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Female Hormone Self-Assessment Test

Check any of the following statements that apply to you.

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Have you had a hysterectomy? Yes No

Do You...
Have a history of antibiotic use
Continuously use prescription medication
Take synthetic hormones in topical cream, patch or orally
Experience difficulty sleeping
Experience mood swings
Experience hot flashes
Experience low libido
Drink more than one glass of alcohol weekly
Drink caffeine daily
Experience Exhaustion
Experience irregular menstrual cycle
Experience infertility
Experience frequent urination

Menstrual or Menopause Concern
Ovarian Dysfunction.......Do You Have?
Vaginal dryness, pain
Painful intercourse
Engorged breasts
Milk production (not nursing)
Lack of interest in sex
Blurred vision
Acne and/or oily skin
Aggressive feelings
Overwhelming sexual urges
Absence of menstrual flow for six or more months
Occasionally skip periods
Menstruation began after 16 years old
Breasts shrinking
Thinning pubic and armpit hair
Unable to get pregnant
Excess facial hair
Poor sense of smell
Monthly abdominal pain without bleeding
Menstrual type pain between menses
Irregular time intervals between periods
Menstrual cycles greater than 32 days
Menstrual cycles less than 24 days
Vaginal bleeding between periods
Pain during periods is getting progressively worse
Pain, cramps

Premenstrual Syndrome
(3 days to 2 weeks prior to menstruation) 
Do You Have...
Premenstrual tension
Painful menses (cramping etc.)

Menstruation excessive or prolonged

Painful/tender breasts
Menstruate too frequently

Acne, worse at menses

Depressed feelings before menstruation
Vaginal discharge
Menses scanty or missed

Hysterectomy/ovaries removed

Abdominal bloating

Breast tenderness, swelling

Depressed, irritable, nervous
Easy to anger, resentful

Easily overwhelmed

Nausea and/or vomiting
Diarrhea or constipation

Food cravings, binge eating

Back pain
Feel faint


Weight gain-water

Dysplasia / Fibrocystic Syndrome
Do You Have...
Lumps are painful, tender
Clear, gray or yellow vaginal discharge
Vaginal bleeding after sex or between periods
Burning or itching or external genitalia
Urgent, painful urination
Lower abdominal or back pain
Heavy, watery and bloody vaginal discharge

Heavy menstrual flow

Pelvic cramps
Thin, scant white vaginal discharge
Greenish yellow or offensive discharge

Cheesy white discharge

Breast lumps or swelling
Lumps hurt just before period
Swelling under armpit
Change in breast size, shape
White or slightly bloody vaginal discharge, one week prior to period
Current diagnosis of fibrocystic breast disease

Do You Have...
Irregular menstrual cycle
Menstruation excessive or prolonged
Menstruation too frequent
Acne, worse at menses
Menses scanty or missed
Hysterectomy / ovaries removed
Dry skin, hair, vagina
Lack of interest in sex
Mood swings, irritable
Depression, anxiety, nervousness
Craving for sweets, binge eating
Headaches or dizziness
Painful intercourse
Sudden hot flashes
Spontaneous sweating
Shortness of breath and/or heart palpitations
Unpredictable vaginal bleeding
Difficulty holding urine
Difficulty sleeping
Mental fogginess
Vaginal pain and/or itching
Thin, scant white vaginal discharge
Low back and/or hip pain
Breast tenderness, pain or tingling, prickling sensation
Easy bruising, loss of skin tone
Thinning armpit and pubic hair
Stopped menstruating
Breasts beginning to shrink, sag
Abnormal growth of hair above lip