Hormonal assay in clinical gynecology

Benha University Hospital, Egypt

Email: [email protected]

ABOUBAKR ELNASHAR

1. Prolactin

2. TSH

3. FSH & LH

4. Estrogen

5. Progesterone

6. 17 OH progestrone

7. Androgens (Total testosterone, DHEAS)

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ABOUBAKR ELNASHAR

It is secreted by:

Mammotropic cells of the anterior pituitary.

It is necessary for initiation & maintenance of lactation

Reference values:

Premenopuasal: <20 ng/ml

Postmenopausal: <12 ng/ml

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Conditions for detection of PRL

Late morning, fasting,

After 60 min rest,

Not in late follicular phase,

2nd blood sample if the first is raised

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Clinical significance:

-Hyposecretion: rare. Pituitary necrosis or infarction

-Hypersecretion:

Idiopathic, Physiologic, pharmacologic, pathologic

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Causes of Hyperprolactinaemia

Physiologic Pharmacologic Pathologic

Pregnancy Metclorpromide Hypothalamic

disorders

Lactation Methyldopa PRL secreting

tumor

Excerise Reserpine Hpothyroidism

Eating Cimetidine Addsion’s

disease

Stress Estrogen Chest wall

disease

Morphine Ch renal failure

Alch cirrhosis ABOUBAKR ELNASHAR

Relation between The level & the cause:

> 100 ng/ml:

60% pituitary tumor.

> 300 ng/ml:

100% pituitary tumor

Modest elevation can be associated with pituitary tumor

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Clinical conditions associate with

hyperprolactinaemia

1. Galactorrhea.

2. Oligomenorhea

3. Hirsutism

4. Anovulation

5. Corpus luteum deficiency

6. Infertility

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Hyperprolactinaemia without galactorrhea: 66%

1. Inadequate detection

2. Hypoestrogenic state.

3. Inadequate estrogenic or progetational priming of the breast

4. High PRL does interact with the breast receptors

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Diagnostic evaluation

History & Examination: Exclude: Recent pregnancy, breast stimulation

Drugs, Breast or chest lesion

Prolactin

>20 ng/ml <20 ng/ml

TSH

Normal High (hypothyroidism)

MRI or CT( Normal or hyperplasia, Microadenoma or Macroadenoma)

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It is secreted by the thyrotrophic cells of the anterior

pituitary .

It stimulates the growth of the thyroid follicular cells

& every step in thyroid hormone synthesis

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Reference values:

Conventional immunoassay: useful in diagnosis of

hypothyroidism.can not dd between normal values

& subnormal values in hyperthyroidism

Sensitive Immunoassay: can dd

Subclinical hypothyroidism: Increase TSH & normal

free T4

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Clinical conditions associated with thyroid

dysfunction:

1. Oligomenorhea

2. Amenorrhea

3. Menorrhagia

4. Anovulation.

5. Inadequate corpus luteum.

4. Subfertility

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Sensitive TSH

High Normal Low

Free T4 Normal thyroid Free T4

Low Normal Normal High

Hypothyroidism Free T3

Subclinical hypothyroidism Normal High

Subclinical hyperthyroidism Hyperthyroidism ABOUBAKR ELNASHAR

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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 midcycle surge of LH & FSH, there is

drop in both.

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Normal values:

FSH LH

Adult 5-10 mIU/ml 5-20

mIU/ml

Mid cycle peak 2 times the basal level 3 times

the basal level

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Clinical uses:

FSH LH

1. Hypogonadotrophic < 5 mIU/ml < 5 IU/ml

state e.g. prepubertal

& pituitary disorders

2. Hypergonadotropic > 40 mIU/ml >40 mIU/ml

state e.g.postmenopuse

Ovarian failure

3. PCOS normal or decreased high

Follicular phase ratio 1 2

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4. Testing for ovarian function:

a. Day 3 FSH

< 10 IU/L = normal

< 15 IU/L : conception rate is twice when FSH 15-

25 IU/L

> 25 IU/L ( or age >44) is independently associated

with near zero chance of pregnancy

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b.Clomiphene citrate challenge test (CCCT)

CC 100 mg /day from D5-9

Check FSH on D3 & 10

Sum of FSH >26 IU/L = poor responder

LH can be used for assessment of ovarian reserve

but FSH is better. FSH rises sooner & more

dramatically than LH.

