Estradiol, Sensitive, LC/MS

CPT: 82670
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Test Details

Synonyms

  • E2

Use

Recommended for clinical situations in which increased sensitivity of E2 levels is appropriate, including postmenopausal women, men, and children and adolescents

Limitations

Estradiol levels tend to fluctuate dramatically during the perimenopausal transition.1 There is significant overlap of the expected range in menopausal women with values observed during normal menstrual cycles. Estradiol results obtained with different assay methods cannot be used interchangeably in serial testing. It is recommended that only one assay method be used consistently to monitor serial patient results.

Methodology

Liquid chromatography/tandem mass spectrometry (LC/MS-MS)

Reference Interval

No patient age and/or gender provided.

Newborn: Levels are markedly elevated at birth and fall rapidly during the first week to prepubertal levels <15.0 pg/mL.

1 to 6 months: Male: Levels increase to 10.0−32.0 pg/mL between 30 and 60 days, then decline to prepubertal levels <15.0 pg/mL by six months.

1 to 11 months: Female: Levels increase to 5.0−50.0 pg/mL between 30 and 60 days, then decline to prepubertal levels <15.0 pg/mL by the first year.

Prepubertal children:

• Male (6 months to 10 years): <15.0

• Female (1 to 9 years): <15.0

Puberty: See table.

Tanner Stage

Age (y)

Range (pg/mL)

Mean (pg/mL)

Male

1

<9.8

5.0−11.0

8.0

2

9.8−14.5

5.0−16.0

11.0

3

10.7−15.4

5.0−25.0

16.0

4

11.8−16.2

10.0−36.0

22.0

5

12.8−17.3

10.0−36.0

21.0

Female

1

<9.2

5.0−20.0

8.0

2

9.2−13.7

10.0−24.0

16.0

3

10.0−14.4

7.0−60.0

25.0

4

10.7−15.6

21.0−85.0

47.0

5

11.8−18.6

34.0−170.0

110.0

Adults

Range (pg/mL)

Male

8.0−35.0

Female

Follicular

30.0−100.0

Luteal

70.0−300.0

Postmenopausal

<15.0

Additional Information

Estradiol is responsible for the regulation of the estrous and female menstrual reproductive cycles and for the development and maintenance of female secondary sex characteristics.2,3 Estradiol plays a key role in germ cell maturation and numerous other, non−gender-specific processes, including growth, bone metabolism, nervous system maturation, and endothelial responsiveness. Estrogens are crucial for the normal development and maintenance of the breasts and the uterus.4 Excessive estrogen levels, however, can promote cell proliferation and may increase the risk of developing breast and uterine cancers as well as uterine endometriosis.4

The three major naturally occurring estrogens in women are estrone (E1), estradiol (E2), and estriol (E3). E2 is the predominant estrogen during reproductive years—both in terms of absolute serum levels as well as estrogenic activity.2 During menopause, a dramatic drop in E2 production leaves estrone as the predominant circulating estrogen. Estriol is the main pregnancy estrogen, but it does not play a significant role in nonpregnant women or men.2 The concentration of E2 in men is much lower than in women of reproductive age. All estrogens are synthesized from androgen precursors by the enzyme aromatase.2,4 Aromatase converts the androgenic substrates androstenedione, testosterone, and 16-hydroxytestosterone to the corresponding estrogens: estrone, estradiol, and estriol.4 E2 is produced primarily in ovaries and testes by aromatization of testosterone.2 A lesser amount of E2 is produced in the adrenal glands and some peripheral sites, most notably adipose tissue. Most of the circulating estrone is derived from peripheral aromatization of androstenedione (mainly in the adrenal glands). E2 and E1 can be converted into each other, and both are inactivated via hydroxylation and conjugation. E2 demonstrates two to five times the biological potency of E1.2

The importance of E2 testing and the need for reliable and accurate estradiol measurements throughout the analytic range are emphasized in several recent publications.1,5,6 Measurement of serum E2 serves an integral role in the assessment of reproductive function in females and in the assessment of infertility, oligo-amenorrhea, and menopausal status. E2 is commonly measured for monitoring ovulation induction, as well as during preparation for in vitro fertilization. Because of the relatively high serum concentrations of E2 in these patients, readily available automated immunoassays methods with modest sensitivity meet the clinical requirements. E2 levels in children, postmenopausal women and men and are much lower than in women of reproductive age. The increased sensitivity and specificity that are achieved by LC/MS-MS are the more appropriate choice for these clinical situations.7,8 LC/MS-MS offers superior analytical sensitivity, specificity and a larger dynamic range than immunoassays.7 The clinical applications benefiting from highly sensitive E2 measurement include the assessment of congenital defects in sex steroid metabolism and disorders of puberty. This sensitive assay also has application in the evaluation of estrogen deficiency in men menopausal women, fracture risk assessment in these populations, and increasingly, in therapeutic drug monitoring of low-dose female hormone replacement therapy or anti-estrogen treatment.

