The Role Of Hormone Tests
Hormones are responsible for crucial bodily functions as well as major changes that occur over your lifetime. They are essential for fertility, libido, muscle tone, skin tone, bone health, energy levels, and weight management, among other functions. Additionally, hormone levels shift at various points to induce life stages such as puberty, reproduction, pregnancy, and menopause. Imbalanced hormone levels are part of the reason why young people going through puberty often develop facial acne and why women going through menopause typically experience hot flashes just to point out a few issues.
Hormones are chemical messengers that manage many bodily functions. Balanced hormones help you maintain good health, but shifting or unbalanced hormones can negatively affect your health. Hormone testing can identify hormonal imbalances to provide insight as to whether hormone therapy to balance your hormone levels could improve your health, vitality, and quality of life.
Throughout our personal healing journey, we used many of the different types of hormone testing to get a good reading on how hormones could be related to everything from catamenial seizures to PMS, menopause to brain fog. I always wondered why some doctors would take blood, others would have me spit into tubes and freeze those tubes for mailing, and yet others would have me collect a jug of urine over 24 hours to bring in (that was always fun trying to be inconspicuous with that one!). Because of this, I decided to pull together all of the benefits as well as the downsides to the varying available hormone test methods to better understand the particulars of each one.
- Blood testing (called serum testing) has been one of the main methods used by most doctors to test hormones in the past. Because they are familiar and have been widely used, doctors feel as if more is known about blood test results and can receive those results quickly. It is a tried-and-true way to check hormones and is regarded by many to be an excellent approach. It is readily accessible, and has good correlation with symptoms.
- “Serum Blood” tests are what your doctor sends you to the lab for. They measure hormone concentrations in to the serum or plasma part of the blood. Plasma is the watery, non-cellular portion of the blood from which cellular components such as red blood cells and white blood cells, are excluded.
- Blood tests provide a snapshot of the total amount of hormone circulating in the bloodstream. It can be good for reproductive hormones: testosterone, estrogens, and progesterone, as well as DHEA-S and estradiol. Yearly blood tests of certain hormones can indicate negatively or positive trending changes as well as provide context for health and wellness problems. For example, research has indicated a relationship between lower levels of bio-available free testosterone and depression in men as well as correlations with diabetes, heart disease and Alzheimer’s. Unfortunately, if you don’t do regular blood tests it’s difficult to see your current results in relation to historical hormone levels. That is why it’s recommended to get these checked yearly.
- Serum testing of hormones has long been accepted by the conventional medical community as the standard for measuring hormones. It has the advantage of being a relatively simple collection, requiring little patient involvement, and has very well-established reference ranges. Serum is ideal for testing peptide hormones such as FSH, LH, prolactin, fasting insulin, and thyroid hormones, including reverse T3, as well as thyroid antibodies. It is also used to measure sex hormone binding globulin (SHBG) and, less commonly, cortisol binding globulin (CBG).
- Although some is bound, and some is free and ‘bio-available’ to show what the hormone does in the body, exact tissue bioavailability cannot be accurately measured. The amount of “free” hormones, however, can be measured. Laboratory scientists use a mathematical model to calculate bioavailability based on the level of total hormone, free hormone, percentage of free hormone, and circulating binding proteins that carry hormones in the blood. A free hormone is one that is not bound to carrier proteins.
- Blood values are useful in monitoring peak levels of absorption of hormones, especially when someone is on hormone replacement therapies, or the normal metabolic lowest point achieved in the natural cyclic secretion of hormones. For example, if you want to see if you are absorbing testosterone from the application of a hormone cream or gel, you can measure your testosterone levels two hours after application.
- For many doctors, blood tests are preferred for estradiol and other estrogens, testosterone and free testosterone, dihydrotestosterone, IGF-I, DHEA-Sulfate, cortisol, and thyroid hormones. A blood sample is also best for the pituitary hormones TSH, LH, and FSH.
- One really good reason to use blood testing is that health insurances are more likely to cover it as an industry standard.
