Hormone Testing – Indications and Appropriate Use

(formerly known as Special Endocrine Testing)

Effective Date: May 25, 2016

Recommendations and Topics

Scope

This guideline provides recommendations on the appropriate indications for testing of selected endocrine hormones in patients aged ≥ 19 years, mainly in a primary health care setting. The document is intended to provide direction to primary care physicians and help constrain inappropriate test utilization particularly as it pertains to so-called wellness and “anti-aging” practices. However, it does not represent exhaustive guidance to the appropriate use of the endocrine tests listed as other indications will be identified in the practices of RCPSC certified gynecologists, urologists, laboratory physicians, and endocrinologists. The document is not intended to address the care of pediatric or transgender patients.

A few of the lab tests mentioned in this guideline may be less than familiar to some practitioners, but their inclusion is intentional.  A goal of completeness required listing all routinely available tests potentially relevant to a given endocrine condition. Additionally, the working group recognized that practitioners routinely vary in their chosen clinical interests, and that some may wish to pursue investigations for some conditions to a greater degree than would their colleagues. Finally, inclusion of some lesser known tests hopefully serves to refine and advance the continuing medical education of all interested guideline readers.

Key Recommendations

  1. Testosterone testing in women for the investigation of low libido is not useful.
  2. Estradiol testing in men is not useful unless there are signs of spontaneous feminization.
  3. 1,25(OH)2 Vitamin D testing, with rare exception, is indicated for the investigation of hypercalcemia with concomitantly low parathyroid hormone (PTH) only and is not indicated for monitoring patients receiving calcitriol.
  4. Insulin testing is primarily useful for investigation of spontaneous hypoglycemia or to help distinguish type I diabetes from type II diabetes, but not for establishment of insulin resistance.
  5. The utility of salivary hormone testing in any clinical context is limited to Cushing Syndrome screening using late night salivary cortisol levels.
  6. Screening for growth hormone (GH) related disorders with insulin-like growth factor 1 (IGF1) is only indicated in patients demonstrating symptoms of GH excess (acromegaly) or deficiency.

Testing

1. Reproduction

Testosterone – Total | Sex Hormone Binding Globulin | Estradiol
Progesterone | Luteinizinng Hormone Follicle Stimulating Hormone Androstenedione | DHEA | DHEA-S | 17-OHP | Prolactin

Testosterone – Total1–10  (T)

MSP cost: $15.81

Indications Non-Indications
Male Female

Investigation of male hypogonadism.

Monitoring of males receiving androgen replacement.

Confirming adequacy of anti-androgen therapy in males with prostate carcinoma. 

Investigation of female androgen excess.

Screening for biochemical evidence of hypogonadism is not indicated in males without symptoms. Some symptoms of hypogonadism overlap with normal effects of aging.3

Not useful for investigation of decreased libido in females.7

Not useful for monitoring females receiving androgen therapy for low libido unless overuse is suspected or unexpected virilization has developed.

Notes: For the investigation of male hypogonadism. Diurnal variation of T requires that collection be performed between 7 and 10 AM or within 3 hours of waking.

Only tandem mass spectrometry is sufficiently sensitive to accurately measure the low total testosterone seen in normal females or males rendered chemically castrate for prostate carcinoma.

For information, refer to BCGuidelines.ca: Testosterone Testing Protocol.

For information about Free Testosterone and Bioavailable Testosterone, see Appendix A: Testosterone Testing and Measurements in BC.

Sex Hormone Binding Globulin  (SHBG)

MSP cost: $13.56

Indications Non-Indications
Male Female

Clarification of borderline low total testosterone.

Investigation of males with high testosterone of endogenous origin.

Clarification of borderline high total testosterone results.

 

Notes: Total testosterone is the first-line test for male hypogonadism.

Estradiol2 (E2)

MSP cost: $22.43

Indications Non-Indications
Male Female

Not indicated in routine clinical practice.

Investigation for estrogen producing neoplasms in males demonstrating spontaneous feminization including gynecomastia. 

Investigation of primary ovarian insufficiency or infertility.

Investigation of primary ovarian insufficiency—where possible, order in conjunction with FSH on day 3 of menstrual cycle (not day 21).

