HORMONE TESTING FOR HARMONY

There are three ways to evaluate different hormone levels:  blood, saliva, urine.  In this blog, I will review which hormones to test, when to test, and why I prefer certain testing methods for various hormones.  Many of my patients are confused about their hormones, especially if they are certain they are struggling with hormone imbalance and have asked their doctor to check their hormones and everything comes back “normal”; in cases like this it is possible that the hormones were not tested during the correct time of the month or that the work-up done was not thorough enough or perhaps blood levels are not the best way to test that particular hormone. 

First let’s review the typical menstrual cycle so you can understand my recommendations for when to test:

Day 1=the first day you see bright red blood.

Day 14=this is the day that ovulation typically occurs but this is not true for every female and/or every cycle; this day is used as a baseline when discussing lab testing and timing.

Day 28=the menstrual cycle is often defined as 28 days, but not every woman has a 28 day cycle; this day is when your hormones drop if you don’t get pregnant which prompts your uterus to bleed again.

Now let’s focus on to each hormone individually!

ESTROGEN

Most women who consult with me assume they have estrogen dominance, but that is not necessarily the case; this presumption is why testing estrogen is integral for a thorough hormone evaluation.  Estrogen can be tested via blood, saliva, or urine; blood levels show total levels whereas saliva and urine show bioavailable levels, so I typically prefer saliva or urinary levels.  Sometimes I consider ordering blood levels of estrogen, especially if the person has good insurance coverage and their deductible has been met.  Urinary levels through Dutch have a distinct advantage because this test also shows estrogen metabolites.  When evaluating estrogen levels, I recommend testing all three forms of estrogen:  estrone (E1), estradiol (E2), and estriol (E3).  Estrone is the “strongest” estrogen, estradiol is the most abundant estrogen, and estriol is the weakest and most breast-protective estrogen.

If blood testing is chosen for estrogen evaluation, it should either be tested on day 3 (day 2-4 if it falls on the weekend when the lab is closed) or day 21 (19-22 if it falls on the weekend when the lab is closed).  If testing on day 3, it is important to also test follicle stimulating hormone (FSH) and luteinizing hormone (LH) levels; these hormones help us understand how the brain is talking to the ovaries and the estrogens tested can tell us how the ovaries respond to those messages.  FSH can also give us clues about your fertility and ovarian egg reserve.

If salivary testing is chosen, I recommend testing around day 21; if the person has a shorter cycle I may shoot for an earlier day of the menstrual cycle.  The goal is to collect roughly 5-7 days after ovulation.

If urinary testing is chosen, I either choose a cycle mapping option where samples are collected throughout the month (this option is ideal for those with irregular cycles (often seen in PCOS and perimenopause) or no cycles due to uterine ablation or partial hysterectomy.    If I choose a 24 hour urinary test, four or five samples are collected around day 21 as I discussed above in the salivary testing section.  Again, my current preference for estrogen testing is urinary in most cases because this option provides data about estrogen metabolism which can shed insight on your risk for hormonal cancers and/or osteopenia/osteoporosis (i.e. bone loss susceptibility).

PROGESTERONE

In my clinical practice I more commonly see progesterone deficiency vs estrogen dominance which reiterates the importance of testing because correcting progesterone deficiency requires an entirely different treatment approach than addressing estrogen dominance.  I generally do not find testing blood levels of progesterone helpful, but of course there are exceptions; I might start with blood levels if the person has good insurance coverage and the deductible has been met.  In the majority of cases, I strongly recommend either salivary or urinary measurements around day 21 as discussed above.

TESTOSTERONE

Testosterone is a key hormone to test in both men and women.  Low libido, fatigue, and/or depression are common symptoms of testosterone deficiency.  Acne, irregular periods, and abnormal hair growth (hirsutism) on the chin, chest, and abdomen can be signs of high testosterone; elevated testosterone can also cause scalp hair loss.  Blood is a very accurate way to measure both free and total testosterone; it is very important to order both parameters along with sex-hormone binding globulin (SHBG).  You can also get a reliable testosterone evaluation via saliva or urine.  Testosterone may be tested anytime during the month, but it is best evaluated with morning specimens as testosterone is highest in the morning.