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5. Detection of ovulation

Follicular rupture occurs:

36 h after the onset of serum LH surge &

12 H after LH peak.

A positive urine result is often found only 12 h

after the onset of serum LH. (around the point

of LH peak).

So ovulation is expected to occur 24 h after

the urine LH surge

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LH surge in urine:

Quick, sensitive, relatively inexpensive,

pinpoint the day of ovulation &

has reduced the uncertainty in interpretation of

progesterone levels by better-identifying the

time of peak progestrone secretion at which to

obtain serum

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6. Diagnosis of the cause of precocious

puberty:

(Breast development <8 y or

menstruation <9 y.)

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X ray of the lower ends of radius & ulna:bone age

a. Retarded: hypothyroidism

b. Normal: Partial

c. Advanced:

FSH: <2 IU/ml: pseudo

> 2 mIU/ml: true:

CT or MRI--------Normal: idiopathic

Abnormal: CNS lesion

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7. Diagnosis of the cause of amenorrhea

Primary A.:

absence of menstruation by the age of 16 yr

regardless of SSC or by the age of 14 yr in absence

of SSC

Secondary A.:

Cessation of menstruation > 6 months

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1. Pregnancy test.

2. TSH &PRL.

3. Progestin challenge test:

(MPA 5mgX2X5d)

+ve: Anovulation

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-ve: E + P :

-ve: outflow or uterine failure

HSG, hysteroscopy, IVP & laparoscopy.

+ve: Ovarian failure or pituitary-hypothalamic

dysfunction.

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3. FSH:

high: Ovarian failure.

If 1ry: Karyotyping.

If 2ndry: premature menopause

Low or Normal: CT of Pituitary-hypothalamic

region.

. Abnormal: pituitary disease

. Normal: hypothalamic dysfunction.

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More than 30 estrogens have been identified,

but only 3 estrogens are used in clinical

practice: estrone (E!), estradiol (E2), estriol

(E3).

In contrast to E2 which is secreted almost

entirely by the ovary, most E1 is derived from

peripheral conversion of androstenedione &

from E2 metabolism.

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E2 is the most abundant E in premenopausal

females

E1 is the E in highest concentration in

postmenopausal females.

E2 is the most potent E

E1, E2 & E3 are bound to SHBG.

E2 & not total E is used for clinical purposes.

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Normal values of E2 (pg/ml)

Follicular phase: 25-27

Midcycle peak: 200-600

Luteal phase: 100-300

Postmenopausal: 5-25

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E2 rises during the 2nd half of the follicular

phase & reach a peak 24 h before LH surge &

36 h before ovulation.

Following LH surge E2 drops to preovulatory

levels, but then rises slightly to 100-300 pg/ml

during luteal phase

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Clinical applications:

1. E increases in E secreting tumors e.g.

granulosa theca cell tumors

2. To classify hypogonadism:

E is usually interpreted with gonadotropin

measurements

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3. Test for ovarian reserve:

Low D3 E2 (<75 pg/ml) combined with normal

FSH: good ovarian reserve

Evaluation of both E2 & FSH is better

predictor of ovarian reserve than using either

measurement alone.

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4. An indication of down regulation in the long

protocol for superovulation in ART. E2: < 50 pg/ml

5. Monitoring Superovulation in ART:

The goal is an E2 level of 200 pg/ml per large

(>14mm) follicle

The risk of OHSS is significant if E2 is >4000 pg/ml

(Sperof,2002)

The number of follicles & the type of patient should

be considered.

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6. Monitoring of induction of ovulation with HMG (Sperof,2002).

E2 1000-1500 pg/ml is optimal

1500-2000 pg/ml: increase risk of OHSS

>2000 pg/ml: high risk of OHSS, consider cycle

cancellation

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In the serum:

18% is bound to cortisol binding globulin

79% is bound to albumin

3% is free

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Normal values (ng/ml):

P level is low prior to the mid cycle gonadotrophin

surge.

