The Role of Hormone Testing
When our hormones are working properly and in the right combinations, life is good. However, those same hormones that keep us happy and healthy can also cause emotional and physical distress if they are not in balance. Optimal hormone balance is critical to our physical and emotional well-being, as well as long-term protection against age-related concerns such as breast cancer, cardiovascular disease, and osteoporosis. (For more information about hormone balance, see our newsletter titled All About Balance.) Hormone testing is a valuable tool for achieving optimal hormone balance, as well as for maintaining that balance once it is achieved.
To appreciate the role of hormone testing, it helps to have a basic understanding of what hormones are, what they do, and how they work.
Hormones are substances secreted by glands and transported through the bloodstream to target tissue, where they regulate the functioning of that target tissue. Simply put, hormones convey information among the different cells and tissues that make up our bodies.
Hormones exist in a very delicate balance, and are just one aspect of the many complex relationships present among our body’s nervous, endocrine, and immune systems. A hormone’s ability to perform its duties is dependent on many factors, including receptors that provide a mechanism for making the hormone available to the tissue, and plasma proteins that are used to transport the hormones throughout the body.
In addition, various factors such as diet, low blood sugar, stress, and sleep deficit can significantly affect both the function of the receptors and the levels of the plasma binding proteins, which subsequently affect the accuracy of hormone level measurements. As such, the accuracy of hormone testing is dependent upon many factors, some of which are within our control and some of which are not.
Although there are many different hormones, as well as different types of hormones, the steroid or sex hormones— estrogens, progesterone, and testosterone—are the first that come to mind for most people. Of equal importance in this discussion are the steroid hormones produced by the adrenal glands, including dehydroepiandrosterone (DHEA) and hydrocortisone.
The family of steroid hormones contributes greatly to our general sense of well-being. This group of hormones supports a broad range of essential physiological functions, such as sexuality and reproduction, thyroid function, bone mineral density, blood lipid levels, and aspects of normal brain function.
The steroid hormones are of particular importance to men and women experiencing menopause or age-related declines in hormone activity. (For more information about male hormone issues, see our newsletter titled A Perspective on Male Hormones.) Because of their familiarity and overall impact on our lives, and because of the complexity of the topic of hormone testing, we will focus only on the steroid hormones in this newsletter. However, many of the concepts discussed apply to other hormones as well.
Being familiar with the symptoms associated with hormone imbalance is critical to assessing your hormone health. Monitoring the occurrences of these symptoms will help you and your healthcare practitioner identify a potential hormone deficiency or excess.
Note that quite a few of the symptoms occur with an imbalance of more than one hormone, and that some symptoms can be associated with both an excess and a deficiency. (Yet another reason you should enlist the help of your healthcare practitioner in sorting it all out.)
- Estrogen Deficiency
Hot flashes, shortness of breath, night sweats, sleep disorders, vaginal dryness, dry skin, anxiety, mood swings, headaches, depression, memory loss, heart palpitations, yeast infections, vaginal shrinkage, painful intercourse, inability to reach orgasm, lack of menstruation.
- Estrogen Excess
Water retention, fatigue, breast swelling, fibrocystic breasts, premenstrual-like mood swings, loss of sex drive, heavy or irregular menses, uterine fibroids, craving for sweets, weight gain.
- Progesterone Deficiency
Headache, low libido, anxiety, swollen breasts, moodiness, fuzzy thinking, depression, food cravings, irritability, insomnia, cramps, emotional swings, painful breasts, weight gain, bloating, inability to concentrate, early menstruation, painful joints, asthma, acne.
- Progesterone Excess
Drowsiness, menstrual cycle changes.
- Testosterone Deficiency
Low or absent libido, depression, lethargy, weakness, foggy thinking.
- Testosterone Excess
Acne, weight gain, fluid retention, male hair growth patterns, exaggerated moods, aggression, impatience, frustration.
- DHEA Deficiency
Low bone density, chronic fatigue, difficulty losing weight, mood swings, sparse hair.
- DHEA Excess
Acne or oily skin, increased facial hair, deepening of the voice, mood swings.
- Hydrocortisone Deficiency
Fatigue, weakness, nausea, anorexia, hypotension, low blood sugar.
- Hydrocortisone Excess
Obesity, thinning/bruising skin, slow wound healing, hypertension, osteoporosis, anxiety, sleep disorders.
Achieving or maintaining hormone balance takes some effort and requires working closely with your healthcare practitioners. One of the most important aspects of this process is careful monitoring of your symptoms.