Adult Women. In premenopausal women, E2 levels, along with luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels, delineate the stage of the menstrual cycle.2 E2 levels are lowest during the early follicular phase and rise gradually. Two to three days before ovulation, estradiol levels start to increase much more rapidly to a peak just before the ovulation. This dramatic increase in circulating E2 levels induces a surge in LH and FSH. E2 levels decline modestly during the ovulatory phase and then increase again gradually until the midpoint of the luteal phase and ultimately decline back to early follicular levels.

Assessment of E2 levels is useful for the evaluation of hypogonadism and oligo-amenorrhea in women. Decreased ovarian estrogen production is classified as hypergonadotropic or hypogonadotropic, depending on whether the disease is of gonadal or pituitary/hypothalamic origin.9-11 Measurement of gonadotropins (LH and FSH) is fundamental in differentiating these two low estradiol states. The main causes of primary gonadal failure (hypergonadotropic) are genetic (Turner syndrome, familial premature ovarian failure), autoimmune (autoimmune ovarian failure, autoimmune polyglandular endocrine failure syndrome type II), and toxic (related to chemotherapy or radiation therapy for malignant disease).

Low E2 with low or inappropriately "normal," LH and/or FSH in young adult females is consistent with hypogonadotrophic hypogonadism.11-13 This can be caused by hypothalamic or pituitary failure due to conditions, including multiple pituitary hormone deficiency and Kallmann syndrome. Diagnostic workup includes the measurement of E2 along with pituitary gonadotropins and prolactin—and possibly imaging. This endocrine presentation can be caused by starvation, over-exercise, severe physical or emotional stress, and drug/alcohol abuse. While early studies suggested that E2 levels could be used to predict ovarian reserve in women of reproductive age undergoing assisted reproduction procedures, more recent studies have found the marker less useful.14 Estradiol measurement is useful in assessing the status of ovulation induction in women with hypogonadotropic hypogonadism15 and for the prediction and prevention of ovarian hyperstimulation syndrome in patients undergoing assisted reproduction.16

Normal or high E2 with irregular or absent menstrual periods is suggestive of possible polycystic ovarian syndrome, androgen-producing tumors, or estrogen-producing tumors. In these cases, measurement of total and bioavailable testosterone, androstenedione, dehydroepiandrosterone (sulfate), and sex hormone-binding globulin can aid in differential diagnosis.

The main site of estrogen biosynthesis in the nonpregnant premenopausal woman is the ovarian granulosa cells, however, the adipose tissue becomes a major source of circulating estradiol in postmenopausal women.4 After menopause, androstenedione, secreted by the adrenal gland, is converted into estrone in the adipose tissue.4 The conversion of plasma androstenedione to estrone increases with excess body weight in both pre- and postmenopausal women.4 Estrone is then eventually converted to estradiol by 17 β-hydroxysteroid dehydrogenase enzymes present in peripheral tissues.4

Measurement of E2 level, together with FSH and/or anti-Müllerian hormone, can be useful in predicting the timing of the transition into menopause.17,18 A large population study (Randolph) found that the mean E2 level started to decline approximately two years prior to the final menstrual period (FMP) and exhibited a maximal rate of change at the FMP. The mean E2 level stabilized a menopausal level approximately two years after FMP.17 A sensitive estradiol assay is required to measure E2 levels accurately in postmenopausal women. The current recommendations for postmenopausal female hormone replacement are to administer therapy in the smallest beneficial doses for as briefly as possible. Estrogen replacement in reproductive-age women should aim to mimic natural estrogen levels as closely as possible, while levels in menopausal women should be held near the lower limit of the premenopausal female reference range. Postmenopausal women with lower E2 levels are at increased risk of osteoporotic fractures, while higher estradiol levels are associated with increased risk of malignancy and cardiovascular disease.19,20 Accurate measurement of E2 in women receiving hormone replacement may play a role in optimizing therapy.