1. Progesterone Blood Hormone Tests
- You can easily evaluate natural levels of estrogen or progesterone during their monthly peaks at mid luteal phase (either 7 days after ovulation, or 7 days prior to expected menses). This is when you’re most likely to catch the peak progesterone level.(typically days 18-22), though this does not apply to women past menopause who no longer have a period. This day will vary according to a woman’s cycle length however (for example, for a 28 day cycle, day 21 progesterone testing is appropriate; but for a 35 day cycle, progesterone would ideally be measured around day 28).Though most hormones are tested for their total circulating level, many hormones can also be tested in blood in their free form.
- Progesterone measured by serum levels is mostly a measure of progesterone that is not going to be used by the body. A serum test can be used to compare one woman’s progesterone production to that of another woman, or to test how much progesterone is being made by a woman’s ovaries.
2. Estrogen Blood Hormone Tests
- Blood testing does very well in assessing estradiol levels. Estradiol (E2) is the female hormone most commonly measured in serum, although estrone (E1) is also available from many labs. Serum estriol (E3) testing, however, is not routinely performed. E3 is an important estrogen, generally considered protective because it binds to estrogen receptor beta (ERb), which is understood to increase differentiation and decrease proliferation of cells.
3. Testosterone Blood Hormone Tests
- Blood serum testing can test both free (active) and total levels of testosterone. It can also be used to assess levels of sex hormone binding globulin (SHBG), which is important for maintaining reservoirs of sex hormones, as well as for protecting them from being excreted or metabolized too quickly. Serum testosterone is commonly available as both total and free, and therefore can be useful in assessing hormone balance. For men, annual blood testing is important because it’s the only way to accurately measure PSA levels. Whether a man chooses to restore youthful hormone balance or not, annual PSA tests to assess the health of one’s prostate gland are vitally important.
- Recently the CDC launched a volunteer program for labs that has further advanced accuracy and reliability in blood testing. The CDC website (www.cdc.gov) shows the names of labs that have passed the performance criteria for the CDC Testosterone Reference Method in adult male and female serum.
4. Cortisol Blood Hormone Tests
- Blood serum hormone tests are able to give you total cortisol results.
The Downside Of Blood Hormone Tests
- For sex hormones, serum testing has a more limited utility. There are several reasons for this. For most sex hormones, no distinction is made in serum between bound and free hormone. Estradiol, estrone, estriol, and progesterone are reported as total hormone and free hormones assays are not commonly available. This may lead to misleading results in which hormone levels appear to be normal or even high normal because of an abundance of bound hormone. However, if the free hormone level is low, the patient can be functionally deficient even with a normal total hormone level. It does not correlate with levels of the same hormone in the tissues, as it is unable to measure the bio-availability of the hormone.
- Another limitation of serum hormones testing is the “snapshot” nature of single-point testing. Because hormones are secreted in a pulsatile manner over the course of the day (and night), it is difficult to know whether the levels in serum represent a peak, a valley, or something in between. Sometimes more information is needed that can be helpful because of the daily/monthly rhythm of hormones.
- Due to it’s ‘snapshot’ of hormones, it can present a difficulty in monitoring treatment for those doing bio-identical hormone replacement , as it is not possible to know whether today’s test was drawn at a similar point of hormone secretion as a previous test.
- It does not evaluate age-related hormonal changes.
1. Downside of Blood Hormone Tests for Progesterone
- Monitoring progesterone supplementation in serum also poses a problem. Transdermal progesterone does raise serum progesterone levels in a statistically significant manner, but the magnitude of change is quite small, which can lead to excessive dosing of progesterone as practitioners strive to achieve therapeutic levels in some opinion.
- Less than 20 percent of progesterone will be found in serum. It is obvious that serum levels would not detect the great majority of the progesterone added to whole blood. The ovary-produced progesterone found in serum is also largely protein-bound. Protein-bound progesterone is not readily bioavailable to receptors in target tissues throughout the body. It is on its way to the liver to be excreted in bile. Only 2 to 5 percent of serum progesterone is “free” or non-protein-bound. This is the progesterone available to target tissues and to saliva.
