There are a number of symptoms that prompt me to recommend hormone testing—such as chronic fatigue, mood changes, stress intolerance, sleep disturbance, fertility challenges, weight gain, acne, hair loss, and menstrual problems like heavy periods or irregular bleeding. Hormone testing can be the key to unlocking some of these problematic issues. Depending on the type of testing used, we can get a good window into the hormonal picture, which can help refine treatment recommendations to be more precise and aimed toward the origins of the imbalance.
There are three main methods of hormone testing: serum, urine and saliva.
Serum hormone testing can be a good first assessment of estrogen, progesterone, DHEA and testosterone to look for overt imbalances. This is the type of testing typically used in conventional medicine offices. Serum testing is well validated, and I use it when I think it will be helpful, often as a ‘first-look’ at hormonal status and when looking for frank imbalances.
Salivary hormone testing is used in many functional medicine offices. For sex hormones, I almost never use salivary testing because it is not as precise as urine or blood testing. On the other hand, for adrenal testing, salivary cortisol is considered a reliable assessment of adrenal output. When performed correctly, it can indicate whether cortisol rises appropriately upon awakening and falls appropriately at night. However, if there is an imbalance in cortisol clearance (rather than cortisol production), salivary results can be misleading, veering someone toward to misdirected therapies.
For a more nuanced assessment of hormone levels, I generally prefer urine testing, which can detect individual hormone levels as well as hormone metabolites. Metabolites provide an indication of how quickly or slowly the body is moving hormones out of circulation. In the case of cortisol, it can identify the difference between a dysfunction in hormone production or issues with clearance. In the case of sex hormones, urine metabolites provide a window into hormone conversion and detoxification pathways. It can reveal whether hormones are preferentially transformed into either more protective or problematic metabolites in terms of potency and risk. When using hormone therapy, we can help identify whether someone is being over or under-treated, and whether steroid hormones are being safely metabolized.
In my experience, urine testing provides the most holistic and reliable assessment of hormonal status. While testing isn’t always essential to addressing hormone balance, I find it helps refine our understanding and provide quantitative data to track progress. This information it provides can help pinpoint therapeutics to address current health concerns and prevent future issues.
For a more technical look and information about the specific lab I use, read on.
My preferred test is The Dried Urine Test for Comprehensive Hormones (DUTCH) method. I have no financial affiliation with this company, but feel that this test is a valuable tool in my practice. In contrast to 24-hour urine tests, which requires filling a urine jug for an entire day, the DUTCH test is more user friendly- it only requires 4 urine samples taken throughout the day, which are then dried and sent to the lab.
The DUTCH test shows 17 different reproductive hormone metabolites. Some of the metabolites give us information about detoxification pathways, including methylation and COMT activity. In terms of estrogens, we can identify whether the metabolites are more protective or more likely to contribute to DNA damage and cancer risk. For testosterone, the DUTCH method can show whether the hormone is being excessively or insufficiently metabolized to estrogen via aromatization. We can also see whether testosterone is preferentially being shunted to 5-alpha-dihydrotestosterone, a more potent androgen associated with inflammation, blood sugar and insulin problems, polycystic ovaries, hair loss, acne, and prostate enlargement. If elevated, it may indicate a stronger need to reduce inflammation, balance blood sugar and provide nutrients that support alternate routes of metabolism. Measuring progesterone metabolites can give us a sense of whether the more calming alpha metabolites are being produced adequately. In cases of anxiety and sleep disturbance, the metabolites can help pinpoint whether a progesterone imbalance is a contributory cause.
In addition to the sex hormones, DUTCH can be used to assess adrenal status. Adrenal health is relevant to stress responses, chronic fatigue, sleep-wake disturbances, blood sugar balance and resilience to inflammation or infection. When using a 4 sample method, we can assess the daily rhythm of cortisol production and breakdown. Similar to a typical salivary adrenal test used by functional medicine practitioners, the dried urine test will reveal whether cortisol levels rise appropriately in the morning and decline appropriately in the evening. However, unlike the salivary testing, DUTCH measures cortisone, an inactive cortisol compound, as well as cortisol metabolites. This can help differentiate whether a dysfunction is caused by excessive or deficient cortisol production, or whether it is more related to how slowly or rapidly cortisol is being metabolized.
For instance, if someone has elevated cortisol, the issue might be excessive stimulation of the Hypothalamic-pituitary-adrenal (HPA) axis or there might be some underlying issue that causes slow metabolism, such as low thyroid or liver congestion. When cortisol and the metabolites are low, then total production is likely low, which may indicate an HPA dysfunction which is commonly called ‘adrenal fatigue.’ On the other hand, if cortisol is low but the inactive metabolites are high, it points to another set of issues. In these situations, it makes more sense to support appropriate metabolism rather than stimulate production.
For those with poor sleep, the waking cortisol levels can reveal cortisol status throughout the night, and hence it can give us a sense of whether cortisol is a factor in sleep disruption. This level of nuance can clarify where to look for underlying causes and can help guide treatments in a more specific manner.
Melatonin levels are also included in the DUTCH, so we can see if adequate amounts of this sleep promoting antioxidant are being produced. If melatonin levels look sufficient, then we’ll probably look elsewhere to address sleep disturbance. However, if melatonin levels are low, then this can shift our focus toward determining which factors might be interfering with melatonin production.
DUTCH also provides an oxidative stress marker into the analysis, called 8-Hydroxy-2-deoxyguanosine (8-OHdG). This is a biomarker indicates oxidative damage to DNA and may provide an indication of one’s risk for various cancers and degenerative diseases. When 8-OHdG is elevated, it can help reinforce a higher need to explore causes of oxidative stress, enhance antioxidant pathways and employ other strategies to protect DNA.
Lastly, DUTCH recently added 6 new organic acid markers to the testing panel. It now includes 3 nutritional markers, looking at B12, B6 and glutathione status. B6 and B12 are relevant to hormone processing, as well as a myriad of other functions in the body. Glutathione is an important antioxidant necessary for cellular health and cancer protection. DUTCH also measures 3 neurotransmitter metabolites, which are relevant to dopamine, norepinephrine and epinephrine and serotonin levels. Looking at all of these markers in relationship to each other can help elucidate the dance between mood and hormone balance, as we look at the interplay between the adrenals, the sex hormones and neurotransmitters.
In summary, urine hormone testing provides the most comprehensive look at hormonal status. While it is often possible to recommend treatments based on symptoms, I find that the testing helps me get a deeper and more nuanced look. Often the testing confirms what I already suspect, but more times than not, it helps clarify which treatments are most likely to be effective for a person’s unique picture and help get to the root of the issue.