helpful.

It is applied either by itself or, for

increased
ability to resolve and measure substances, in
tandem
(MS/MS)
or
downstream
of
liquid
chromatography
(LC/MS) or gas chromatography (GC/MS).
These
approaches provide definitive identification
of
the
relevant hormone or compound according to
its
chemical and physical characteristics, e.g.
par
ticularly
useful
for
the
unequivocal
detection
of
performance-enhancing agents in sport.
GC allows separation of vaporized
molecules
according to their chemical structure. For a
sample
loaded on a GC column, different components
exit
the column and pass to the mass
spectrometer
at
different times. MS ionizes compounds to
charge
them, after which the spectrometer measures
mass
and charge during passage through an
electromag
netic field. This gives a characteristic mass-tocharge
ratio for any one substance. As with
immunoassays,
patient samples can be judged against the
perform
ance of precisely known standards. LC/MS is
similar
to GC/MS; however, the initial separation is
per
formed in the liquid rather than the gaseous
phase.
Enzymatic assays
Some metabolites are assayed enzymatically,
fre
quently using dye substrates that are
catalyzed
to
products that are coloured or fluoresce. By
incorpo
rating known standards, the amount of
colour
or
fluorescence can be used for precise
quantification.
For
example,
glycated
haemoglobin
(HbA1c),
a
measure of long-term diabetes control (see

Chapter
11) can be measured in an enzymatic assay
as
well
as
by
immunoassay
and
chromatography/MS
approaches. Serum glucose can be measured
by
oxi
dation to generate a product that interacts
with
a
dye to generate colour or fluorescence in
an
enzy
matic assay.
Reference ranges
Typical adult reference ranges are listed for a
number
of hormones in Table 4.1. Whenever
possible,
hor
mones are measured in molar units (e.g.
pmol/L)
or
mass units (e.g. ng/L). However, this is not
possible
for
complex hormones such as the glycoproteins
thyroidstimulating hormone (TSH), luteinizing
hormone
(LH) and follicle-stimulating hormone
(FSH),

because they circulate in a variety of slightly

different
forms (microheterogeneity). In this scenario,
inter
national reference preparations are agreed,
with
potency expressed in units (U) and their
subdivisions
[e.g. milliunits (mU)]. Potency is assigned after
large
collaborative trials involving many laboratories
world
wide using a range of assay platforms and
physical
analytical techniques. Patient results are then
expressed
relative to the reference data.
Static and dynamic testing
Most of endocrinology testing is static; the
meas
urement of hormones and metabolites as
they
circulate at any one time. However,
rhythmical,
pulsatile or variable hormone secretion makes
inter
pretation
of
single
random
samples
meaningless
or
misleading (see Chapter 1). For some
hormones,
such as GH, a clinical impression can be
gained
from a series of six to eight measurements
during
the course of a day. Alternatively, dynamic
testing
can
be
necessary
where,
based
on
understanding
normal physiology, responses are measured
follow
ing a stimulus. This might be metabolic, such
as
insulin-induced
hypoglycaemia
to
study

the
expected rise in serum GH and cortisol (see
Chapter
5), or the administration of glucose during a
glucose
tolerance test to diagnose diabetes (see
Chapter
11).
Alternatively, the stimulus might be hormonal,
such
as injecting adrenocorticotrophic hormone
(ACTH;
the anterior pituitary hormone) to measure
secre
tion of cortisol (the adrenocortical hormone).
In
this sense, fasting measurements, as
required
for
serum lipids or commonly for glucose, could
be
viewed as dynamic, where fasting is the
stimulus.
Dynamic tests can be split into two
categories:
provocative ones to interrogate suspected
inade
quate function; or suppression tests, taking
advan
tage of negative feedback to investigate
potential
overactivity (Box 4.2). For instance, ACTH
is
injected to see if cortisol secretion rises in
suspected
adrenocortical
inadequacy
(Addison
disease;
see
Chapter 6); whereas dexamethasone, a
potent
syn
thetic glucocorticoid, is given to see if
pituitary
ACTH and consequently cortisol secretion
is
appropriately diminished. If it is not, it
implies
that
the adrenal cortex is overactive (Cushing
syndrome;
see Chapter 6).