Monitoring of patients receiving aromatase inhibitor therapy.

Detection of estrogen-producing neoplasms.

For monitoring of females undergoing fertility treatment.

Not indicated in the investigation of male osteoporosis.11

Not indicated for monitoring of men receiving testosterone therapy.12

Not indicated to determine if a woman is in menopause except in those with prior hysterectomy without bilateral salpingo-oophrectomy.

Not indicated for monitoring of patients receiving ERT.

Notes: E2 immunoassay performance is poor at low concentration2,13 ranges making these assays inadequate for use in females receiving aromatase inhibitors14 and in most male patients. E2 analysis by tandem mass spectrometry can be arranged for females receiving aromatase inhibitors.

For the investigations of female osteoporosis, see BCGuidelines.ca: Osteoporosis: Diagnosis, Treatment and Fracture Prevention.

Progesterone 

MSP cost: $14.86

Indications Non-Indications
Male Female

Not indicated.

Investigation of infertility.

Identification of prior ovulation.

Investigation of pregnancy viability.15

Not indicated to determine if a woman is in menopause except in those with prior hysterectomy without bilateral salpingo-oophrectomy.

Notes: Usually performed in combination with measurement of appropriate sex steroids (T for males, E2 for females).

Luteinizing Hormone16, 17 (LH)

MSP cost: $12.41

Indications Non-Indications
Male Female

Investigation of primary or secondary hypogonadism.

Investigation of primary or secondary hypogonadism.

Investigation of infertility.

Prediction of ovulation (by LH surge).

LH / FSH ratio is not  recommended to identify women with PCOS, but has clinical value in established cases.18

Not indicated to determine if a woman is in menopause except in those with prior hysterectomy without bilateral salpingo-oophrectomy.

Notes: Usually performed in combination with measurement of appropriate sex steroids (T for males, E2 for females).

Follicle Stimulating Hormone16, 17 (FSH)

MSP cost: $36.09

Indications Non-Indications
Male Female

Investigation of primary or secondary hypogonadism.

Investigation of oligospermia or azoospermia. .

Investigation of primary or secondary hypogonadism.

Investigation of infertility.

Investigation of primary ovarian insufficiency or infertility—where possible, order in conjunction with E2 on day 3 of menstrual cycle.

LH / FSH ratio is not recommended to identify women with PCOS, but has clinical value in established cases.18

Not indicated to determine if a woman is in menopause except in those with prior hysterectomy without bilateral salpingo-oophrectomy.

Notes: Usually performed in combination with measurement of appropriate sex steroids (T for males, E2 for females).

Androstenedione

MSP cost: $36.09

Indications Non-Indications
Male Female

Not indicated in routine clinical practice.

May be useful in monitoring therapy in patients with established CAH.19

Not indicated in routine clinical practice.

Functions as a second–line tool in the investigation of PCOS often in specialty practice.

May be useful in monitoring therapy in patients with established CAH.19

Not indicated in the investigation of male hypogonadism as this is primarily an adrenal steroid.

Dehydroepiandrosterone (DHEA)

MSP cost: $18.55

Indications Non-Indications
Male Female

Not indicated.

Not indicated in the investigation of male hypogonadism as this is an adrenal steroid. 

Dehydroepiandrosterone–sulphate20 (DHEA-S)

MSP cost: $18.55

Indications Non-Indications
Male Female

Not indicated in routine clinical practice.

Investigation of adrenal carcinoma. 

Investigation of PCOS.

Investigation of adrenal mass.

Not useful for the investigation of male hypogonadism as this is an adrenal steroid.

17-hydroxyprogesterone (17-OHP)                    

MSP cost: $41.71

Indications Non-Indications
Male Female

Not indicated in routine clinical practice.

For the diagnosis of non-classic CAH as a cause of hirsutism and for monitoring of CAH therapy.

 

Prolactin

MSP cost: $13.49

Indications Non-Indications
Male Female

Investigation of infertility / hypogonadism /amenorrhea.

Investigation of galactorrhea.

Investigation for prolactinoma and other pituitary tumours.

Monitoring of prolactinoma in patients treated medically or surgically.