2. Downside of Blood Hormone Tests for Estrogen
- It is important to know that blood testing cannot easily be used to assess estrogen metabolites to provide a 2/16 hydroxyestrone ratio. This ratio can be helpful since there are scientific studies that found some of the estrogen metabolites may promote cancer while others may have beneficial anticancer qualities.
- Blood testing cannot be used to check estriol levels. Since most bio-identical hormone replacement is typically done using a combination of estradiol and estriol, sometimes it is helpful to check both. However, for many women, an improvement in estradiol correlates with improvement in estriol so it is not necessary to test for estriol except in situations where the woman’s symptoms are not improving as expected.
3. Downside of Blood Hormone Tests for Metabolites
- Serum hormone testing does not typically allow for the measurement of estrogen, androgen, and adrenal metabolites, which can provide a wealth of information to assist practitioners in understanding their patient’s condition and help to guide and fine-tune treatment options.
4. Downside of Blood Hormone Tests for Cortisol
- Blood serum tests don’t provide free cortisol, metabolites or diurnal pattern.
- Obtaining a saliva sample for a saliva hormone test does not require highly trained personnel. Testing for hormones in a saliva sample is stress free, non-invasive, easy to collect, store and transport as well as convenient because you are able to do it at home.
- Many compounds found in saliva, including hormones, can provide useful clinical information. Because saliva is a “real-time” fluid from glands, it produces profiles indicative of an individual’s health and well-being status at the moment of collection. Hormones secreted at different times during the day, such as free cortisol and melatonin, can be measured using multiple samples collected throughout the day and night, allowing for a representation of the normal (or deviation from) cyclical pattern in real time.
- Another advantage of salivary testing is that it measures the free hormone levels, or bio-available hormone fractions of the total amount of hormone. ‘Free’ means that the hormone is unbound by binding proteins in the blood such as sex hormone binding globulin and can give an approximation of how much hormone is available to enter the tissues.
- In the past decade and a half, saliva testing has gained in popularity among practitioners of functional medicine. Saliva has the advantage of being noninvasive as well as being accessible to practitioners such as naturopathic physicians, chiropractors, and acupuncturists who may be practicing in states where they are not licensed to order blood tests or draw blood. Saliva collection also allows for multiple collections over a period of a day or month, which can help elucidate abnormal hormonal patterns, such as a shortened luteal phase. While this can theoretically be done with a serum test, it would be logistically cumbersome.
Saliva for Estrogen, Progesterone, Testosterone and Cortisol Hormone Tests
- Saliva hormone tests can be beneficial for testing the hormone estriol, which is helpful for difficult cases when doing bio-identical hormone therapy. Saliva hormone testing allows for charting changes in hormones over time (such as a monthly menstrual cycle) through multiple samples, thus providing information about the peaks and troughs of a person’s hormone levels.
- Saliva is best used to evaluate the balance and flow of the estrogens and progesterone in women who are still having menstrual cycles. It can also be used to evaluate cortisol secretion patterns by taking multiple samples over the course of a day and evening, giving you free coritsol and diurnal patterns. A saliva test measures free hormone and its multi-point versatility makes it a better measure than serum for evaluating un-supplemented hormone status.
- Saliva hormone testing is also valuable in pregnancy, as salivary estriol spikes about two weeks before the onset of labor and can be used to identify women who are at risk for preterm labor.
The Downside of Saliva Hormone Tests
- There is no common standard among saliva testing laboratories, and many are not FDA approved, meaning that they are not held to the high standards of clinical laboratories.
- Not all hormones, such as follicle- stimulating hormone (FSH) or IGF-1 (used as a marker for growth hormone) are offered in salivary tests by all laboratories.
- Saliva tests cannot test both free (active) and total levels of testosterone.
- Saliva production and collecting multiple samples is difficult for some patients. Dry mouth due to lack of saliva can be caused by some prescription drugs, atrophy of salivary glands, or because of certain types of autoimmune disorders that cause dry eyes and mouth.
- There are multiple restrictions regarding eating, drinking, gum-chewing, makeup use, topical application, and toothbrushing that must be observed to get a usable saliva specimen.
