Measuring hormone levels is essential for the proper diagnoses of perimenopause, menopause, andropause or other hormone related disease states such as hypothyroidism and adrenal exhaustion (chronic fatigue syndrome), which all exhibit similar and overlapping symptoms making an accurate diagnosis based on symptoms alone very difficult. Hormone level testing also enables you to closely monitor your hormones ensuring they all remain adequately balanced and within the optimal physiological range.
The hormone test results used in conjunction with any symptoms you have are invaluable tools when designing an Individual Bioidentical Hormone Replacement Therapy (IBHRT) regime. It is very surprising, not to mention dangerous, how many women and men on HRT have never had their hormone levels tested. Hormonal imbalances that are not accurately identified and appropriately treated may lead to inappropriate treatments with very serious side effects so the importance of monitoring their levels cannot be overstated.
There is currently some criticism against hormone testing by some whom claim they are worthless and that it is best to diagnose and dose hormones based on symptoms alone. We do not agree with this argument as many conditions share similar symptoms making it difficult to differentiate between them making an accurate diagnosis difficult. In addition some people can tolerate very high hormone levels or hormone imbalances and display no symptoms yet these imbalances in the long term could potentially create a problem such as cysts, fibroids or cancer. The critics of hormone testing usually pay little to no attention to the appropriate balance of hormones which can only be accurately determined by hormone testing.
A couple of common examples we see regularly are given to illustrate the necessity for testing. Firstly if a women presents with hot flushes many practitioners will assume she is menopausal and requires estrogen when in actual fact the hot flushes may by high cortisol levels. By giving estrogen to her is an inappropriate and possibly dangerous treatment which may cause further hormone imbalances and side effects. Secondly, again a women presents with hot flushes which were caused by excessively high levels of estrogen which resulted in a down regulation of her estrogen receptors causing her hot flushes. By assuming it is caused by an estrogen deficiency and giving estrogen to this women, which would be the most common diagnosis based on her symptoms, would make her condition worse. Finally in order to reduce the long term risks of hormone replacement an appropriate balance of the three estrogens is essential and also their balance with progesterone. Therefore ongoing monitoring is essential in order to ensure a healthy hormone balance is maintained throughout therapy. These can only be determined by hormone testing. Here are only a couple of examples we see in our practice which emphasize the need for hormone testing.
Finally another criticism of hormone testing is that women’s sex hormone levels fluctuate throughout the month and thus testing is useless. Sex hormone levels do indeed fluctuate in pre-menopausal women yet if the menstral cycle is correctly understood it is easy to test during the luteal phase of the cycle (around day 21) where progesterone levels peak, being the most significant time of the cycle progesterone wise, and also avoiding the mid cycle estrogen surge and thus this problem is easily overcome with a little knowledge of the menstral cycle. Post menopausal women’s sex hormones do not fluctuate nor do any of the adrenal or thyroid hormones with the menstral cycle so can be tested any day in the early morning.
Types of Hormone Tests – Blood Tests v 24 hour Urine Tests v Saliva Tests
(1) Blood (Serum) tests – are commonly used by conventional doctors to determine total hormone levels in the serum. These serum tests are unable to distinguish the protein-bound, and therefore inactive form of the hormone, from its free and biologically active form, thus giving only a rough estimate of your active hormone levels. This may lead to inappropriate diagnosis as quite often total hormone levels are within normal limits but once the free and active levels are tested deficiencies are identified.
VERY IMPORTANT: When monitoring hormone levels while on transdermal (creams) hormones serum testing is not accurate. This is due to a number of factors the first being how the hormones are distributed around the body after absorption. Once absorbed topically applied hormones are collected by the lymphatic system and travel through the lymphatic vessels into the subclavian veins where it re-enters the blood circulation and from there goes straight to the heart, lungs and then the rest of the body via the arteries, arteriols and capillaries feeding tissues and organs around the body with oxygen and nutrient rich blood with the hormones. They are taken up by the cells and ultilized and once excreted by the cell return back to the heart via veins. The venous system carries oxygen-depleted blood rich in cellular waste back to the heart along with excess hormones no longer required by the cells. Therefore venous serum measures the spill over of hormones from the cells. In addition once the hormones enter into the blood stream following absorption they bind to red blood cell membranes in order to minimize unfavorable interactions with the aqueous water as most hormones are “fat loving” and prefer to bind to fats. Once your blood sample is taken it is centrifuged and the red blood cells along with the hormones are removed prior to analysis.
This phenomenon was described by Frank Z. Stanczyk for transdermal progesterone but it also seems to occur for all other hydrophobic sex hormones. See reference below:
This is a significant problem if monitoring levels using serum testing if you are using transdermal hormone creams.
(2) Blood (Capillary) Spot Testing – uses capillary blood obtained from your finger tip, as opposed to venous blood serum taken from a vein. Levels obtained from capillary blood correlate well with serum blood so appears to be the method of choice.