Not useful for monitoring pregnant or lactating patients.

2. Calcium and Bone Metabolism

25-hydroxyvitamin D1,25 dihydroxyvitamin D | Parathyroid Hormone​

25-hydroxyvitamin D (25(OH)D)

MSP cost: $61.32

Indications Non-Indications

Investigation of vitamin D nutritional status only by specialists in clinical scenarios where biochemical identification of vitamin D deficiency is necessary.

Not useful in the investigation of hypercalcemia unless there is clinical suspicion of vitamin D supplement overdose.

Notes: If ordered by a family physician, the patient must pay for analysis. For information, refer to BC Guidelines.ca: Vitamin D Testing Protocol.

1,25 dihydroxyvitamin D (1,25(OH)2D)

MSP cost: $94.49

Indications Non-Indications

Investigation of hypercalemia with concomitantly low PTH.

Should not be used for the investigation of vitamin D nutritional status.

Should not be used to monitor levels of pharmaceutically administered calcitriol.

Notes: If ordered by a family physician, the patient must pay for analysis. For information, refer to BC Guidelines.ca: Vitamin D Testing Protocol.

Parathyroid Hormone (PTH)

MSP cost: $17.52–25.18

Indications Non-Indications

Investigation of hyper and hypocalcemia.

Monitoring and treatment of renal osteodystrophy.

 

Notes: In patients with previously identified hypo or hypercalcemia, measure concomitantly with a repeat total or ionized calcium.

3. Adrenal

Aldosterone | Renin | Cortisol, 24-hour urine free | Cortisol, serum/plasma​ | Cortisol, late night salivary​ | ACTH stimulation test​ | ACTH​ | Catecholamines and Metanephrines (urinary excretion) | Plasma Catecholamines​ | Plasma Free Metanephrines​

Aldosterone, plasma and urine

MSP cost: $170.92

Indications Non-Indications

Investigation of secondary causes of hypertension: primary aldosteronism, renal artery stenosis.

Not indicated for the initial investigation of syncope or hypotension caused by possible adrenal insufficiency. For adrenal insufficiency, screen with am cortisol and proceed to 250 µg ACTH stimulation test as indicated.

Notes: For ambulatory patients meeting criteria for primary aldosteronism screening, order upright plasma aldosterone and plasma renin activity after 1-2 hours ambulation and before 10 AM.21

Numerous physiological states and medications interfere with sensitivity and specificity of screening.21

Renin

MSP cost: $63.87 – $98.11

Indications Non-Indications

Investigation of secondary causes of hypertension: primary aldosteronism and renal artery stenosis.

Monitoring of CAH and mineralocorticoid supplementation in Addison’s Disease.

 

Cortisol, 24-hour urine free

Indications Non-Indications

Used for targeted screening for Cushing Syndrome caused by endogenous cortisol excess only.

Not useful for the diagnosis of Addison's Disease.

Do not order in patients receiving exogenous glucocorticoids.

Notes: Numerous studies have found males to have higher excretion rates than females. Application of sex specific reference intervals advised in cases where elevation is equivocal.22, 23  

Cortisol, serum/plasma

MSP cost: $13.28

Indications Non-Indications

Used in the targeted screening and diagnosis of both Addison's Disease (primary adrenal insufficiency) and Cushing Syndrome.

Not useful in the investigation of non-specific fatigue and lethargy unless accompanied by clinical syndromes of Addison's Disease or Cushing Syndrome.

Measurement of morning and afternoon cortisol (for diurnal variation) is not useful.

Notes: A morning cortisol measurement can be used to exclude adrenal insufficiency. Collect sample between 7 AM and 10 AM or within 3 hours of waking. Do not order random cortisol levels for this purpose.

An am serum/plasma cortisol is not useful as a screen for Cushing Syndrome. Use 1 mg overnight dexamethasone suppression, 24-hour urinary free cortisol or late night salivary cortisol.24, 25

For cortisol analysis after ACTH stimulation, see adrenocorticotropic hormone simulation test.

Measurement of cortisol in patients being treated with exogenous glucocorticoids presents numerous bioanalytical and interpretive challenges and is not advised without consultation with an endocrinologists and/or laboratory physician/scientist.