Shortly after that, P begin to rise rapidly reaching

peak levels during the middle of the luteal phase

(8days after LH peak).

Thereafter, a progressive fall occurs with barely

detectable P levels reached prior to menses.

Follicular phase: <1

Luteal phase: 5-20

Post menopause: <1

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Clinical applications

1. Diagnosis of ovulation:

in cases of infertility & DUB

midluteal phase serum level of 5 ng/ml

2. Diagnosis of corpus luteal dysfunction:

Midluteal phase level of 10 ng/ml.

Sum of 3 progesterone levels from D11-4 before

menses: 15 ng/ml

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It is an intermediate metabolite in steroidogenesis in

the adrenals

It is used for diagnosis of enzymatic deficiency in

the adrenals.

Increased 17 OH progesterone indicates congenital

adrenal hyperplasia

Clinical application

1. Hirsutism

2. Ambigous genitalia

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17 oh P(ng/dl) morning

< 200 > 200

Rules out adrenal hyperplasia ACTH stimulation test (0.25

21-hydroxylase defiency mg ACTH I.V.& 17 oh P at time

zero & after 1 hour)

Normal Abnormal

Rules out adrenal hyperplasia Adrenal hyperplasia

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Androgen production Androstenedione

Testosterone

Adrenal DHEA Ovary

DHEAS

50% 50% 50%

25% 25%

90% 10%

100%

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Androgen in the blood Male Normal female Hirsute female

Free 3% 1% 2%

Albumin 19% 19% 19%

SHBG 78% 80% 79%

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Normal values (ng/dl): Premenopause Postmenopause

Testosterone 20-80 15-70

Androstenedione 60-300 30-150

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Free testosterone

Good correlation with total production rate (= secretion

rate + peripheral conversion rate) which correlate well

with degree of virilization

Normal level: 1.5-11.4 pg/ml

Not done routinely in presence of hirsutism

•Free androgen index (FAI)=

TX 100 / SHBG if > 4.5 : PCOS

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•Dehydoepiandrosterone sulphate

(DHEAS)

The principal contribution of 17 ketosteroids

(KS) is from DHES.

It correlates with urinary 17 KS. It is more

reliable indicator of adrenal androgen than 24

h 17 KS.

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Clinical application

In PCOS: DHEAS > 2ug/ml

CC + Corticosteroid (ACOG,2002)

In hirsutism: DHEAS: >2 ug/ml

COCs + Corticosteroids

DHEAS: not essential

(Sperof,2002)

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DHES is not essential (Speroff,2002)

1. If 17 OHP is normal: adrenal enzyme defect can

be excluded .

2. Moderate elevations of DHES can be suppressed

by suppression of ovulation.

3. DHES > 700 ug/dl is rare & is associated with high

levels of testosterone

4. Imaging of the adrenals is more cost-effective than

measuring DHES.

N.B:Hyperprolactinaemia can cause an increase in

DHEAS. Treatment with Bromocriptin will decrease

prolactin & DHEAS ABOUBAKR ELNASHAR

Total teststerone

Clinical application:

1. Initial laboratory investigation of hirsutism

Total testosterone: measures the ovarian & adrenal

activity.

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Testosterone (ng/dl)

>200 <200

U/S of the ovary Anovulation

( FG/I. PRL, endom biopsy)

Adenxal mass Nothing

Laparotomy CT of the adrenala & ovaries

Laparotomy ABOUBAKR ELNASHAR

2. Evaluation of infant with ambiguous

genitalia

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Karyotype, Androgens, 17OHP

XX Y-containing

abnormal

karyotype

Elevated androgens Normal androgen

Elevated 17OHP Normal 17OHP

CAH Elevated maternal True H.phrodite

(21OH androgen Gonadal dysgenesis

11BOH)

Gonadectomy ABOUBAKR ELNASHAR

Karyotype, Androgens, 17 OHP

XY

Normal androgens Normal androgens

signs of adrenal failure Normal 17OHP

normal 17 OHP

CAH with 3B IAIS, 5reductase def, true hph,

. Dehydogenase mixed gonadal dysgenesis,

block in male. abnormal androgen synthesis

Gonadectomy ABOUBAKR ELNASHAR

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