Endocrinology and Diabetes —
Training activity: 3

Details

Perform and interpret the analyses to laboratory standard operating procedures on patients with:

• Male hypo- and hypergonadism
• Female hypo- and hypergonadism
• Infertility and/or patients undergoing fertility treatment
• Pubertal disorders
• Intersex disorders
• Gonadal malignancies

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Considerations

• Local and national training guidelines, including standards and pathways
• Method selection, including assay advantages and limitations, quality parameters, and interferences
• Equipment calibration and maintenance
• Quality control; EQA and IQC
• National and international guidelines
• Role of the duty biochemist

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

What does success look like?

• Identify what is expected of you in relation to effectively performing and interpreting analyses related to gonadal and reproductive disorders according to laboratory SOPs.
• Consider how the learning outcomes apply, specifically in relation to performing clinical and laboratory investigation, analysis and management of endocrine disorders and diabetes mellitus.
• Discuss with your training officer to gain clarity of what is expected of you in relation to accurate interpretation in diverse patient groups (e.g., pubertal staging, undisclosed sex/transgender patients) and handling specific fertility treatment protocols.

What is your prior experience of this activity?

• Think about what you already know about performing and interpreting analyses for gonadal hormones (e.g., testosterone, oestradiol, LH/FSH) and related markers (e.g., prolactin).
• Consider possible challenges you might face during the activity, such as understanding complex hormonal feedback loops, interpreting results in intersex or pubertal disorders, or ensuring correct sample timing (e.g., follicular vs luteal phase sampling).
• Recognise the scope of your own practice for this activity i.e. know when you will need to seek advice or help, and from whom. You will need to seek advice from your Training Officer when required, for example if interpreting results from a patient with a pubertal disorder whose findings are ambiguous regarding the expected stage of development, or if handling assays affected by high-dose fertility drugs.
• Acknowledge how you feel about embarking on performing and interpreting these specific analyses.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop, such as applying knowledge of hormonal regulation in different physiological states (e.g., menopause, puberty) and calculating free hormone indices.
• Identify the specific insights you hope to gain into the clinical interpretation in the context of diverse gonadal/reproductive conditions (e.g., Polycystic Ovarian Syndrome (PCOS)) or the specific reference intervals for different patient groups including undisclosed sex/transgender patients.

What additional considerations do you need to make?

• Consult actions identified following previous experiences of gonadal hormone analysis where specific sample requirements or interpretation difficulties arose.
• Identify important information you need to consider before embarking on the activity, such as understanding of pubertal development, menstrual cycle, fertility treatment protocols, and the use of age/gender-specific reference ranges.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst performing the analysis or interpreting results for a gonadal/reproductive disorder?
• Are you encountering situations such as:
  • A result that seems inconsistent with the established reference range for the patient’s age, sex, or menstrual cycle phase?
  • Difficulties in accounting for factors like hormone replacement therapy or fertility treatment in the interpretation?
  • Suspecting assay interference is affecting a gonadal hormone measurement?

How are you reacting to the unexpected development?

• How is this impacting your actions? For example, are you responding to the situation appropriately? Are you adapting or changing your approach to considering assay interference or complex clinical context?
• Consider the steps you are taking in the moment, such as:
  • Immediately reviewing the patient’s medication history to check for common interfering substances
  • Pausing the interpretation to consult reference intervals specific to menstrual cycle phase or pubertal stage
  • Seeking advice from the Training Officer on the appropriate approach for interpreting results in complex cases like intersex disorders
• How are you feeling in that moment? For instance, are you finding it difficult to integrate conflicting hormone levels? Is it affecting your confidence in using reference intervals for different patient groups?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully interpreting the results within the context of a straightforward pubertal disorder? Or are you needing support because the complex hormonal axis interpretation (e.g., hypergonadism) requires senior clinical consultation?
• What are you learning as a result of the unexpected development? For example, are you mastering the use of age- and sex-specific reference intervals? Or gaining insight into recognising potential assay interference in reproductive endocrinology?

On action

What happened?