Cortisol, late night salivary

MSP cost: $77.25

Indications Non-Indications

Used to screen for Cushing Syndrome caused by endogenous cortisol excess only.

 

Notes: Only available through Vancouver General Hospital.

Measurement of cortisol in patients being treated with exogenous glucocorticoids presents numerous bioanalytical and interpretive challenges and is not advised without consultation with an endocrinologists and/or laboratory physician/scientist.

Adrenocorticotropic hormone stimulation test (ACTH stimulation test)

MSP cost: $45.24

Indications Non-Indications

Used in the diagnosis of Addison's Disease (primary adrenal insufficiency) and secondary adrenal insufficiency.

Used in the diagnosis of non-classic CAH.

 

Notes: Patients with Addison's Disease have marked elevations of plasma ACTH at initial presentation provided that they are not exposed to exogenous glucocorticoid.

17-OHP is also ordered if non-classic CAH is a diagnostic consideration.

Measurement of cortisol in patients being treated with exogenous glucocorticoids presents numerous bioanalytical and interpretive challenges and is not advised without consultation with an endocrinologists and/or laboratory physician/scientist.

Adrenocorticotropic (ACTH)

MSP cost: $36.57

Indications Non-Indications

Used in the diagnosis Addison's Disease (primary adrenal insufficiency) and secondary adrenal insufficiency.

Used to distinguish between Cushing Syndrome caused by adrenal adenoma and Cushing Syndrome caused by inappropriate ACTH production from pituitary adenoma or ectopic source.

Used in the diagnosis of non-classic CAH.

 

Notes: For the investigation of adrenal insufficiency, concomitant am ACTH and cortisol should be performed before pursuit of ACTH stimulation testing. 

24-hour urinary excretion of catecholamines and metanephrines

MSP cost: $46.45 catecholamines
$155.77 metanephrines

Indications Non-Indications

Used in the diagnosis of pheochromocytoma and functional paraganglioma. 

Urinary vanillylmandelic acid, although the end metabolite of both epinephrine and norepinephrine, has test characteristics inferior to urinary catecholamines and metanephrines and is not required for the investigation of pheochromocytoma.26

Urinary dopamine and homovanillic acid are not required for the initial investigation of pheochromocytoma.

This test is not to be used as a tool for psychiatric assessment.

Notes: This test is subject to false positives from physiological stressors, certain foods, and numerous medications. Appropriate patient preparation is required to yield meaningful results.27, 28 

Plasma Catecholamines

MSP cost: $59.27

Indications Non-Indications

Of limited use in the diagnosis of pheochromocytoma and functional paraganglioma.

This test is not to be used as a tool for psychiatric assessment.

Notes: This test is very sensitive to stress-related fluctuations during collection and requires an indwelling catheter, supine posture and a calm environment to generate useful results.

Plasma Free Metanephrines

Indications Non-Indications

Used in the diagnosis of pheochromocytoma and functional paraganglioma. 

This test is not to be used as a tool for psychiatric assessment.

Notes: Not currently offered in BC. Can be arranged as an out of province send–out where required (e.g. for diagnostic clarity in ambiguous cases or for the oliguric patient). This test is sensitive to patient posture and supine collections are recommended.27

4. Thyroid

Thyroid Stimulating Hormone | Free Thyroxine​ | Free Triiodothyronine​ | Total thyroxine/ triiodothyronine​ | Anti-thyroid peroxidase​ | Thyroglobulin / Antithyroglobulin | Thyroid stimulating hormone receptor antibodies

Thyroid Stimulating Hormone (TSH)

MSP cost: $9.90

Indications Non-indications

Used to screen for all causes of primary hypothyroidism and hyperthyrodism.

Monitoring of patients treated with thyroid hormone.

 

Notes: TSH may be repeated after at least 6-12 weeks following a change in thyroid hormone replacement dose or after a change in a patient’s clinical status.

TSH monitoring in pregnancy can be as frequent as every 4 -6 weeks.29 

Once the TSH has normalized with treatment, it should be checked annually unless clinically indicated.