- As a rule, most health insurance companies do not reimburse for hormone saliva testing.
- One of the most significant technological roadblocks in the development of salivary diagnostics is the low concentration of hormones found in saliva compared to blood (300 to 3,000 times lower than in blood). With saliva testing the hormones are found in much lower concentrations than in blood or urine. Hormones are passed from the blood into saliva by a process called ultrafiltration. For molecules to squeeze through by this process, they have to be very small. Because the levels are so tiny, this makes the reference ranges in salivary samples difficult to interpret for their clinical significance. Another reason that makes it much harder for labs to consistently report salivary hormones with as much accuracy as blood or urine.
- Contamination by blood, as from bleeding gums, even in invisible amounts, is common in saliva testing and can affect a person’s results and make the levels seem artificially high. Microdamage from toothbrushing can result in elevated salivary testosterone levels for up to an hour after brushing, even in the absence of visible signs of bleeding, such as “pink toothbrush.” This results in higher values than expected because of the added blood hormones introduced in the saliva. Since there is no easy way to adjust for this kind of contamination, the results must be discarded and another sample taken.
- Other factors such as salivary pH and flow rate can affect results. In the past, when split samples from the same person were sent to different salivary testing labs, the results from the different labs were unfortunately very different, leading some researchers to discount saliva testing altogether. Fortunately, as the technology has improved, many of the labs have improved their ability to provide accurate and reproducible results. However, the fact remains that because hormone levels are much lower in the saliva, any lab that tests salivary hormones will need highly proficient quality control standards to assure consistent and reliable accuracy.
- Saliva can only be used to evaluate steroid hormones. Peptide hormones, such as growth hormone and thyroid, are not available. While estradiol, estrone, and estriol, progesterone, testosterone, DHEA, and cortisol are all available, depending on the lab, steroid hormone metabolites are not measured in saliva, limiting its utility in assessing metabolism of hormones.
- Saliva hormone tests struggles to accurately measure and decipher between low, normal and elevated levels of estrogen – sometimes they even co-mingle together. It’s simply not sensitive enough to see the various different levels of estrogen therefore lacking in accuracy, which is an issue for women when it comes to trying to figure out their estrogen state, which can impact overall health.
- Saliva measurements are greatly affected by the use of hormone therapy. Transdermal progesterone and testosterone, in particular, can result in supra-physiological levels in saliva testing, but all exogenous hormone use seems to distort results to some extent. Because of this, patients are instructed to discontinue hormone use for between 12 and 36 hours prior to collection, depending on the hormone preparation. This can pose problems for practitioners who want to monitor hormone therapy. Estrogen, for example, washes out of the system almost entirely in 20 hours and drops significantly within 12 hours.
- Saliva collection, like blood, is a single-point collection. Although cortisol can be collected at multiple points, sex hormones are measured from a single morning collection. Just as with serum tests, a single point of collection does not account for individual variation and may catch a peak or a valley in hormonal secretion – or perhaps a peak for one hormone and a valley for another.
- Some practitioners feel that relying exclusively on salivary hormone testing, despite obvious advantages in collection, can be clinically misleading.
- To help ensure accuracy, some labs and their total testosterone hormone testing have been CDC-certified every year since the program’s inception in 2011. Unfortunately, there is no similar certification program for overall saliva hormone testing at this time.
- The 24-hour urinary hormone panel has several positive qualities. It shows a good overall picture of hormone levels by providing the average hormone level over a 24-hour period, removing the variable of daily fluctuations in one’s hormone levels. It accounts for the full day and night of hormonal secretion. This eliminates the possibility of falsely elevated or depressed levels that may be obtained when a single point collection occurs at a peak or valley of an individual’s secretory cycle. Since higher amounts of hormones are secreted at different times during the day, this gives a picture of the average level of hormone secretion.
- Urine assays measure systemic, circulating, unbound hormone, reflecting that which is bio-available and ready for the body to use. Urine hormone tests shows hormones in their water-soluble form, meaning that the body has prepared it and made it ready for excretion.
