eMedicine Specialties > Obstetrics and Gynecology > Reproductive Endocrinology and Infertility

Luteinizing Hormone Deficiency: Differential Diagnoses & Workup

Author: Nichole M Giannios, DO, Reproductive Endocrinology and Infertility Fellow, Department of Obstetrics and Gynecology, University Hospitals/Case Medical Center
Coauthor(s): Rebecca Flyckt, MD, Resident in Obstetrics and Gynecology, University Hospitals/Case Medical Center; Allen Donald Seftel, MD, Professor, Department of Urology, Case School of Medicine; William W Hurd, MD, MSc, Professor of Reproductive Biology, Case Western Reserve University School of Medicine; Lilian Hanna Baldwin Chair in Gynecology and Obstetrics, Director, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University Hospitals Case Medical Center
Contributor Information and Disclosures

Updated: Feb 12, 2008

Differential Diagnoses

Amenorrhea, Primary
Luteal Phase Dysfunction
Amenorrhea, Secondary
Ovarian Insufficiency
Anovulation
Polycystic Ovarian Syndrome
Hyperthyroidism
Prolactinoma

Workup

Laboratory Studies

The basic laboratory evaluation for females or males suspected of having luteinizing hormone (LH) deficiency includes serum levels of thyroid-stimulating hormone (TSH), prolactin (PRL), LH, follicle-stimulating hormone (FSH), and estradiol. Low or normal LH and FSH levels in the presence of low estradiol suggest a hypothalamic problem. A pituitary problem is most commonly associated with elevated PRL levels. 

Imaging Studies

When hypothalamic or pituitary dysfunction is suspected, the most important imaging study is magnetic resonance imaging (MRI) of the head to determine the presence of a tumor or other abnormality (see Media File 2).

Other Tests

Olfactory testing

When Kallmann syndrome is suspected, olfactory testing can be performed. Screening tests can be performed using vanilla or aromatic oils (eg, wintergreen, cinnamon). Quantitative tests have been developed using either scratch-and-sniff panels or serial dilutions of odorants such as dimethyl sulfide or acetic acid. Perhaps the most widely used clinical olfactory test is the University of Pennsylvania Smell Identification Test (UPSIT) that uses scratch-and-sniff panels.
 
Screening for eating disorders

Patients suspected of have an eating disorders can be screened for by asking the British SCOFF questions: 

  • Do you ever make yourself SICK when you feel uncomfortably full?
  • Do you worry you have lost CONTROL over how much you eat? 
  • Have you lost more than 14 pounds (ONE stone's worth of weight) within the last 3 months?
  • Do you believe you are FAT when others say you are too thin?
  • Would you say that FOOD dominates your life?
Luteal phase deficiency

When infertile women are suspected of having luteal phase deficiency (LPD), the luteal phase should be evaluated.

  • Duration (normal ≥12 d): Luteal phase duration is measured as the time from the onset of the LH surge detected in the urine to the onset of menses or as the number of days of basal body temperature rise (see Media File 1).
  • Peak luteal phase progesterone (normal ≥12 ng/mL): Peak luteal phase serum progesterone is obtained 1 week after ovulation. 

Procedures

Transsphenoidal resection is used to remove pituitary macroadenomas (>1 cm in diameter) that remain symptomatic or increase in size despite medical treatment.

Luteal phase endometrial biopsies were used in the past to diagnose LPD. However, because of the day-to-day variation in the histologic findings within the luteal phase, biopsies are now rarely performed for this purpose.

Histologic Findings

Pituitary adenomas are rarely malignant. The most common benign adenomas are prolactinomas (70%). Approximately 25% of adenomas do not secrete any hormone (null cell tumors). The remainder secrete TSH, GH, ACTH, and in rare cases, LH and FSH.

More on Luteinizing Hormone Deficiency

Overview: Luteinizing Hormone Deficiency
Differential Diagnoses & Workup: Luteinizing Hormone Deficiency
Treatment & Medication: Luteinizing Hormone Deficiency
Follow-up: Luteinizing Hormone Deficiency
Multimedia: Luteinizing Hormone Deficiency
References
[ CLOSE WINDOW ]

References

  1. Cahill DJ, Wardle PG, Harlow CR, Hull MG. Onset of the preovulatory luteinizing hormone surge: diurnal timing and critical follicular prerequisites. Fertil Steril. Jul 1998;70(1):56-9. [Medline].

  2. Fluker M, Fisher S. Anovulation and ovulatory dysfunction. In: Falcone T, Hurd WW. Clinical reproductive medicine and surgery. New York: Elsevier; 2007:277-86.

  3. Kalantaridou SN, Makrigiannakis A, Zoumakis E, Chrousos GP. Stress and the female reproductive system. J Reprod Immunol. Jun 2004;62(1-2):61-8. [Medline].

  4. Lofrano-Porto A, Barra GB, Giacomini LA, Nascimento PP, Latronico AC, Casulari LA. Luteinizing hormone beta mutation and hypogonadism in men and women. N Engl J Med. Aug 30 2007;357(9):897-904. [Medline].

  5. Loret de Mola JR. Amenorrhea. In: Falcone T, Hurd WW, eds. Clinical reproductive medicine and surgery. New York: Elsevier; 2007:233-52.

  6. Mahutte NG, Ouhilal S. Hypothalamic-pituitary-ovarian axis & control of the menstrual cycle. In: Falcone T, Hurd WW, eds. Clinical reproductive medicine and surgery. First ed. New York: Elsevier; 2007:1-16.

