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Practice Cases in primary care laboratory medicine

Cases in primary care laboratory medicine: testing pitfalls and summary of guidance on sex hormone testing

BMJ 2007; 334 doi: (Published 11 January 2007) Cite this as: BMJ 2007;334:91
  1. W Stuart A Smellie, consultant
  1. 1Clinical Laboratory, General Hospital, Bishop Auckland DL14 6AD
  1. Correspondence to: W S A Smellie info{at}
  • Accepted 9 November 2006

Sex hormone testing in women is difficult to interpret, and to produce valid conclusions tests must be timed correctly and follow a rational sequential testing strategy

Laboratories see large differences in the use of tests to investigate subfertility. The use and interpretation of tests for the female sex hormones can be problematic; although population reference data exist, values change markedly within and between the different phases of the menstrual cycle, and values outside of quoted reference ranges often provide very limited information and can be misleading. This is particularly true for women with cycles that are irregular or atypical in length. Good examples of this can be seen in both menopause and subfertility.

Summary points

  • Hormone testing has very limited use in diagnosing the menopause

  • Monitoring patients on hormone replacement therapy relies on clinical response in most situations

  • Early investigation of subfertility is recommended only in specific groups of patients

  • A detailed menstrual history is essential to interpret gonadotrophin results

  • A luteal progesterone concentration above 20-30 nmol/l seven days before onset of menses effectively excludes endocrine related subfertility; intermediate concentrations may necessitate a repeat test

This paper presents two typical clinical cases involving biochemical investigation of female reproductive capacity and menopause and considers the further investigations that may or may not be helpful in these situations. It also presents a summary of the relevant researched guidance.

Case 1

A 47 year old woman with no gynaecological history apart from two uncomplicated term pregnancies in her 20s presented to her general practitioner with a three month history of tiredness, 2.5 kg weight gain, and low mood with occasional flushing. On questioning, she reported that she had had irregular and occasionally missed periods over the previous five months, and she had no specific features of an affective disorder. She had not had a period in the …

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