For information, refer to BCGuidelines.ca: Thyroid Function Tests: Diagnoses and Monitoring of Thyroid Function Disorders in Adults.

Free Thyroxine (fT4)

MSP cost: $12.12

Indications Non-Indications

Used to screen for all causes of primary hypothyroidism and hyperthyrodism.

Monitoring of patients treated with thyroid hormone.

Not for use in an initial screen for thyroid dysfunction except in the unusual circumstance that there is specific reason to suspect pituitary disease. 

Free Triiodothyronine (fT3)

MSP cost: $9.35

Indications Non-Indications

Rarely indicated. Reserved for situations where hyperthyroidism is suspected clinically and TSH is suppressed, but fT4 is not elevated.

Not for use in an initial screen for thyroid dysfunction.

Total thyroxine/ triiodothyronine (Total T4/T3)

Indications Non-Indications

Not currently offered by any lab in BC.

Replaced by free hormone determination.

 

Anti-thyroid peroxidase

MSP cost: $20.22

Indications Non-Indications

Used for the diagnosis of Hashimoto’s thyroiditis in the investigation of primary hypothyroidism.

Serial measurements are not indicated.

Thyroglobulin/Antithyroglobulin 
(Tg/Anti Tg)

MSP cost: $27.90/$20.40

Indications Non-Indications

Serves as a tumor marker for patients who have undergone previous treatment for papillary or follicular thyroid carcinoma.

Anti-Tg measurements are not indicated for the investigation for general thyroid autoimmunity.

Tg measurement is not indicated in patients with an intact thyroid except in rare circumstances.

Notes: Anti-Tg must be measured concomitantly with Tg as the presence of Anti-Tg makes Tg results unreliable.

Antibodies to the thyroid stimulating hormone receptor (TRAb)

MSP cost: $22.48

Indications Non-Indications

Used for the diagnosis of Graves’ Disease.

In certain clinical scenarios TRAb testing may be used as a first-line tool to distinguish Graves’ Disease from other forms of hyperthyroidism. See notes.

Not indicated for the investigation for general thyroid autoimmunity.

Notes: Although radioactive iodine uptake remains the gold standard for the identification of hyperthyroidism caused Graves’ Disease, TRAb offers advantages in specific clinical scenarios: investigation of unilateral exophthalmos, euthyroid Graves opthalmopathy, diagnosis of Graves’ Disease where exposure to radioactive iodine is contraindicated (pregnancy) or where the patient is apprehensive about exposure to radiotracers. TRAb also serves as a prognostic tool in a number of clinical scenarios.30, 31 TRAb testing is more easily arranged and results are typically available sooner than radioactive iodine uptake and scan.

5. Growth

Growth Hormone | Insulin-like Growth Factor 1​

Growth Hormone (GH)

MSP cost: $30.38

Indications Non-Indications

Used to confirm diagnosis and to assess response to treatment in acromegaly by use of dynamic function tests.

Used to assess pituitary ability to generate GH in dynamic function tests for hypopituitarism or pituitary growth hormone deficiency.

A random GH should not be ordered to screen for the investigation of either acromegaly or GH deficiency.

Insulin-like Growth Factor 1 (IGF1)

MSP cost: $55.08

Indications Non-Indications

Used to screen for acromegaly and growth hormone deficiency in symptomatic patients.

Used for the monitoring response to treatment (surgical or medical) for acromegaly.

Used to monitor response to therapy in patients receiving recombinant GH.

Should not be ordered unless there are specific symptoms of acromegaly or evidence/risk factors for hypopitutarism.32

Notes: Reference intervals are highly dependent on age. Please use age-specific reference interval provided on the lab report. A complete chart of reference intervals by age is available from St. Paul’s Hospital Department of Pathology and Laboratory Medicine, at website: providencelaboratory.com.

6. Glucose Homeostasis

Insulin | C-peptide​

Insulin

MSP cost: $27.55

Indications Non-Indications

Investigation of hypoglycemia. Note that the specimen collected at the time of hypoglycemia must be analyzed.

Fasting insulin may be useful in the investigation of PCOS in females.33

Not indicated for patients receiving insulin therapy.

Not for the investigation of impaired fasting glucose or the establishment of insulin resistance.