Gonadotropin receptor hormone (GNRH) analogues are used therapeutically to reduce the ovarian production of estradiol in sex hormone-dependent disorders, including endometriosis and uterine fibroids.21 Aromatase inhibitors are also used therapeutically to reduce circulating estrogens (E2 and E1) levels in hyperestrogenic conditions (ie, endometriosis in women and gynecomastia in men) and in estrogen-sensitive malignancies.22-26 The complete or near complete suppression of estradiol production induced by the treatments produce serum low levels that can only be accurately measured by sensitive methods.27

Adult Men. The use of a sensitive, LC/MS assay for serum E2 measurement in males is preferred over direct immunoassays because of its greater sensitivity and lesser interference by other steroids.28 In males, estradiol is present at low concentrations in blood, but it is extraordinarily high in semen.4 Estradiol plays an important role in epididymal function and sperm maturation and is essential for normal spermatogenesis and sperm motility.4

Gynecomastia refers to a syndrome of abnormal feminization with swelling of the breast tissue in boys or men, caused by an imbalance of the hormones estrogen and testosterone.29 Gynecomastia is common during puberty in boys and can be seen in older males due to increased estrogen level-related obesity (increase aromatase activity), decreased hepatic clearance, estrogen ingestion, and estrogen producing tumors. Asymptomatic gynecomastia is common in older men, but individuals who present with gynecomastia of recent onset associated with pain and tenderness may require clinical workup.29 Gynecomastia and other signs of male feminization may be caused by an absolute increase in E2 and/or E1. The testes may directly secrete too much estradiol due to a Leydif-cell or Sertoli-cell tumor. They may also secrete estradiol indirectly through the stimulatory effects of a human chorionic gonadotropin-secreting tumor of gonadal or extragonadal germ-cell origin.29

Alternatively, men with normal estrogen levels can develop gynecomastia, if testosterone levels are low due to primary/secondary testicular failure, resulting in an abnormally elevated estrogen-to-androgen ratio. Feminization may also occur in men treated with antiandrogen therapy or drugs with antiandrogenic effects (eg, spironolactone, digitalis). Conversely, individuals with elevated androgen levels will often exhibit gynecomastia caused by aromatase catalyzed estrogen production.

Estrogens (and androgens) play an important role in the normal physiology of the skeleton in both sexes.4 Males with diminished estrogen levels due to congenital aromatase deficiency or insensitivity to estrogens due to estrogen receptor deficiency have a characteristic phenotype with regard to bone development.4,25,30 These males exhibit significant increased overall height due to lack of estrogen-induced epiphyseal closure.25 The importance of estradiol in bone health is further supported by the fact that estradiol levels correlate better with bone mineral density than do testosterone levels in aging men.25 The Endocrine Society has recently reported that low estradiol levels are associated with increased fracture risk and accelerated bone loss in older men.31

Children and Adolescents. A sensitive method is required to measure accurately the E2 concentrations found in boys and prepubertal girls. Levels in boys and heavier girls are generally lower than in girls of normal weight.32,33 Adrenal steroids tend to increase prior to gonadal steroids at the beginning of the pubertal transition.32 In girls, E2 concentrations increase just before breast development.32

In precocious puberty (PP), estradiol and the gonadotropins, LH and FSH, tend to be above the prepubertal range.34 E2 measurement in children suspected of having PP is performed to support the diagnosis and to determine the origin of the condition or disease. The source of increased estradiol can be exogenous estrogens or an ovarian cyst that has produced transient estrogens. Elevation of E1 or E2 alone suggests pseudo-precocious puberty, possibly due to a steroid-producing tumor.

It is not normal for an adolescent to be amenorrheic for greater than three months, even in the early gynecologic years,35 and menstrual cycle duration persistently outside 21 to 45 days in adolescents is unusual.36 Since estrogen deficiency is a risk factor for later development of osteoporosis and cardiovascular disease, a workup including sensitive E2 measurement is recommended for adolescent girls and women with potentially disordered hypothalamic-pituitary-gonadal function.11,35 Persistently low estrogens and elevated gonadotropins in children with delayed puberty suggest primary ovarian failure, while low gonadotropins suggest hypogonadotrophic hypogonadism. In this latter case, Kallmann syndrome (or related disorders) or hypothalamic/pituitary tumors should be excluded in well-nourished children.37 Both E2 and E1 levels are very low or undetectable in children with aromatase deficiency.36 Affected girls have hypergonadotropic hypogonadism, fail to develop secondary sexual characteristics, and exhibit progressive virilization.36 The affected boys exhibit normal male sexual differentiation and pubertal maturation. Boys with aromatase deficiency, however, are typically extremely tall with eunuchoid proportions and continued linear growth into adulthood, severely delayed epiphyseal closure, and osteoporosis due to estrogen deficiency. Highly sensitive E2 measurement can be of value in the assessment of therapeutic efficacy of estrogen replacement in hypogonadal girls.33

Specimen Requirements

Specimen

Serum

Volume

1 mL

Minimum Volume

0.6 mL (Note: This volume does not allow for repeat testing.)

