Hormonal assay

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Hormonal assay in clinical gynecology
Prof. Aboubakr Elnashar
Benha University Hospital, Egypt Email
elnashar53_at_hotmail.com
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1. Prolactin 2. TSH 3. FSH LH 4. Estrogen 5.
Progesterone 6. 17 OH progestrone 7. Androgens
(Total testosterone, DHEAS)
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Prolactin
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It is secreted by Mammotropic cells of the
anterior pituitary. It is necessary for
initiation maintenance of lactation Reference
values Premenopuasal lt20 ng/ml Postmenopausal
lt12 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
Addsions disease Stress
Estrogen Chest wall
disease
Morphine Chronic renal
failure
Alcholoic
cirrhosis
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Relation between The level the cause gt 100
ng/ml 60 pituitary tumor. gt 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 gt20
ng/ml
lt20 ng/ml TSH Normal
High (hypothyroidism) MRI or
CT( Normal or hyperplasia, Microadenoma or
Macroadenoma)
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TSH
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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
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FSH LH
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(No Transcript)
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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 lt 5 mIU/ml
lt 5 IU/ml state e.g. prepubertal pituitary
disorders 2. Hypergonadotropic gt 40
mIU/ml gt40 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 lt
10 IU/L normal lt 15 IU/L conception rate is
twice when FSH 15-25 IU/L gt 25 IU/L ( or age gt44)
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
gt26 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 LH surge 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 lt8 y or
menstruation lt9 y.)
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X ray of the lower ends of radius ulnabone
age a. Retarded hypothyroidism b. Normal
Partial c. Advanced FSH lt2 IU/ml) ---- pseudo
gt 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 gt 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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Estrogens
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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, while 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 (lt75
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 lt 50
pg/ml 5. Monitoring Superovulation in ART The
goal is an E2 level of 200 pg/ml per large (gt14
mm) follicle The risk of OHSS is significant if
E2 is gt4000 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 gt2000 pg/ml high risk of OHSS, consider
cycle cancellation
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Progesterone
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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 (8
days after LH peak). Thereafter, a progressive
fall occurs with barely detectable P levels
reached prior to menses. Follicular phase
lt1 Luteal phase 5-20 Post menopause lt1
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Clinical applications 1. Diagnosis of ovulation
in cases of infertility DUB a 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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Serum 17 OH progesterone
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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
• Hirsutism
• Ambigous genitalia

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17 oh P(ng/dl) morning lt 200

gt 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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Androgens
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• Androgen production
• Androstenedione
• 
  Testosterone
• Adrenal DHEA
  Ovary
• DHEAS

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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 gt
  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 gt 2ug/ml CC
Corticosteroid (ACOG,2002) In hirsutism DHEAS
gt2 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 gt
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.BHyperprolactinaemia can cause an
increase in DHEAS. Treatment with Bromocriptin
will decrease prolactin DHEAS
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• Total teststerone
• Clinical application
• 1. Initial laboratory investigation of hirsutism
• Total testosterone measures the ovarian
  adrenal activity.

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Testosterone (ng/dl) gt200

lt200 U/S of the ovary

Anovulation
( FG/I. PRL,
endom biopsy) Adenxal mass
Nothing Laparotomy CT
of the adrenala ovaries

Laparotomy
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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
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Karyotype, Androgens, 17 OHP XY
Normal androgens
Normal androgens signs of
adrenal failure
Normal 17OHP normal 17 OHP
CAH with 3B
IAIS, 5?reductase def, true hph, .
Dehydogenase
mixed gonadal dysgenesis, block in male.
abnormal androgen
synthesis

Gonadectomy
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Thank you
Prof. Aboubakr Elnashar
Benha University Hospital,Egypt Email
elnashar53_at_hotmail.com