Chapter 4: Investigations in endocrinology and diabetes / 53

Table 4.1 Endocrine reference ranges

Adult reference hormone

Range

Units

Range

Unit

17-hydroxyprogesterone (male)

0.18-9.1

nmol/L

5.9-300

ng/dL

17-hydroxyprogesterone (female)

0.6-3.0

nmol/L

20-99

ng/dL

Adrenocorticotrophic hormone (ACTH,

9 am)

0-8.8

pmol/L

0-40

ng/L

Aldosterone (am; out of bed for 2 h;

seated 5-15 min)a

100-500

pmol/L

3.6-18.1

ng/dL

Androstenedione (adult male and

female)

2.1-9.4

nmol/L

60-270

ng/dL

Anti-Mllerian hormone (to indicate

poor ovarian reserve)b

>7

pmol/L

>1

ng/mL

Chromogranin A (fasting)

0-5.2

nmol/L

0-250

ng/ml

Cortisol (9 am)

140-700

nmol/L

5-25

g/dL

Cortisol (midnight)

80-350

nmol/L

2.9-12.5

g/dL

Cortisol (post low dose

dexamethsaone)

<50

nmol/L

1.8

g/dL

Cortisol (urinary free)

0-280

nmol/24 h

0-10

g/24 h

Epinephrine (adrenaline)

0-546

pmol/L

0-100

pg/mL

Epinephrine (adrenaline; urine)

0-1.0

mol/24 h

0.5-20

g/24 h

1.0-8.0

U/L

Early follicular phase

1.0-11.0

U/L

Post-menopausal

>30

U/L

0-40

pmol/L

0-154

pg/mL

0-50

pmol/L

0-139

pg/mL

Fasting (normal)

<6.1

mmol/L

<110

mg/dL

Fasting (impaired fasting glycaemia;

pre-diabetes)

6.1-6.9

mmol/L

110-125

mg/dL

Fasting (diabetes)

7.0

mmol/L

126

mg/dL

Post-glucose tolerance test (normal)

<7.8

mmol/L

<140

mg/dL

Follicle-stimulating hormone (FSH)

Males

(adult)

Females

Gastrin

(fasting)

Glucagon (fasting)
Glucose

(Continued)

54 / Chapter 4: Investigations in endocrinology and diabetes

Table 4.1 (Continued)

Adult reference hormone

Range

Units

Range

Unit

Post-glucose tolerance test (impaired

glucose tolerance; pre-diabetes)

7.8-11.0

mmol/L

140-200

mg/dL

Post-glucose tolerance test

(diabetes)

11.1

mmol/L

200

mg/dL

After a glucose load

<0.3d

ng/mL

<0.8

mU/L

Stress-induced [e.g. glucose

<2.2 mmol/L (<40 mg/dL)]

>6.7

ng/mL

>17

mU/L

47

mmol/
mol

6.5

Fasting

<69.5

pmol/L

<10

mU/L

When glucose <2.5 mmol/L

(<45 mg/dL)

<34.7

pmol/L

<5

mU/L

When glucose <1.5 mmol/L

(<27 mg/dL)

<13.9

pmol/L

<2

mU/L

25-39 years

114-492

ng/mL

40-54 years

90-360

ng/mL

>54 years

71-290

ng/mL

0.5-9.0

U/L

Early follicular phase

0.5-14.5

U/L

Postmenopausal

>20

U/L

Metanephrine

0-0.5

nmol/L

0-99

pg/mL

Metanephrine (urine)

0-2.0

mol/24 h

24-96

g/24 h

Norepinephrine (noradrenaline)

0-3.5

nmol/L

0-600

pg/mL

Norepinephrine (urine)

0-0.2

mol/24 h

15-80

g/24 h

Normetanephrine

0-1.0

nmol/L

0-180

pg/mL

Normetanephrine (urine)

0-3.0

mol/24 h

75-375

g/24 h

37-130

pmol/L

10-35

pg/mL

Growth hormone

HbA1c (to diagnose diabetes)e

Insulin

Insulin-like growth factor If

Luteinizing hormone (LH)

Males
Females

Oestradiol
Males
Females