• Begin by summarising the key steps you took when performing and interpreting analyses for gonadal hormones (e.g., testosterone and LH/FSH).
• Consider specific events, actions, or interactions which felt important, such as verifying the appropriate reference intervals based on patient sex, age, and pubertal status or noting challenges related to the sensitivity of a specific assay.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately confirming the patient’s phase of the menstrual cycle when interpreting a borderline oestradiol result.
• How did you feel during this experience, e.g., did you feel focused on understanding the importance of biological variation or challenged by interpreting results in a patient undergoing fertility treatment?

How has this experience contributed to your developing practice?

• Identify what learning you can take from this experience regarding the analysis and interpretation of reproductive hormones. What strengths did you demonstrate, e.g., systematic checking of patient demographics against available reference ranges?
• What skills and/or knowledge gaps were evident, e.g., unfamiliarity with the complex hormonal profiles associated with certain intersex disorders?
• Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved? Has your practice improved in applying knowledge of biological variation when interpreting gonadal results?
• Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding the appropriate interpretation of results affected by high-dose fertility drugs, and how you reacted to this.

What will you take from the experience moving forward?

• Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you have received, with regards to ensuring context-appropriate interpretation of gonadal hormone analyses.
• What will you do differently next time you approach interpreting results for pubertal disorders, for instance, by proactively referencing guidelines for interpreting results in undisclosed sex or transgender patients?
• Do you need to practise any aspect of the activity further, such as investigating the analytical considerations for low-concentration gonadal hormone assays or key learning outcomes related to using specific reference intervals for different patient groups?

Beyond action

Have you revisited the experiences?

• How have your subsequent experiences of interpreting complex reproductive hormone profiles since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, how an instance where a subsequent patient required monitoring during fertility treatment with high-dose hormones forced you to re-evaluate the rigidity of standard analytical reference ranges you applied during your first attempt at interpreting a routine gonadal hormone profile?
• Considering what you understand about hormonal changes throughout the lifespan, appropriate reference intervals for diverse patient groups (e.g., undisclosed sex/transgender patients), and complex cases (e.g., intersex disorders) now, were the actions or considerations you identified after your initial reflection on this training activity sufficient? How have you since implemented or adapted improvements in your gonadal result interpretation methodology based on further learning and experiences? For example, how you proactively reviewed and integrated guidelines for interpreting results in pubertal disorders, demonstrating you have adapted improvements based on further learning?
• Has discussing ambiguous reproductive hormone findings or the impact of clinical context (e.g., menstrual cycle phase) on result validation with colleagues, peers, or supervisors changed how you now view your initial experience in this training activity? For example, how professional storytelling with a senior colleague about a case where key menstrual cycle information was missed, leading to misclassification of ovarian reserve, refined your understanding of the critical nature of clinical correlation?

How have these experiences impacted upon current practice?

• How has the learning from this initial training activity, in combination with subsequent gonadal hormone analysis and interpretation experiences, contributed to your overall confidence and competence in effectively performing analysis and interpretation, particularly in preparing for assessments like Case-based Discussions (CBDs) or Observed Clinical Events (OCEs)? For example, how your accumulated ability in applying appropriate reference intervals (e.g., based on age, sex, and physiological state) and interpreting complex gonadal hormone profiles now enables you to confidently discuss investigations for conditions like Polycystic Ovarian Syndrome (PCOS) during a CBD assessment.
• How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to gonadal hormone analysis? How does this evolved understanding help you identify when something is beyond your scope of practice or requires escalation? For example, how your evolved approach means you now routinely check patient history against specific reference interval requirements (e.g., pubertal status, menstrual cycle phase) and seek advice immediately when interpreting results from complex cases (e.g., intersex disorders or high-dose fertility treatment), recognising this falls outside routine interpretation scope.
• Looking holistically at your training journey, how has this initial gonadal hormone analysis experience, revisited with your current perspective, contributed to your development in meeting the learning outcomes related to performing clinical and laboratory investigation, analysis and management of endocrine disorders and diabetes mellitus? For example, how this foundational experience has supported your development in understanding the hormonal changes throughout the lifespan.

Relevant learning outcomes

#	Outcome
# 1	Outcome Perform clinical and laboratory investigation, analysis and management of endocrine disorders.
# 2	Outcome Perform clinical and laboratory investigation, analysis and management of diabetes mellitus.