When our hormones are out of balance, we typically suffer from a variety of symptoms ranging from fatigue, headaches and depression, to food cravings and acne (see box at right). While self-diagnosis and treatment with over-the-counter products such as hormone creams, herbs, and soy-based foods or diet supplements may be tempting, it is recommended that you enlist the help and support of your healthcare practitioner in achieving a healthy hormone balance. There are far too many factors and complex relationships involved to rely on the claims of the latest popular treatment when your overall health and well-being are at stake.
One of the first steps in achieving optimal hormone balance is to get a baseline of your hormone levels using one or more of the various hormone testing methods. Then, you and your healthcare practitioner can begin to assess hormone excess and/or deficiencies, and monitor hormonal fluctuations.
As part of your initial assessment, you may be asked about your family medical history and your symptoms. You may want to use a form or checklist that makes it easier to track and record your symptoms on a daily basis. This ongoing record helps your healthcare practitioner identify any cyclical patterns, which may be related to your hormone levels.
Ongoing symptom assessment and hormone testing allow you and your healthcare practitioner to monitor the progress of your hormone therapy, and the impact of using any products containing hormones, such as skin creams, birth control pills, and foods or herbs containing phytoestrogens. Although the hormones in these products may not be measured directly, they may have an impact on the hormones being measured with the hormone tests.
The commercially available laboratory kits for measuring hormones include urine, blood, and saliva tests. The different types of hormone tests vary in their sampling and analysis techniques, and each has its own proponents and critics, as well as limitations.
Before beginning hormone testing, discuss which type of test is most appropriate for your needs with your healthcare practitioner.
The oldest and perhaps easiest method of measuring hormones is urine testing. It is relatively easy to measure hormones in urine because larger amounts of hormone appear in urine than in blood or saliva.
Urine testing requires that the patient collect every drop of urine for 24 hours. The test is not accurate if only some of the urine is collected over the 24-hour period, or if some of the urine is discarded. In addition, if kidney function is impaired, test results may not be reliable. For this reason, a kidney function test is often requested in conjunction with a urine-based hormone test.
Identification of hormones in urine is usually achieved using a technique called mass spectroscopy, which precisely identifies each hormone found. Although this method does not identify the high and low levels that can occur within normal daily fluctuations, it is still a good measure of how much of a specific hormone is available on that particular day.
Some urine tests also track specific hormones and their metabolites, which helps assess if hormone supplementation has had an impact on more than one hormone.
As testing techniques improved and it became possible to identify smaller quantities of hormones, tests and hormone measurements using blood samples became more readily available.
In one method of blood testing, one or more vials of a patient’s blood are collected during a lab appointment and the separated serum is measured for hormone levels. Serum measurements account for hormones bound to carrier proteins and small amounts of unbound hormones.
Critics of this method claim that the invasive procedure, in and of itself, can alter the circulating hormones. They also contend that serum measurements do not take into account the insoluble hormones carried by the red blood cells, which are separated out from the serum, and which may have a higher hormone concentration inside the cell. Others counter this argument with the explanation that, even though very small amounts of hormones are found in the serum, it is only the hormones in the serum that are available to other tissues in the body, so the measurement is accurate and appropriate.
A potential problem with this method of collection is that, unlike a urine test, this type of blood sample is just a snapshot in time. The levels of the various hormones in the bloodstream can change from moment to moment and from day to day. If a perimenopausal woman’s blood sample indicates that her estradiol level is in the normal range, it does not necessarily mean that she has a normal amount all day long. She could be higher or lower at any given time throughout the day or throughout the month.
However, another form of blood collection called blood spot testing can account for hormone fluctuations because it can easily be scheduled for specific days of the month, such as before or after hormone therapies, or specific times of the day, such as before or after meals or other medications.
For blood spot testing, a patient collects drops of their own blood from a finger prick onto a card for submission to a lab for analysis. With this method, results are typically comparable to those from serum tests, but without the cost and inconvenience of a lab visit, so it is rapidly gaining in popularity.
With both types of blood tests, the hormones are typically analyzed using techniques such as radioimmunoassay. Unlike the mass spectroscopy used in the urine analysis, these methods may or may not be hormone specific.
Because there are so many steroidal hormones and they are all so close to each other in chemical structure, there might be “spill over” from one hormone to other similar hormones, depending on the process that the lab uses.
For example, a lab kit for testosterone analysis might report that 50% of the hormone analyzed may be dihydrotestosterone. In the case of a male concerned about prostate enlargement, a more specific distinction may be necessary or important.
Saliva testing is also commonly used to evaluate hormone levels, although the majority of information available on hormones has been done with blood or urine measurements. One potential drawback is that saliva samples can be easily contaminated if gum disease is present, or if blood gets into the saliva sample.
Radioimmunoassay, the same technique used for blood tests, is often used to analyze hormones from a collection of saliva.
