Measuring Hormone Levels

Measuring hormone levels are essential for the proper diagnoses of perimenopause, menopause, andropause or other disease states, such as hypothyroidism and adrenal exhaustion (chronic fatigue syndrome) , which may mimic perimenopausal symptoms. Hormone level determination also enables you to closely monitor your hormones ensuring they all remain within a normal physiological range. The 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 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. A couple of examples of this are, firstly if a women presents with hot flushes the doctor may assume she is menopausal and requires estrogen when in actual fact the hot flushes were caused by high cortisol levels. By giving estrogen to her an inappropriate and possibly dangerous treatment would commense causing further hormone imbalances. 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 would make her condition worse. These are examples of two quite common sinarios we see in our practice which emphasise the need for hormone testing.

As a generalisation I recommend that before IBHRT is commenced the levels of estriol, estradiol, estrone, progesterone, testosterone, DHEA, cortisol and thyroid (T3 and T4) be tested. The first five hormones make up the basis of IBHRT while measuring DHEA, cortisol and thyroid hormones may indicate if adrenal exhaustion or hypothyroidism are present which have been implicated in perimenopause and menopause.

Blood Tests 'v' Saliva Tests 'v' Urine Tests

(1) Blood tests commonly used to determine hormone levels will measure the total amount of hormones in serum. This type of hormone testing is considered the least accurate of all methods available. 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 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. In addition hormones attached to red blood cell receptors are not measured as these tests only measure what is present in serum. This is a significant problem monitoring levels if you are using transdermal hormone creams with the hormones binding to red blood cells once absorbed through the skin and therefore not being measured by serum analysis. In addition serum test results only reflect hormone levels outside the cells in the serum and do not reflect levels else where in the body. Clinical trials performed by the American Academy of Anti-Aging on over 300 patients revealed that every patient whom hormone levels were deemed at optimal levels by serum blood tests had in actual fact excessive levels based on saliva tests. The doses used to achieve optimal serum levels were higher than standard physiological doses which was all that was required to achieve optimal levels by saliva tests. In every case the patients doses were reduced until saliva tests reflected optimal levels. In our own practice we see this same phenomena on a regular basis with those patients being monitored by serum blood tests, that is their current doses are too high! In addition serum tests are unable to detect progesterone level increases when used as a creams for weeks when in fact saliva testing shows it to appear within 2 hours. And finally serum tests are not available for estriol and estrone in Australia. Therefore two very important estrogens will go undetected when using serum analysis and quite often we see test results where estradiol is normal however estrone is elevated whichis a problem that would go undetected by blood tests.

NOTE: If you are using troches then blood tests or urine tests are recommended as hormone residues in the mouth can affect saliva test results for up to 36 hours after your last troche dose. It is not wise to wait 36 hours and then do the saliva test as these hormones have a short half life and will be mostly eliminated from your sytem so you will only be measuring baseline levels.

(2) 24 hour urine hormone test which is very accurate and should be used when ever available however due to the collection of 24 hours of urine has obvious compliance problems

(3) Saliva testing measures the free and therefore biologically active form of several of the major hormones in saliva - estriol, estradiol, estrone, progesterone, testosterone, DHEA and cortisol. Saliva tests have been proven to be an accurate reflection of hormone levels present inside cells, where the hormone action takes place, whereas blood tests measure hormones outside the cells. It is considered to be the gold standard for hormone analysis by the World Health Organisation (WHO). Despite the WHO's recommendation to use saliva hormone testing it is often neglected by medical practitioners, many whom refuse to order such tests as they are not informed of the differences. In these cases blood test will do as they still give us an indication of your hormone levels although they may not be as accurate.

Saliva hormone testing is a less painful and a more accurate way of determining your hormone status which can be performed in the comfort of your own home. The tests may be ordered by your doctor, or alternatively we can arrange them for you with a consultation if your doctor refuses to do so. Saliva hormone testing involves a test kit being sent to your home with printed instructions. Saliva samples are taken at a uniform time of the day for more meaningful comparisons 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 whom ever ordered the tests for interpretation and to determine the appropriate therapy.

Timing of Tests

The best time of the day to collect a sample for any baseline hormone analysis is in the early morning (except for 24 hour urine analysis), and the best time of the month is between days 20 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.

When doing subsequent follow up tests to monitor levels while on any hormone replacement it is best to take the sample midway between doses so an overall daily average is measured. This is very important in order to obtain useful results.

Many doctors are critical of any form of hormone testing as they claim hormone levels fluctuate so testing is therefore useless. This is true, hormone levels do naturally fluctuate on a monthly cycle. 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 day. 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.

