pregnant

44. FSH & LH levels vary

45. > 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

46. 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

47. 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

48. 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

49. Request: - FSH, LH - Prolactin - Testosterone - Oestradiol Oligo- or Poly-Menorrhoea NO Menopausal Symptoms

50. The Toilet of Venus 1650 Venus - Diego Velazquez

51. 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

52. Recommendations for requesting - 2 Galactorrhoea –Prolactin on day 2 - 5, after 12 midday Infertility: –Progesterone day 21

54. 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

55. Post Pill Amenorrhoea Weight Loss Hypopituitarism Low –LH, FSH –Oestradiol

56. 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

57. Hypothyroidism increases Prolactin

58. Amenorrhoea: Primary Failure to establish menstruation Absent by 13 years - Without secondary sexual development Absent by 16 years - With secondary sexual characteristics

59. 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

60. 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