This method also appears to be more accurate than serum testing when monitoring topically applied hormones. The study above shows that a dose of 80 mg progesterone with serum testing progesterone levels only increase marginally (1-3 ng/ml). However with saliva testing levels of progesterone increased 10-fold while with capillary blood testing levels increased 100-fold compared to levels in venous whole blood. This led to the conclusion that when hormones are delivered through the skin or oral or vaginal mucosa, conventional serum hormone tests grossly underestimate hormone delivery to tissues. In contrast, hormone levels in saliva or capillary blood spot better represent tissue hormone uptake. Using serum test results to monitor topical progesterone supplementation has led to confusion and can result in over-dosing in an attempt to achieve physiological luteal levels of progesterone. The same is observed for other hydrophobic sex hormones in our practice so we do not recommend using serum testing to monitor.
Serum or capillary testing still remains the method of choice for thyroid hormone monitoring.
(3) Urine Hormone Testing (DUTCH TEST) is a convenient test that can be done at home and is an accurate method supplying great detail on your hormone status. It measures the free and active form of most sex and adrenal hormones, including many of their metabolites, and is easy to do. It is also gives accurate results when using creams or troches. The main problems with urine testing is the cost – being the most expensive way to test!
(4) Saliva testing measures the free and therefore biologically active form of most sex and adrenal hormones. Saliva tests have been proven to be an accurate reflection of hormone levels present inside cells, where the hormone action takes place. Despite all the research to validate this method it is often the most criticized and neglected method by medical practitioners. Click here for references that validate saliva testing.
It does have some down sides. The problem with saliva testing is that hormones are found in much lower concentrations in saliva than in blood or urine. This makes it much harder for some labs to consistently report salivary hormones with as much accuracy as blood or urine. In addition, contamination from bleeding gums or even aggressive tooth brushing can affect a person’s results and make the levels seem artificially high. Further, other factors such as salivary pH and flow rate can also affect results. Finally you CANNOT use saliva testing if your using troches/lozenges as the method of hormone administration as the results are not accurate due to accumulation of hormones in salivary ducts. To get around this some practitioners recommend to stop troches for 24-48hrs before testing but this will not measure supplemented levels but rather baseline levels as hormone levels drop rapidly so the results are not useful.
So Which Test Method is the Best?
We use all forms of hormone testing as each has advantages in certain situations so it is best to determine the most appropriate test for each individual based on their particular circumstances. For example saliva testing is great for testing adrenal function throughout the day. Capillary Blood tests are great to monitor hormone levels while on hormone replacement (including hormone creams), and regular serum tests can be used to monitor thyroid function.
We can arrange any of these tests for you with a consultation if your doctor refuses to do so. Hormone testing involves a test kit being sent to your home with printed instructions. Samples are taken and placed into provided containers at one or more specific times of the day, then sent directly to the laboratory for analysis. The results are then sent back to us where we can interpret the results and determine the appropriate therapy.
Timing of Tests in Relation to your Last Dose
The best time of the day to collect a sample for any baseline hormone analysis for diagnosis is in the early morning (except for 24 hour urine analysis) before breakfast, and the best time of the month for menstrating women is between days 19 to 23 of a 28 day menstral cycle (day one is first day of mensus). This is when progesterone levels are apt to be highest (luteal phase) during the entire cycle. Men can do the test any day that is convenient but again before breakfast.
When doing subsequent follow up tests to monitor hormone levels while on any hormone replacement it is best to take the sample 8 to 12 hour after the last dose if your using creams and capsules. This is very important in order to obtain meaningful results. If your using troches then blood tests should be done approximately 4 hours after your last troche dose. Be consistent so all follow up tests can be compared to each other. If the timing of the test is mixed on each occasion the test is performed then the results are not comparable!
For thyroid testing if a patient is on T4 (oroxine) therapy, it is best to test about 8 to 12 hours after the last dose of medication to get the best correlation of levels produced by the T4 replacement. With T3, the best time to test is 1.5 to 4 hours after the last dose. For thyroid extract (Armour thyroid), which is a combination of T3 and T4, you should test 4 hours after the last dose. Any sooner could produce a peak of T4 and any later could produce a drop off from the T3. All repeat tests should use the same timing as previous testing so results can be directly compared. If not then no direct accurate comparison can be made between tests.
Many doctors are critical of any form of hormone testing for women as they claim hormone levels fluctuate so testing is therefore useless. This is true, hormone levels do naturally fluctuate on a monthly cycle in menstrating women. However if that cycle is clearly understood the tests should be performed on a specific day of the cycle (luteal phase), as mentioned above, where we are well aware of the appropriate hormone levels for that time of the month and thus the results are meaningful. If periods are irregular it is more difficult to accurately assess hormone levels with just one sample. Therefore take samples on two different occasions before starting IBHRT to increase the chance that testing will reveal natural biological variations. Post menopausal women do not experience hormonal fluctuations so tests can be done on any day.