DHEA

Dehydroepiandrosterone (DHEA) is an important anti-aging hormone that can be converted into testosterone or estrogen.  It is produced in the adrenal gland and helps to counter-balance cortisol.  DHEA levels decline with age.  This parameter can be tested via blood, urine or saliva; I have not found blood levels of this hormone to be very valuable in the clinical setting, so I generally recommend urinary or salivary evaluation.  DHEA can be collected at any time during the month and should be tested along with cortisol (see next section).

CORTISOL

Cortisol is produced in the adrenal glands and helps people respond to stress; cortisol also plays an integral role with hair loss and blood sugar regulation.  Blood levels of cortisol can be helpful in ruling out Addison’s and Cushing’s disease; this marker is best run at 8 AM.  It can also be helpful to get an adrenocorticotropic hormone (ACTH) blood test when measuring blood cortisol levels; ACTH is produced in the pituitary gland and aids in adrenal function.

For the condition formerly known as “adrenal fatigue”, the best way to assess whether someone is struggling with hypothalamic-pituitary-adrenal (HPA) axis dysfunction is via salivary or urinary measurements.  Cortisol is highest in the early morning and gradually diminishes throughout the day so my favorite way to determine bioavailable levels of cortisol is via a four-part saliva collection so that you can assess the actual diurnal rhythm, thereby individualizing adrenal support recommendations.  The beauty of urinary testing is that it provides cortisol metabolites which can be helpful when providing more technical treatment guidance.

Cortisol labs of any type can be collected at any time during the month.

THYROID

When initially screening for thyroid dysfunction, it is important to test all the following parameters:  thyroid stimulating hormone (TSH), free T4, free T3, thyroid peroxidase antibody (TPO), thyroglobulin antibody (TGB), and reverse T3.  Additionally, the standard reference ranges are quite wide.  Optimal TSH=0.5-1.5; optimal free T4=1.1-1.8; optimal free T3=3.0-4.2.  If your doctor tells you that your numbers are “normal” do not accept that evaluation at face value.  Do get the actual thyroid results, look at which parameters have been done, and determine if the levels are optimal.  If not, I encourage you to seek out a second opinion from me or another licensed integrative/functional medicine practitioner.  Thyroid labs should be drawn before noon while fasting for at least 8 hours; please do hold any morning thyroid medication and take it immediately after the blood draw.  Added bonus:  there is a lab company that offers bloodspot testing for thyroid.

INSULIN

Insulin is a hormone produce from the interior (endocrine) portion of the pancreas and helps people maintain stable blood glucose levels.  Most people (adults and children) in the USA are insulin resistant or have metabolic syndrome; insulin resistance (IR) frequently precedes prediabetes and full-blown type II diabetes.  IR is also common in polycystic ovarian syndrome (PCOS) and indirectly can impact other hormone levels.  This blood marker should be drawn in the morning after a 12 hour fast.

To briefly summarize (TLDR):

·       It’s important not to self-diagnose and self-treat when it comes to hormones

·       Blood is best for: testosterone, thyroid, insulin

·       Urine is best for: estrogen, progesterone, DHEA, cortisol, testosterone

·       Saliva is best for:  cortisol, estrogen, progesterone, DHEA, testosterone

If you are ready to optimize your hormonal health in 2022 and are not a patient, please contact us to schedule a free discovery call to determine if I am the right person to help you decide what tests need to be done and subsequently guide your wellness journey.  If you are already a patient, please ChARM message me so we can determine the next step to help you find hormonal harmony.

Wishing you clarity, creativity, and compassion in 2022!!!

Rachel Oppitz, ND