What to Test For

Your current signs and symptoms will help determine exactly what tests are appropriate to preform. Therefore the types of tests required is very individual however generally I would recommend a urine or saliva test for estriol, estradiol, estrone, progesterone, testosterone, DHEA, and cortisol. Thyroid hormones (T3, T4, Reverse T3) are determined by either blood tests or 24 hour urine excretion tests. All of these ideally should be measured before you start any IBHRT which will give you a good baseline assessment of your overall hormone status. From these initial results it can be determined which hormones need supplementation and the appropriate starting dose of each hormone.

It should be clarified that test results must be used in conjunction with signs and symptoms and not be totally relied upon 100% for a diagnosis and latter on to determine appropriate dosages. There is always a general optimal physiological level we try to achieve with tests however these levels can vary in some patients and this must be taken into account and can only be done so by also using symptoms to go by. Every day I am sent hormone test results from people wanting my advice on how to adjust their hormone doses. I cannot responsibly offer any advice without an appropriate background into their signs and symptoms to help make a final decision.

Interpreting Test Results

A major problem with interpretation of test results is that medical practitioners with little experince in hormonal matters often observe results that lie at the low end of the so called “normal range” and determine that no hormone imbalance or deficiency exists thus determine no action is required. A major problem is that laboratory test “normal” ranges are defined and standardised according to statistical norms instead of physiological optimal levels. That is, mathematics rather than patient symptoms define “normal” hormone levels.

Instead of using “normal” laboratory ranges we prefer to use optimal ranges which as a general rule lie within the upper one third of the normal laboratory range. This general rule is only a guide as it does not take the appropriate balance between certain hormones into account which is also very important. Therefore it is important that someone with experience and knowledge on appropriate hormone balance views your test results for an accurate diagnosis. Often there is a marked improvement in symptoms when levels at the low end of the normal range are increased to the upper end of the normal range with supplementation. For a more detailed explaination on the shortfall of using "normal" laboratory ranges - click here

Once you have started IBHRT it is essential to retest your hormone levels after four to six weeks to ensure your hormone levels remain within the upper one third of the normal physiological range, that they are appropriately balanced, and also to ensure the supplemented hormones are absorbed and utilized by the body. If you use lozenges to deliver your hormones you must have blood tests as saliva test will be adversely affected if performed within 36 hours after your last dose. The best time to retest for oral and transdermal doses is half way between consecutive doses so an overall daily average is measured. After your hormone levels have stabilized to suitable levels continue to retest at least annually for the rest of your life.

Further Monitoring

In addition to saliva/urine analysis we also recommend that both men and women have their 24 hour urine estriol, estradiol, estrone, 2-hydroxy-estrone, 4-hydroxy-estrone, 16-hydroxy-estrone levels checked. The goal is to assess and reduce any potential risk of disease by monitoring which estrogen metabolites are being produced, the relationship between metabolites, and how replacement affects metabolite levels. For more information on an unfavourable estrogen metabolite balance possibly causing breast and prostate cancer please refer to appropriate sections.

Annual breast screening and endometrial ultrasounds are also important to detect if any problems arise from hormone therapy.

Genetic Assessments

Genomic assessments are available to help detect the susceptability for certain diseases before they surface, which then allows individual measures to be taken to help the prevention of it from actually occuring. This can be done by analysing your DNA and looking for certain single nucleotide polymorphisms (SNP). Most SNP's have no functional significance however a small number impact on the activity of the gene which can ultimately increase or decrease the risk of developing a disease or group of diseases. SNP's can also influence your response to environmental stimuli so can be used to predict your response to specific diets, supplements and lifestyle changes. It is therefore a useful tool in predictive and preventative medicine. The downside it that they are expensive and can take up to 3 months to get your results.

Full Parasite and Culture Stool Analysis

In addition to hormone testing many of our patients exhibit gastrointestinal symptoms which can be diagnosed with the aid of a full parasite and culture stool analysis looking for the presence of parasites, yeasts and bacteria. We recommend Histopath Laboratories for this type of analysis as they are one of only a few laboratories that use a fixing agent which is essential to accurately diagnose the presence of certain parasites. In addition a Complete Digestive Stool Analysis (CDSA) may be required which will indicate amungst other things the pancreatic function and the presence of beneficial bacteria in the gut. Gut permeability tests may also detect the presence of leaky gut syndrome.

ALCAT Allergy/Intollerance Blood Tests

ALCAT blood tests are available to help identify any food intollerances that may be present. These appear to be better than IgG antibody allergy tests as these tests look for specific antibodies and may miss other mechanisms that can cause an intollerance reaction.

Availability

You may contact us for a consultation were we are able to organise all the appropriate tests and then interpret the results and make recommendations on the best possible coarse of action. Phone consultations are available if you live outside the Northern Rivers Area. All saliva and urine tests will be sent to your home as described above.

For Saliva Hormone, Urine hormone, Urine Thyroid Excretion and Urine Estrogen Metabolite Testing we recommend:

NATA-Accredited Testing Laboratory
PathLab
68 Burwood Hwy
Burwood, VIC, 3125
Ph: 03 88313000
Fax: 03 98082247