- Although the test is more expensive than blood or saliva, it provides a more comprehensive hormone picture by testing a broader range of hormones, pro-hormones, and hormone metabolites than any blood or saliva panel, which results in a higher level of information that is especially helpful in difficult cases. Pro-hormones are the precursors or biochemical building blocks for hormones. Hormone metabolites are the biochemical by-products or end products of hormone metabolism.
- Measuring hormones in urine is quite common in research. A 24-hour urine collection is the preferred method for testing hormones that are secreted at night and during deep sleep, such as growth hormone and melatonin, and is the most economical and reliable way to evaluate steroid hormone metabolites. This method has been gaining in popularity among integrative practitioners since it was brought into clinical practice by Dr. Jonathan Wright in the early 1980s.
1. Urine Hormone Tests For Estrogen
- Urine tests for all three estrogens (estrone, estradiol, and estriol) and provides additional helpful information, such as the levels of 2/16 hydroxyestrone ratio and 2-methoxyestradiol (suspected to have anticancer qualities).
- Other useful hormone tests are available using the urine, including different sub-types of estrogens such as 16 alpha (OH) estrone.
2. Urine Hormone Tests for Cortisol
Twenty-four hour urine hormone panels are excellent for evaluating adrenal health and function. In addition to measuring DHEA and cortisol, a complete panel also measures cortisone (the storage form of cortisol) and several important cortisol and cortisone metabolites, as well as aldosterone and other mineralocorticoids. The importance of measuring these metabolites can be seen in the stressed patient with normal or high-normal cortisol. Cortisol and cortisone metabolites can point to decreasing daily cortisol production that signals adrenal deficiency. The ratio of cortisol and cortisone is another important indicator of adrenal function, as are the mineralocorticoids: low mineralocorticoids are a clear indicator of chronic adrenal fatigue and are an excellent marker to monitor adrenal recovery with treatment.
3. Urine Hormone Tests for Metabolites
- An important advantage of a 24-hour urine hormone collection is the ability to measure hormone metabolites. This is most important when evaluating the adequacy and safety of exogenous estrogen supplementation and in assessing adrenal function. It is well established that certain estrogen metabolites are “good” estrogens, having a protective effect on estrogen-sensitive tissues. Other metabolites are known to have more carcinogenic effects.
- The utility of measuring estrogen metabolites has been the focus of much recent attention. Studies from 2012 and 2013 (a prospective case-control study and a retrospective case-control study) uncover new data that find a statistically significant association between 2-hydroxylation pathway estrogen metabolites and lower breast cancer risk. These studies focused on postmenopausal women not taking hormone replacement. While there are no studies to date that examine estrogen metabolite ratios in postmenopausal women while concurrently taking hormone replacement, it stands to reason that supplemented levels of parent estrogens will make estrogen metabolite analyses an important test in this population group.
- Thierry Hertoghe, M.D., from Belgium and the author of The Hormone Solution, proposes that urinary hormone studies provide the best overall picture of hormone metabolism. He says they are a critical component for evaluating age-related hormonal changes, one that blood studies do not provide, and he suggests a comprehensive 24- hour urinary hormone profile as the initial test to be used in hormone balancing therapy.
- Estrogen metabolism is also easily influenced, being easily altered with supplements such as diindolylmethane (DIM), indol-3-carbinol (I3C), methylated B vitamins, and magnesium. Being able to evaluate the relative balance of protective estrogens to potentially harmful estrogens and see the effects of treatment interventions is invaluable to the clinician working to maximize quality of life while also protecting against harmful effects. Because 24-hour urine hormone profiles measure both phase 1 and phase 2 liver metabolites of estrogen, these profiles also offer a peek into liver function and may suggest further avenues for treatment. It also shows urinary metabolites of steroid sex hormones, such as those involved in testosterone and pregnenolone metabolism.
Downside to Urine Hormone Tests
Even though it has so many benefits, the 24-hour urinary hormone panel has a few limitations as well.
- This method is considered inconvenient by some because it requires a person to collect all their urine over a 24-hour period.
