MON-204 Beyond Menopause: Investigating Markedly Elevated FSH and LH in End Stage Renal Disease

Abstract Disclosure: F. Waqar: None. S. Sridhar: None. A. Siddiqui: None. N. Raja-Khan: None. A.W. Paracha: None. A. Tall: None. Y. Zhu: None. Background:Elevated FSH and LH levels in menopause are a physiological response to declining ovarian function. These levels are below 100 mIU/mL in most cases. Markedly higher levels may be seen in menopausal women with ESRD.Clinical Case:A 42-year-old woman with complex medical history including ESRD (on peritoneal dialysis), hypertension and SLE presented to the ER with confusion in the setting of hypertensive emergency. Before obtaining a brain MRI, serum hCG was checked and found to be elevated at 15 mIU/mL (reference <5 mIU/mL). This was pursued by prolactin and gonadotropin levels which were all elevated. Prolactin was 45.6 ng/mL (4.8-23.3 ng/mL), FSH>200 mIU/ml and LH>200 mIU/ml (all measured on the Roche electrochemiluminescence analyzers). Her brain MRI revealed an unremarkable sella. She had no signs or symptoms of any endocrine abnormality. She had a Mirena IUD placed seven years ago and was amenorrheic since then. She had three pregnancies and no issues with fertility. She did report a family history of early menopause and endorsed hot flashes. The differential diagnoses considered included early menopause or premature ovarian failure, gonadotropin-secreting tumor (less likely with a normal MRI), assay-related artifact and reduced clearance due to renal failure. Repeat labs obtained after a peritoneal dialysis session yielded similar results, while serum estradiol and AMH levels were noted to be low at 31 pg/ml and <0.03 pmol/mL (0.03-5.47 pmol/mL) respectively. The remaining pituitary hormones were normal. Elevated gonadotropins with low estradiol and AMH levels pointed towards premature ovarian failure/early menopause. However, this alone was not enough to explain the degree of elevation of gonadotropins. Labs were repeated by dilution in another lab using Siemens analyzers and results were consistent with LH 338.7 mIU/mL; FSH >200 mIU/mL. Repeat lab testing after heterophilic antibody blocking reagent treatment yielded similar results. Hence, an assay related artifact was ruled out. Conclusion: This case highlights the diagnostic complexity of markedly elevated gonadotropins in a patient with ESRD. There is limited literature looking into sex hormones in ESRD patients. Loss of normal cyclic release of GnRH is noted resulting in impaired estradiol release. GnRH, FSH, and LH levels are elevated due to impaired clearance. Hyperprolactinemia is the result of reduced clearance and increased production due to inhibition of dopaminergic activity. Although a combination of premature menopause and ESRD-associated hormonal alterations were plausible explanations, the unusually high FSH and LH levels necessitated consideration of other causes such as assay artifacts. Clinicians should maintain a high index of suspicion and confirm abnormal findings with alternate tests. More research is needed to explore the levels of gonadotropins in menopausal women with ESRD. Presentation: Monday, July 14, 2025