Lack of standardization in insulin assays and lack of data for normative responses mean that glucose-stimulated insulin measurements are not recommended in clinical practice.34, 35

Notes: Reference intervals are BMI-dependent and require fasting state.

May be helpful in distinguishing type 1 from type 2 diabetics in equivocal cases, prior to commencement of therapy.

For investigation of hypoglycemia, the specimen demonstrating hypoglycemia is required and must be frozen at the earliest possible opportunity.

Occasionally confirmation of surreptitious or accidental insulin administration is clinically indicated in cases of hypoglycemia. However, many insulin assays do not detect synthetic analog insulins well. Specialized analysis is required to detect synthetic analogues. Consult with laboratory physician or scientist for advice.

C-peptide

MSP cost: $47.42

Indications Non-Indications

Investigation of hypoglycemia.

 

Notes: Reference intervals are BMI-dependent and require fasting state.

May be helpful in distinguishing type 1 from type 2 diabetics in equivocal cases, prior to commencement of therapy.

C-peptide clearance is poor in patients with CKD, where large elevations above the reference interval are common.

Abbreviations:

1,25(OH)2D = 1,25 dihydroxyvitamin D; 17-OHP = 17-hydroxyprogesterone; 25(OH)D = 25-hydroxyvitamin D; ACTH = adrenocorticotropic hormone; Anti-TPO = Anti-thyroid peroxidase; BMI = body mass index; CAH = congenital adrenal hyperplasia; CKD = chronic kidney disease; DHEA = dehydroepiandrosterone; DHEA-S = dehydroepiandrosterone-sulphate; E2 = estradiol; ERT = estrogen replacement therapy; FSH = follicle stimulating hormone; fT3 = free triiodothyronine; fT4 = free thyroxine; GH = growth hormone; h = hour; IGF1 = insulin-like growth factor 1; LH = luteinizing hormone; PCOS = polycystic ovary syndrome; SHBG = sex hormone binding globulin; T = testosterone-total; T4 = thyroxine; T3 = triiodothyronine; Tg = thyroglobin; TRAb = TSH Receptor Antibody; TSH = thyroid stimulating hormone.
 

Note: Includes the Fee-for-Service costs as per the Schedule of Fees – Laboratory Services Payment Schedule, as of October 1, 2015.

