Trip Answers

Question answered:24/04/08

In answering this question, we do not the age of the patient.

 

The CKS guideline on the menopause discusses the use of FSH and LH tests:

 

“How do I know my patient’s symptoms are due to the perimenopause?

 

Investigations
• Laboratory investigations are not routinely recommended for diagnosing the menopause. The diagnosis of menopause in women older than 45 years of age with typical menopausal symptoms is clinical:
o Measurement of follicle-stimulating hormone (FSH) is of limited value and may cause confusion, as FSH levels fluctuate during the peri-menopause [Smellie et al, 2006; Smellie, 2007]:
? Normal results do not exclude the menopause.
? An increased concentration is suggestive of ovarian failure.
? An increased concentration does not indicate an inability to conceive.
o Measurement of luteinzing hormone, estradiol, progesterone, or testosterone is of no value in diagnosing ovarian failure but is relevant in diagnosing other causes of secondary amenorrhoea, including polycystic ovary syndrome, and also in investigating infertility.
When might the measurement of FSH provide useful information?
Women less than 45 years of age. Measurement of follicle-stimulating hormone (FSH) levels may be helpful in younger women with suspected premature menopause (< 45 years). Serial measurements over time may be needed to make a diagnosis. High FSH levels (above 30 IU/L) suggest ovarian failure [Smellie et al, 2006]…” [1]

 

The Lab Tests Online offering the following information on interpreting FSH and LH results:

 

 

“What does the test result mean?
In women, FSH and LH levels can help to tell the difference between primary ovarian failure (failure of the ovaries themselves) and secondary ovarian failure (failure of the ovaries due to disorders of either the pituitary gland or the hypothalamus in the brain). Increased levels of FSH and LH are consistent with primary ovarian failure. Some causes of primary ovarian failure are listed below.

 

Developmental defects:
• Ovarian agenesis (failure to develop ovaries) 
• Chromosomal abnormality, such as Turner’s syndrome
• Ovarian steroidogenesis defect, such as 17 alpha hydroxylase deficiency
Premature ovarian failure due to:
• Radiation therapy 
• Chemotherapy 
• Autoimmune disease
Chronic anovulation (failure to ovulate) due to:
• Polycystic ovary syndrome (PCOS)
• Adrenal disease 
• Thyroid disease 
• Ovarian tumour
When a woman enters the menopause and her ovaries stop working, FSH levels will rise.” [2]

 

In an article on follicle-stimulating hormone abnormalies, Jabbour states:

 

• “In women presenting with low FSH levels or high FSH levels secondary to ovarian failure, manifestations include oligomenorrhea or amenorrhea.
• 
o Galactorrhea may be present in the setting of high prolactin levels.
o Symptoms of other pituitary hormone deficiencies may also be evident if a mass or a destructive process involves the pituitary gland.
o Women may have primary or secondary infertility.
o In women with ovarian failure, other symptoms may include hot flashes, sleep disturbance, mood swings, depression, vaginal dryness and dyspareunia, urinary incontinence, and urinary tract infections.
• In women with high FSH levels from a gonadotroph adenoma, symptoms are frequently due to mass effect (eg, headaches, visual changes, hypopituitarism). However, a high FSH level may also lead to ovarian hyperstimulation in premenopausal women, with multiple ovarian cysts and a thickened endometrium; this leads to disturbed menstrual cycles, ie, oligomenorrhea or amenorrhea.”
Later on in the article, the author notes:
• “In women with high FSH levels, the differential diagnosis is either ovarian failure or gonadotroph adenoma. The following points should be remembered:
• 
o In women with ovarian failure, both FSH and LH levels rise. In women with gonadotroph adenomas, FSH levels are usually high, but LH levels remain within reference ranges. Other pituitary hormone abnormalities may be present.
o If the diagnosis of ovarian failure is confirmed in patients younger than 30 years, a karyotype evaluation should be performed to exclude Turner syndrome or the presence of Y chromatin material because of the high risk of gonadal tumors, mandating gonadectomy.
o In the presence of a normal karyotype, autoimmune disease is likely (30% of these patients); therefore, assessment for autoimmune disorders, including thyroid or adrenal disease, is important. Testing may include TSH, antithyroid antibodies, morning serum cortisol, and ACTH evaluations, followed by an ACTH stimulation test if necessary.” [3]

 

References
1. CKS. Menopause. January 2008.  (http://www.cks.library.nhs.uk/menopause/in_depth/background_information)
2. Lab Tests Online. FSH Test. May 2004 (http://www.labtestsonline.org.uk/understanding/analytes/fsh/test.html)
3. Jabbour S. Follicle-stimulating hormone abnormalities. E-Medicine. August 2007. (http://www.emedicine.com/med/topic803.htm)

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