The Female Hormone Panel: Oestrogen, Progesterone and More

Testing a Menstruating Woman

Days 2 to 5 of the cycle, counting from the first day of full flow, for a baseline: FSH, LH and oestradiol. This is the early follicular phase, when values are at their lowest and most comparable between cycles.

Around day 21, or roughly seven days before the expected period, for progesterone, to assess whether ovulation occurred. A raised mid-luteal progesterone indicates ovulation; a low value may mean no ovulation or mistimed sampling in a longer cycle, which is why cycle length matters for the timing.

Any time, for cycle-independent measures: anti-Müllerian hormone, prolactin, thyroid function, and androgens where relevant.

Total and free testosterone with SHBG, plus DHEA-S, where there are features of androgen excess: acne, hirsutism, scalp hair loss or irregular cycles.

What a result without a cycle day is worth: very little. An oestradiol of 300 pmol/L is unremarkable mid-cycle and would be notable on day 3. Laboratories cannot supply the context, so it has to be recorded at the time of the draw.

What Each Test Answers

LH to FSH ratio is often cited in PCOS assessment and is neither necessary nor sufficient for it. Current criteria rest on clinical and ultrasound features alongside androgen excess, and the ratio adds little.

Anti-Müllerian hormone deserves a caveat: it estimates ovarian reserve and does not predict natural fertility well in an individual, and it is not a useful general longevity marker despite being marketed as one.

Perimenopause: Why Testing Disappoints

This is the most common reason for a female hormone panel and the situation where it helps least.

During the transition, oestradiol fluctuates unpredictably rather than declining smoothly, and can be high as well as low. FSH rises overall while varying substantially between cycles. Symptoms frequently precede any change in cycle regularity, and a normal FSH does not exclude perimenopause.

Consequently, guidelines identify perimenopause clinically, on symptoms and cycle pattern in a woman of appropriate age, rather than biochemically. Testing has a role in specific situations: in women under 40 to assess premature ovarian insufficiency, where the stakes are higher and identifying it matters; in women under 45 where the picture is unclear; where another cause needs excluding; and on hormonal contraception, which masks the pattern.

What is worth testing instead, because it changes management: thyroid function, since symptoms overlap substantially; ferritin and full blood count, since heavy bleeding is common in perimenopause and iron shortfall explains much of the fatigue; vitamin D; HbA1c and lipids, since cardiovascular risk shifts after the transition; and mood assessment.

That panel answers more questions than an FSH does, and it identifies things that are addressable.

Contraception, and What It Does to the Panel

Hormonal contraception changes the panel substantially and is frequently not accounted for.

Combined oral contraceptives suppress FSH, LH, endogenous oestradiol and progesterone, and raise SHBG substantially, which lowers free testosterone. A hormone panel on the combined pill measures the suppression rather than the woman's own axis.

Progestogen-only methods vary in whether they suppress ovulation, so results depend on the method.

Hormonal intrauterine systems act largely locally, and ovulation often continues, so systemic measurements are less affected.

The practical implication: to assess the underlying axis, testing generally needs to be done off hormonal contraception for a few cycles, which is a real cost and worth weighing against what the result would change.

Also relevant: combined contraceptives raise CRP and SHBG and lower free testosterone, which affects the interpretation of markers beyond the hormone panel.

The Post-Menopausal Panel

After menopause, routine sex hormone monitoring is generally not indicated, and the useful measurements change.

What matters instead: apolipoprotein B and blood pressure, since cardiovascular risk rises after the transition; bone density assessment per guideline age or earlier with risk factors; HbA1c; thyroid function; vitamin D; and ferritin, since post-menopausal iron shortfall requires investigation rather than supplementation.

Where hormone measurement does have a role: monitoring some forms of hormone therapy, investigating unexpected bleeding, which always requires assessment, and assessing suspected androgen-producing tumours where androgen excess is new and marked.

Hormone therapy monitoring is generally clinical, guided by symptoms and dose response rather than by target levels, with some exceptions for particular preparations.

Post-menopausal bleeding is worth stating separately: it always warrants prompt assessment regardless of hormone levels, and no laboratory result substitutes for that.

What Not to Order, and What To

Not useful: salivary hormone panels, which are not validated for reproductive hormone assessment; broad dried urine hormone metabolite panels, whose interpretive frameworks exceed validation; a single random oestradiol or progesterone without a cycle day; FSH to confirm perimenopause in a woman over 45 with typical symptoms; anti-Müllerian hormone as a general ageing marker; and repeated panels at short intervals in a stable person.

Useful, in the right situation: the cycle-timed core panel where cycles are irregular or fertility is a question; androgen assessment where there are features of excess; prolactin where cycles are absent; thyroid function almost always; and the non-hormonal panel that explains most symptoms attributed to hormones.

Escalate clinically for: absent periods, post-menopausal bleeding, galactorrhoea, visual field changes or headaches suggesting a pituitary cause, rapidly progressive hirsutism or virilisation, suspected premature ovarian insufficiency under 40, or perimenopausal symptoms substantially affecting function, where hormone therapy is an effective option worth discussing.

The last point matters. Symptoms affecting daily function are a reason to have a clinical conversation about hormone therapy rather than to pursue further testing, since testing rarely changes that decision and the therapy is guided by symptoms.