Saliva tests tend to be more accurate with younger people than with older individuals because, in general, they have higher levels of hormones available.
When measuring the hormones of a menopausal woman, for example, saliva tests are at their limits of sensitivity. This is due to the fact that the amount of hormone available for measurement is so small that test results may be inconsistent or inaccurate.
Similar to blood tests, each saliva sample represents only a snapshot. Some commercial labs offer saliva test kits for collecting several samples throughout a day or throughout a month, so that they have more data to evaluate. Saliva samples are noninvasive and easy to collect with such frequency.
Proponents of saliva tests claim that only the “free” hormone is filtered from the blood into the saliva and, therefore, these tests are an accurate measure of the hormone that is biologically active or available to other tissues. But there is still some difficulty in evaluating the results of hormone supplements with some dosage formulations because the impact is far more dramatic in saliva than it is in blood or urine.
A hormone test simply provides a single measure of one or more hormones, which your healthcare practitioner will compare against a prior measure and/or against the broad ranges of “normal” hormone levels that have been accepted as the standard criteria.
However, there are significant variations across populations, genders, ages, and even within individuals, that must be factored into the equation. For instance, as would be expected, women have higher levels of estrogens and progesterone than men, and women who are still menstruating have higher levels than menopausal women.
Another example of these differences is that, in general, men have higher DHEA and testosterone levels than women and, in both sexes, the available levels drop dramatically with age.
In the case of testosterone, for instance, more of the available testosterone becomes tightly bound to sex hormone-binding globulin (a water-soluble carrier protein), which increases with age. To account for this, some practitioners will also order a test to measure sex hormone-binding globulin to get a better sense of testosterone activity.
Another potential issue with hormone test results is that the currently available tests only measure “bioidentical” hormones, that is, only those hormones that are chemically identical to those hormones that exist naturally in our bodies. Some hormone replacement therapies include animal-based hormones,which are not measured by hormone tests but are probably affecting the balance of other hormones being measured.
Hormone tests also do not measure what is happening at receptor sites. For instance, birth control hormones may affect hormone measurements because they occupy receptor sites, with the result that the body may not then perceive a need for hormone production.
Nor do hormone tests evaluate tissue concentration. For example, estrogens concentrate in tissues such as the uterus. The only technique known for evaluating this tissue would be to surgically remove bits of the tissue, and then extract and measure the hormone found in that tissue.
And, as we’ve discussed previously, a host of factors can wreak havoc with test measurements, including the time of collection and any other therapy administered within hours of collection. When monitoring a bioidentical hormone supplement, a sample may be taken within 2 hours of the last dose to evaluate the effects at its highest impact, or at least 6 to 8 hours after the last dose to see the effects at its lowest point.
Fortunately, new hormone tests are now available. One such test evaluates how the liver metabolizes estradiol, which may prove helpful in assessing the risk of breast cancer and measuring treatment effectiveness.
Another test, which is being marketed as a “home menopause kit,” measures a pituitary hormone called follicle stimulating hormone (FSH). This same test has been used in doctors’ offices for years to diagnose menopause. However, FSH production is not static but dynamic. It increases as estrogen decreases, which might suggest menopause, but FSH levels can spike during a menstrual cycle. Therefore, this test may not be the most reliable measure of whether or not you are menopausal.
In summary, a hormone test, which represents just a single measure (or a single day’s measure) of one or more hormones, is simply one of the tools available for helping to assess and maintain your hormone balance.
Hormone testing, in combination with clinical observation and monitoring of symptoms, may help your healthcare practitioner determine if you have a hormone deficiency or excess, and if hormone therapy may be an appropriate treatment for you.
If hormone supplementation is prescribed, hormone testing may help your practitioner determine the optimum dosage for maintaining hormone balance.
With the availability of individually compounded bioidentical hormone therapies, hormone testing is especially helpful for determining which hormones to use and the amounts needed. Supplementing one or more hormones will most likely have effects on other hormones.
In most cases, a comprehensive understanding of your total hormone picture—that is, the balance or ratios of your hormones—may be more important than the exact measure of a few specific hormones.
If you suspect you have a hormone imbalance, talk with your healthcare practitioner about all of the tools available for assessing hormone health, including but not limited to:
- an evaluation of your family history
- a detailed symptoms chart
- urine, blood, or saliva hormone tests
- bone density and/or uterine lining monitoring, if it seems warranted.
The more information your healthcare practitioner has, the better he or she will be able to accurately assess and monitor your hormone health to help you achieve optimum hormone balance.
This newsletter is a compilation of scientific literature and other information gathered from various labs that offer hormone testing and analysis. For more information, please refer to our web site: womensinternational.com/testing