Container

Red-top tube or gel-barrier tube

Collection

If a red-top tube is used, transfer separated serum to a plastic transport tube.

Storage Instructions

Refrigerate.

Stability Requirements

Temperature

Period

Room temperature

14 days

Refrigerated

14 days

Frozen

14 days

Freeze/thaw cycles

Stable x3

Causes for Rejection

Gross lipemia

Clinical Information

Footnotes

1. Rosner W, Hankinson SE, Sluss PM, Vesper HW, Wierman ME. Challenges to the measurement of estradiol: An Endocrine Society position statement. J Clin Endocrinol Metab. 2013 Apr; 98(4):1376-1387. 8124478
2. Kronenberg H, Williams HR. The physiology and pathology of the female reproductive axis. In: Williams Textbook of Endocrinology. 11th ed. Philadelphia, Pa: Saunders/Elsevier; 2008: 541-614.
3. Gruber CJ, Tschugguel W, Schneeberger C, Huber JC. Production and actions of estrogens. N Engl J Med. 2002 Jan 31; 346(5):340-352. 11821512
4. Stocco C. Tissue physiology and pathology of aromatase. Steroids. 2012 Jan; 77(1-2):27-35. 22108547
5. Newman JD, Handelsman DJ. Challenges to the measurement of oestradiol: comments on an endocrine society position statement. Clin Biochem Rev. 2014 May; 35(2):75-79. 25210207
6. Vesper HW, Botelho JC, Vidal ML, Rahmani Y, Thienpont LM, Caudill SP. High variability in serum estradiol measurements in men and women. Steroids. 2014 Apr; 82:7-13. 24407040
7. Ketha H, Kaur S, Grebe SK, Singh RJ. Clinical applications of LC-MS sex steroid assays: Evolution of methodologies in the 21st century. Curr Opin Endocrinol Diabetes Obes. 2014 Jun; 21(3):217-226. 24739314
8. Rothman MS, Carlson NE, Xu M, et al. Reexamination of testosterone dihydrotestosterone, estradiol and estrone levels across the menstrual cycle and in postmenopausal women measured by liquid chromatography-tandem mass spectrometry. Steroids. 2011 Jan;76(1-2):177-182. 21070796
9. Brassard M, AinMelk Y, Baillargeon JP. Basic infertility including polycystic ovary syndrome. Med Clin North Am. 2008 Sep; 92(5):1163-1192. 18721657
10. Nelson LM. Clinical practice. Primary ovarian insufficiency. N Engl J Med. 2009 Feb 5; 360(6):606-614. 19196677
11. Santoro N. Update in hyper- and hypogonadotropic amenorrhea. J Clin Endocrinol Metab. 2011 Nov; 96(11):3281-3288. 22058375
12. Harrington J, Palmert MR. Clinical review: Distinguishing constitutional delay of growth and puberty from isolated hypogonadotropic hypogonadism: critical appraisal of available diagnostic test. J Clin Endocrinol Metab. 2012 Sep; 97(9):3056-3067. 22723321
13. Silveira LF, Latronico AC. Approach to the patient with hypogonadotropic hypogonadism. J Clin Endocrinol Metab. 2013 May; 98(5):1781-1788. 23650335
14. de Carvalho BR, Rosa-e-Silva AC, Rosa-e-Silva JC, dos Reis RM, Ferriani RA, Silva de Sá MF. Ovarian reserve evaluation: State of the art. J Assist Reprod Genet. 2008 Jul; 25(7):311-322. 18679790
15. Messinis IE. Ovulation induction: A mini review. Hum Reprod. 2005 Oct; 20(10):2688-2697. 16006478
16. Nastri CO, Ferriani RA, Rocha IA, Martins WP. Ovarian hyperstimulation syndrome: Pathophysiology and prevention. J Assist Reprod Genet. 2010 Feb; 27(2-3):121-128. 20140640
17. Overlie I, Moen MH, Morkrid L, Skjaeraasen JS, Holte A. The endocrine transition around menopause—a five years prospective study with profiles of gonadotropins, estrogens, androgens and SHBG among healthy women. Acta Obstet Gynecol Scand. 1999 Aug; 78(7):642-647. 10422913