Resources

References

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  2. Vesper HW, Botelho JC, Wang Y. Challenges and improvements in testosterone and estradiol testing. Asian J Androl. 2014;16(2):178-84.
  3. Morales A, Bebb RA, Manjoo P, et al. Diagnosis and management of testosterone deficiency syndrome in men: clinical practice guideline. CMAJ. 2015; 187(18):1369-1377.
  4. Paduch DA, Brannigan RE, Fuchs EF, et al. The laboratory diagnosis of testosterone deficiency. Urology. 2014;83(5):980.
  5. Davis SR, Davison SL, Donath S, et al. Circulating androgen levels and self-reported sexual function in women. JAMA. 2005;294(1):91-6.
  6. Basson R, Brotto LA, Petkau AJ, et al. Role of androgens in women's sexual dysfunction. Menopause. 2010;17(5):962-71.
  7. Wierman ME, Arlt W, Basson R, et al. Androgen therapy in women: a reappraisal: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2014;99(10):3489-510.
  8. Yun YM, Botelho JC, Chandler DW, et al. Performance criteria for testosterone measurements based on biological variation in adult males: recommendations from the Partnership for the Accurate Testing of Hormones. Clinical chemistry. 2012;58(12):1703-10.
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  13. Rosner W, Hankinson SE, Sluss PM, et al. Challenges to the measurement of estradiol: an endocrine society position statement. J Clin Endocrinol Metab. 2013 Mar 5;98(4):1376-87.
  14. Folkerd EJ, Lønning PE, Dowsett M. Interpreting plasma estrogen levels in breast cancer: caution needed. JOC. 2014;32(14):1396-1400.
  15. Canavan TP, Mastrobattista JM. First-Trimester Ultrasound: Early Pregnancy Failure. InFirst-Trimester Ultrasound 2016 (pp. 253-282). Springer International Publishing.
  16. Legro SA, Arslanian DA, Ehrmann KM, et al. Diagnosis and Treatment of Polycystic Ovary Syndrome: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab, 2013; 98(12):4565–4592.
  17. Conway G, Dewailly D, Diamanti-Kandarakis E, Escobar-Morreale HF, Franks S, Gambineri A, et al. The polycystic ovary syndrome: a position statement from the European Society of Endocrinology. Eur J Endocrinol. 2014;171(4):P1–29.
  18. Cho LW, Jayagopal V, Kilpatrick ES, et al. The LH/FSH ratio has little use in diagnosing polycystic ovarian syndrome. Annals of clinical biochemistry. 2006 May 1;43(3):217-9.
  19. Speiser PW, Azziz R, Baskin LS, et al. Congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2010 Sep;95(9):4133-60.
  20. Allolio B, Fassnacht M. Adrenocortical carcinoma: Clinical Update. J Clin Endocrinol Metab, 2006, 91(6):2027–2037.
  21. Funder JW, Carey RM, Mantero F, et al. The Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016 Mar 2:jc-20154061[Epub ahead of print].
  22. Murphy BE. Urinary free cortisol determinations: what they measure. The Endocrinologist. 2002;12(2):143-50.
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  25. Nieman LK, Biller BM, Findling JW, et al. The diagnosis of Cushing's syndrome: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2008;93(5):1526-40.
  26. Boyle JG, Davidson DF, Perry CG, et al. Comparison of diagnostic accuracy of urinary free metanephrines, vanillyl mandelic acid, and catecholamines and plasma catecholamines for diagnosis of pheochromocytoma. J Clin Endocrinol Metab. 2007;92(12):4602-8.
  27. Lenders JW, Duh QY, Eisenhofer G, et al. Pheochromocytoma and paraganglioma: An endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2014;99(6):1915-42.
  28. van Berkel A, Lenders JW, Timmers HJ. Diagnosis of endocrine disease: Biochemical diagnosis of phaeochromocytoma and paraganglioma. Eur J Endocrinol. 2014;170(3):R109-19.
  29. De Groot L, Abalovich M, Alexander EK, et al. Management of thyroid dysfunction during pregnancy and postpartum: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2012 Aug;97(8):2543-65.
  30. Matthews DC, Syed AA. The role of TSH receptor antibodies in the management of Graves' disease. Eur J Intern Med. 201;22(3):213-6.
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  32. Katznelson L, Laws ER, Melmed S, et al. Acromegaly: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2014; 99(11):3933–3951.
  33. Traub ML. Assessing and treating insulin resistance in women in with polycystic ovarian syndrome. World J Diabetes. 2011;2(3):33-40.
  34. Buchanan TA, Watanabe RM, Xiang AH. Limitations in surrogate measures of insulin resistance. T J Clin Endocrinol Metab. 2010;95(11):4874-6.
  35. Antuna-Puente B, Disse E, Rabasa-Lhoret R, et al. How can we measure insulin sensitivity/resistance?. Diabetes & metabolism. 2011;37(3):179-88.

Appendices

Appendix A: Testosterone Testing and Measurements in BC

Associated Documents

The following associated BC Guidelines and Protocols accompany this guideline:

This guideline is based on scientific evidence current as of the Effective Date.

This guideline was developed by the Guidelines and Protocols Advisory Committee, approved by the British Columbia Medical Association, and adopted by the Medical Services Commission.

The principles of the Guidelines and Protocols Advisory Committee are to:

  • encourage appropriate responses to common medical situations
  • recommend actions that are sufficient and efficient, neither excessive nor deficient
  • permit exceptions when justified by clinical circumstances.

Contact Information

Guidelines and Protocols Advisory Committee
PO Box 9642 STN PROV GOVT
Victoria BC V8W 9P1

E-mail: hlth.guidelines@gov.bc.ca

Web site: www.BCGuidelines.ca

 


Disclaimer

The Clinical Practice Guidelines (the “Guidelines”) have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem, and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problem. We cannot respond to patients or patient advocates requesting advice on issues related to medical conditions. If you need medical advice, please contact a health care professional