Estradiol (E2)

Pick Ordered or Not ordered to see the note.

Indicated when

• —Investigating amenorrhea in a woman under 45, alongside FSH, to help find the cause [2]
• —Suspected premature ovarian insufficiency in a woman under 40, alongside FSH (a low estradiol with a high FSH supports the diagnosis, though estradiol alone is not required) [1, 2]

Not indicated when

• —Diagnosing perimenopause or menopause in a woman 45 or older: NICE explicitly lists estradiol among the tests not to use for this [1]
• —Routine hormone-level screening in postmenopausal women or after a hysterectomy [3]
• —Investigating non-specific symptoms (fatigue, mood, weight) as a general 'hormone check' without a specific question the level would answer

Why not

Estradiol fluctuates substantially through the menstrual cycle and, during perimenopause, from day to day, so a single level does not reliably characterize a woman's hormonal status at that time [2]. In a woman 45 or older with typical menopausal symptoms, current guidance is to diagnose by history and menstrual pattern; NICE specifically advises against using estradiol for this [1], and Choosing Wisely Canada advises against routinely ordering it in postmenopausal or post-hysterectomy women [3]. A result that does not match how a patient feels can prompt unnecessary reassurance-seeking, repeat testing, or a search for an explanation that isn't there.

Better first step

In a woman 45 or older with typical symptoms, diagnose perimenopause or menopause from history and menstrual pattern alone. Reserve estradiol for amenorrhea under 45 or suspected premature ovarian insufficiency under 40, paired with FSH [2, 1].

Typical ND rationale

An ND may order estradiol to see whether low or high estrogen explains symptoms such as mood changes, weight gain, hot flashes, or irregular periods, reasoning that measuring the hormone directly is the most direct way to understand what is happening, and that a number is more concrete than a symptom checklist.

Ontario coverage & CONO orderability

OHIP status

insured

Estradiol (L310) is listed by name in the 2026 Schedule of Benefits for Laboratory Services with no restricting condition noted, so it is insured when a physician orders it, clinically assessing the patient first (Reg. 552 s.22). The related analytes sometimes requisitioned alongside it, estriol (L311) and estrone (L313), are also listed by name. ND-ordered testing of any of these is patient-paid regardless of Schedule status [7, 8].

CONO orderable

Yes — CONO list #58, #152, #176

CONO list item 58 (blood), 152 (urine) and 176 (saliva), all 'Estradiol.' Estriol (blood 59) and estrone (blood 61) are separate CONO line items and separate analytes, not specimen variants of estradiol; they are listed here as aliases only because requisitions sometimes use the terms loosely or as part of an 'estrogens' panel.

Linked conditions

• menopause ↗
• "Estrogen dominance" / "progesterone deficiency" ↗

Counselling script

“If you're 45 or older with typical symptoms, perimenopause or menopause is diagnosed from your history and periods, and an estradiol level won't change that. The hormone swings too much at this stage to give a reliable answer. It becomes a useful test if periods stop before 45 without a clear reason, or before 40, and then I'd order it with FSH.”

Revisit if

• —Menstrual periods change or stop before age 45 without an established cause
• —Periods stop before age 40 (assess for premature ovarian insufficiency)
• —A specific, prescribed estrogen therapy needs level-based titration

References

1. [1]NICE (2026). Menopause: identification and management (NG23) (published 2015, last updated 15 April 2026). linkDo not use estradiol (or AMH, inhibin A/B, antral follicle count, ovarian volume) to identify perimenopause or menopause in people 45 or over
2. [2]Canadian Menopause Society (2026). Diagnosis and Management (Menopause HUB). linkMenopause diagnosis is primarily clinical; hormone testing (FSH and estradiol) is reserved for amenorrhea under 45 and suspected POI under 40
3. [3]Society of Obstetricians and Gynaecologists of Canada / Choosing Wisely Canada (2021). Obstetrics and Gynaecology recommendations. linkDon't routinely order hormone levels including estradiol in postmenopausal women or after a hysterectomy
4. [4]Ontario Ministry of Health (2026). Schedule of Benefits for Laboratory Services (effective April 1, 2026) — L310 Estradiol. linkEstradiol (L310) listed in the 2026 OHIP Schedule of Benefits for Laboratory Services
5. [5]Ontario Ministry of Health (2026). Schedule of Benefits for Laboratory Services (effective April 1, 2026) — L311 Estriol. linkEstriol (L311) listed in the 2026 Schedule, a related but distinct analyte
6. [6]Ontario Ministry of Health (2026). Schedule of Benefits for Laboratory Services (effective April 1, 2026) — L313 Estrone. linkEstrone (L313) listed in the 2026 Schedule, a related but distinct analyte
7. [7]Government of Ontario (e-Laws) (2026). Health Insurance Act, R.R.O. 1990, Reg. 552: General, s. 22 (insured laboratory services). linkA lab test is insured only when ordered by a physician, midwife, or NP who has clinically assessed the patient
8. [8]Ontario Ministry of Health (2026). Ontario Health Insurance Plan: Schedule of Benefits for Laboratory Services (effective April 1, 2026). linkTests ordered by anyone other than an authorized provider, including NDs, are not insured services