18. Randolph JF Jr, Zheng H, Sowers MR, et al. Change in follicle-stimulating hormone and estradiol across the menopausal transition: Effect of age at the final menstrual period. J Clin Endocrinol Metab. 2011 Mar; 96(3):746-754.
19. Taylor HS, Manson JE. Update in hormone therapy use in menopause. J Clin Endocrinol Metab. 2011 Feb; 96(2):255-264. 21296989
20. Yager JD, Davidson NE. Estrogen carcinogenesis in breast cancer. N Engl J Med. 2006 Jan 19; 354(3):270-282. 16421368
21. McLaren JS, Morris E, Rymer J. Gonadotrophin receptor hormone analogues in combination with add-back therapy: An update. Menopause Int. 2012 Jun; 18(2):68-72. 22611225
22. Ferrero S, Remorgida V, Maganza C, et al. Aromatase and endometriosis: Estrogens play a role. Ann N Y Acad Sci. 2014 May; 1317:17-23. 24738993
23. Lønning PE. Estradiol measurement in translational studies of breast cancer. Steroids. 2014 Aug 24. pii: S0039-128X(14)00201-3. 25159101
24. Pauwels S, Lintermans A, Neven P, et al. Need for estradiol assays with a lower functional sensitivity in clinical studies examining postmenopausal women treated with aromatase inhibitors. J Clin Oncol. 2013Feb 1; 31(4):509. 23270000
25. Santen RJ, Brodie H, Simpson ER, Siiteri PK, Brodie A. History of aromatase: Saga of an important biological mediator and therapeutic target. Endocr Rev. 2009 Jun; 30(4):343-375. 19389994
26. Shulman DI, Francis GL, Palmert MR, et al. Use of aromatase inhibitors in children and adolescents with disorders of growth and adolescent development. Pediatrics 2008 Apr; 121(4):e975-e983. 18381525
27. Santen RJ, Demers L, Ohorodnik S, et al. Superiority of gas chromatography/tandem mass spectrometry assay (GC/MS/MS) for estradiol for monitoring of aromatase inhibitor therapy. Steroids. 2007 Jul; 72(8):666-671. 17588628
28. Handelsman DJ, Newman JD, Jiménez M, McLachlan R, Sartorius G, Jones GR. Performance of direct estradiol immunoassays with human male serum samples. Clin Chem. 2014 Mar; 60(3):510-517. 24334824
29. Braunstein GD. Clinical practice. Gynecomastia N Engl J Med. 2007 Sep 20; 357(12):1229-1237. 17881754
30. Bulun SE. Aromatase and estrogen receptor α deficiency. Fertil Steril. 2014 Feb; 101(2):323-329. 24485503
31. Watts NB, Adler RA, Bilezikian JP, et al. Osteoporosis in men: An endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2012 Jun; 97(6):1802-1822. 22675062
32. Biro FM, Pinney SM, Huang B, Baker ER, Chandler DW, Dorn LD. Hormone changes in peripubertal girls. J Clin Endocrinol Metab. 2014 Oct; 99(10):3829-3835. 25029416
33. Ankarberg-Lindgren C, Kriström B, Norjavaara E. Physiological estrogen replacement therapy for puberty induction in girls: A clinical observational study. Horm Res Paediatr. 2014; 81(4):239-244. 24503929
34. Carel JC, Léger J. Clinical practice. Precocious puberty. N Engl J Med. 2008 May 29; 358(22):2366-2377. 18509122
35. Popat VB, Prodanov T, Calis KA, Nelson LM. The menstrual cycle: A biological marker of general health in adolescents. Ann N Y Acad Sci. 2008; 1135:43-51. 18574207
36. Rosenfield RL. Clinical review: Adolescent anovulation: Maturational mechanisms and implications. J Clin Endocrinol Metab. 2013 Sep; 98(9):3572-3583. 23913942
37. Gordon CM. Clinical practice. Functional hypothalamic amenorrhea. N Engl J Med. 2010 Jul 22; 363(4):365-371. 20660404

LOINC® Map

Order Code Order Code Name Order Loinc Result Code Result Code Name UofM Result LOINC
140244 Estradiol, Sensitive 35384-7 140249 Estradiol, Sensitive pg/mL 35384-7

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