- Older people are often unable to manage urine collection with accuracy, and for these individuals urine testing may be too cumbersome.
- Dehydration or excessive fluid intake can also affect the results.
- It only measures the hormones the body is excreting in the urine. And while excreted hormones often correlate with tissue and blood levels, this is not always the case.
- Not all urine hormone testing methods are equal. Serial single-point urine collection does not account for individual differences in hormone secretion, especially for patients with nontraditional schedules, such as shift workers.
- Just as single-point and 24-hour collection are different, not all technical methods of urine assay are equally accurate. Highly sophisticated gas chromatography (GC) run in tandem with mass spectrometry (MS) is emerging as the method against which all other methods are measured.
- People with kidney disease do not excrete urine or metabolic products normally, so a urine hormone test is not suitable in these cases as hormone results may be altered in people with significant liver or kidney disease.
- As with all other methods of testing, non bio-identical hormone substances are not measured.
- Urine testing cannot test both free (active) and total levels of testosterone.
- This test is complex and difficult to interpret, so you need to consult a physician who is an expert in this type of testing to tell you what it means.
- The 24-hour urine collection does not shed light on the diurnal cortisol pattern. It has been observed clinically, however, that an elevated cortisol and cortisone in the 24-hour urine panel may be related to nighttime cortisol spikes.
- Some practitioners have expressed a concern about the convenience of a 24-hour urine collection.
- To help ensure accuracy, some labs and their total testosterone hormone testing have been CDC-certified every year since the program’s inception in 2011. Unfortunately, there is no similar certification program for overall urine hormone testing at this time.
DUTCH – Dried Urine Test Comprehensive Hormone Tests
Hormone blood tests, saliva test and 24 hour urine hormone tests are useful tools, but according to Precision Laboratories, they are not the same as the comprehensive DUTCH test. Blood tests won’t measure your cortisol rhythms and estrogen metabolism. Blood tests will not track hormone replacement as thoroughly. They will not shed light on adrenal, cortisol and sleep problems.
The DUTCH test was created to provide insight into many of these concerns. It has been designed to provide the most complete assessment of sex and adrenal hormones, along with their metabolites, in one easy to administer test available in the comfort of your own home. The DUTCH test tests your reproductive and adrenal hormones as well as melatonin and oxidative stress. No blood to draw, spitting in tubes or filling up jugs of urine. The DUTCH test uses a dried urine collection process that is great for baseline measurements of women with hormonal imbalances and for Hormone Replacement Therapy (HRT) monitoring. Once receiving the results of your DUTCH test, you can work with your medical professional to achieve optimum hormone balance.
More than just a test for the reproductive hormones, the DUTCH hormone test adds testing for metabolites and is able to focus on androgens (testosterone, DHT), as well as break down estrogens further to see if there may be metabolism issues involved. One of the most exciting parts of the DUTCH hormone test is the daily cortisol component which improves urine testing because it includes getting a full picture of all hormones throughout the day: Cortisol metabolites rather than just the free cortisol reading, progesterone and melatonin, as well as more specific readings overall for the estrogens are all included in the DUTCH hormone test, which when combined with all of the other findings will give the best overall picture in order for health professionals to make the best clinical decisions for each person.
The total hormones tested with the DUTCH hormone test include:
The DUTCH test is considered to be the most cutting edge, comprehensive, Functional Medicine hormone test.
The clinical bottom line is that blood, urine, and saliva tests each have advantages and disadvantages. One test type doesn’t replace the rest, but adds information that can be part of an assessment for the best outcome for the individual patient.
Every practitioner has his/her preference. Each of the hormone tests provide information that is valuable. The best part about having so many options is that if you do not have insurance, your insurance doesn’t cover it, or you practitioner is only familiar or uses one specific kind, having some information, regardless of how comprehensive, can benefit your understanding in trying to re-balance your hormones and regain optimal health if the hormones are involved.
Hormone tests contain a wealth of information, and it may appear overwhelming to some. If you don’t have a knowledgeable health professional who is well versed in hormones, a good laboratory will have experts with clinical experience available to help you get the most from your results.
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