  7. McComb JJ, Qian XP, Veldhuis JD, J McGlone J, Norman RL. Neuroendocrine responses to psychological stress in eumenorrheic and oligomenorrheic women. Stress. Mar 2006;9(1):41-51. [Medline].

  8. Patel SS, Bamigboye V. Hyperprolactinaemia. J Obstet Gynaecol. Jul 2007;27(5):455-9. [Medline].

  9. Pritts SD, Susman J. Diagnosis of eating disorders in primary care. Am Fam Physician. Jan 15 2003;67(2):297-304. [Medline].

  10. Raivio T, Falardeau J, Dwyer A, Quinton R, Hayes FJ, Hughes VA. Reversal of idiopathic hypogonadotropic hypogonadism. N Engl J Med. Aug 30 2007;357(9):863-73. [Medline].

  11. Sehu S, Reddy K, Fleseriu M. Management of pituitary, thyroid and adrenal disorders. In: Falcone T, Hurd WW, eds. Clinical reproductive medicine and surgery. New York: Elsevier; 2007:311-34.

  12. Seidenfeld ME, Rickert VI. Impact of anorexia, bulimia and obesity on the gynecologic health of adolescents. Am Fam Physician. Aug 1 2001;64(3):445-50. [Medline].

  13. Sharma RK. Physiology of Male Gametogenesis. In: Falcone T, Hurd WW, eds. Clinical reproductive medicine and surgery. New York: Elsevier; 2007:73-84.

  14. Solnik JM, Sanfilippo JS. Normal puberty and pubertal disorders. In: Falcone T, Hurd WW, eds. Clinical reproductive medicine and surgery. New York: Elsevier; 2007:157-70.

  15. Walsh BT, Roose SP, Katz JL, Dyrenfurth I, Wright L, Vande Wiele R. Hypothalamic-pituitary-adrenal-cortical activity in anorexia nervosa and bulimia. Psychoneuroendocrinology. 1987;12(2):131-40. [Medline].

  16. Yao MWM, Batchu K. Oogenesis. In: Falcone T, Hurd WW, eds. Clinical reproductive medicine and surgery. New York: Elsevier; 2007:51-72.

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

Kallmann syndrome, hypothalamic suppression, hypogonadotropic hypogonadism, pituitary dysfunction, hyperprolactinemia, luteal phase deficiency, luteinizing hormone deficiency, LH, follicle-stimulating hormone, FSH, thyroid-stimulating hormone, TSH, human chorionic gonadotropin, hCG, gonadotropin-releasing hormone, GnRH, hormone replacement therapy

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Nichole M Giannios, DO, Reproductive Endocrinology and Infertility Fellow, Department of Obstetrics and Gynecology, University Hospitals/Case Medical Center
Nichole M Giannios, DO is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, and American Osteopathic Association
Disclosure: Nothing to disclose.

Coauthor(s)

Rebecca Flyckt, MD, Resident in Obstetrics and Gynecology, University Hospitals/Case Medical Center
Disclosure: Nothing to disclose.

Allen Donald Seftel, MD, Professor, Department of Urology, Case School of Medicine
Allen Donald Seftel, MD is a member of the following medical societies: Ohio State Medical Association
Disclosure: lilly Consulting fee Consulting; sanofi-aventis Consulting fee Consulting; auxilium Consulting fee Consulting; solvay Consulting fee Consulting; plethora Grant/research funds clinical trial; indevus Consulting fee Consulting; nature publishing  journal editor

William W Hurd, MD, MSc, Professor of Reproductive Biology, Case Western Reserve University School of Medicine; Lilian Hanna Baldwin Chair in Gynecology and Obstetrics, Director, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University Hospitals Case Medical Center
William W Hurd, MD, MSc is a member of the following medical societies: Alpha Omega Alpha, American Association of Gynecologic Laparoscopists, American College of Obstetricians and Gynecologists, American College of Physician Executives, American College of Surgeons, American Gynecological and Obstetrical Society, American Medical Association, American Society for Reproductive Medicine, Society for Gynecologic Investigation, and Society of Reproductive Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Karen Loeb Lifford, MD, Director of General Gynecology, Associate Program Director, Department of Obstetrics and Gynecology, Instructor, Brigham and Women's Hospital, Harvard Medical School
Karen Loeb Lifford, MD is a member of the following medical societies: Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Antonio V Sison, MD, Medical Director, Ob/Gyn Group, Robert Wood Johnson University Hospital at Hamilton
Antonio V Sison, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists and Association of Professors of Gynecology and Obstetrics
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

Bryan D Cowan, MD, Professor and Chairman, Department of Obstetrics and Gynecology, University of Mississippi College of Medicine; Consulting Staff, Department of Obstetrics and Gynecology, Veterans Affairs Medical Center; Medical Director, Wiser Hospital for Women, University of Mississippi Medical Center
Bryan D Cowan, MD is a member of the following medical societies: American Association of Gynecologic Laparoscopists, American College of Obstetricians and Gynecologists, American Gynecological and Obstetrical Society, American Medical Association, American Society for Reproductive Medicine, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Endocrine Society, Sigma Xi, Society for Assisted Reproductive Technologies, Society for Gynecologic Investigation, Society for the Study of Reproduction, and Society of Laparoendoscopic Surgeons
Disclosure: Wyeth None Speaking and teaching

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.