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The Role of Hormone Testing

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. However, those same hormones that keep us healthy may also cause emotional and physical distress if they are not in balance. Hormone testing is a valuable tool for achieving optimal hormone balance, as well as for maintaining that balance once it is achieved.

What Are Hormones?
Hormones are substances secreted by glands and transported through the bloodstream to target tissues, 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 delicate balance, representing just one aspect of the many relationships present among the nervous, endocrine, and immune systems.

A hormone’s ability to perform its duties is dependent on myriad 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. Other factors including diet, blood sugar, stress, and sleep 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 relies on many variables; while some of these variables may be affected by changes we make in lifestyle, some are beyond our control.

Steroid Hormones

Of the many different hormones and hormone types, the first that comes to mind for most people are steroid or sex hormones: estrogens, progesterone, and testosterone. Other steroid hormones are produced by the adrenal glands, including dehydroepiandrosterone (DHEA) and hydrocortisone. These groups of hormones support 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.

Steroid hormones are of particular importance to men and women experiencing menopause or age-related decline in hormonal activity. Because of their overall impact on health, and because of the complexity of the topic of hormone testing, this article will focus only on the steroid hormones. However, many of the concepts discussed apply to other hormones as well.

Achieving and Maintaining Hormone Balance

Achieving and maintaining hormone balance requires working closely with your healthcare practitioner. One of the most important aspects of this process is the 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.

If you suspect you have a hormone imbalance, talk with your healthcare practitioner about the tools available for assessing hormone health, including:

  • 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. You may want to use a form or checklist that makes it easier to track and record your symptoms on a daily basis. This record helps your practitioner identify any cyclical patterns that might be related to your hormone levels.

Ongoing symptom assessments and hormone testing allow you and your healthcare practitioner to monitor the progress of your hormone therapy. This will include tracking 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 might not be measured directly, they may affect the hormones being measured with the hormone tests.

Examples of Steroid Hormone Imbalance Symptoms

Being familiar with the symptoms associated with hormone imbalance is critical to assessing hormone health.  Many symptoms of hormonal imbalance occur with more than one hormone, and some symptoms may be associated with both an excess and a deficiency. Monitoring the occurrences of these symptoms will help you and your healthcare practitioner identify a potential hormone imbalance and determine a course of action to treat it.

HormoneSymptoms of DeficiencySymptoms of Excess
DHEALow bone density, chronic fatigue, difficulty losing weight, mood swings, sparse hairAcne or oily skin, increased facial hair, deepening of the voice, mood swings
EstrogenHot 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 menstruationWater 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
HydrocortisoneFatigue, weakness, nausea, anorexia, hypotension, low blood sugarObesity, thinning or bruising skin, slow wound healing, hypertension, osteoporosis, anxiety, sleep disorders
ProgesteroneHeadache, 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, acneDrowsiness, menstrual cycle changes
TestosteroneLow or absent libido, depression, lethargy, weakness, foggy thinkingAcne, weight gain, fluid retention, male hair growth patterns, exaggerated moods, aggression, impatience, frustration

How are Hormone Tests Performed?

One of the first steps in achieving optimal hormone balance is to get a baseline of your current hormone levels. This can be achieved by using one or more of the various commercially-available laboratory kits for measuring hormones such as urine, blood, or saliva tests. Once this baseline is identified, you and your healthcare practitioner can begin to evaluate hormone excesses and/or deficiencies as well as track hormonal fluctuations.

The different types of hormone tests vary in their sampling and analysis techniques. Each has its own proponents and critics, as well as limitations. Before beginning hormone testing, discuss with your practitioner which type of test is most appropriate for your needs.

Urine Tests

The oldest 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.

Hormone identification 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.

The test is not accurate if only some of the urine is collected over the 24-hour period, if some of the urine is discarded, or if kidney function is impaired. (For this reason, the practitioner will often request a kidney function test in conjunction with a urine-based hormone test.) A variation on 24-hour urine collection measures hormones in urine samples collected at timed intervals throughout the day. This test may help identify the daily rhythm of the adrenal hormone cortisol.

Blood Tests

As testing techniques have improved and it has become possible to identify smaller quantities of hormones, and tests and hormone measurements using blood samples are more readily available. One method of blood testing is serum testing, in which one or more vials of a patient’s blood are collected during a laboratory 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 itself can alter the circulating hormones. They also contend that serum measurements do not account for 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 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.

Another downside with this collection method 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. For instance, 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 even throughout the month.

Another form of blood collection called blood spot testing can account for these hormone fluctuations. It can 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. Some labs have converted to mass spectroscopy for serum testing. Unequivocal identification of specific hormones is now possible and worth seeking out.

Because there are so many steroidal hormones, and because their chemical structures are similar to each other, there might be “spill over” from one hormone to other similar hormones when using the older testing methods. For example, a lab kit for testosterone analysis might report that 50% of the hormone analyzed may be dihydrotestosterone (DHT). In this case, a male concerned about prostate treatment may need a more specific distinction between these two hormones.

Saliva Tests

Although the majority of information available on hormones has been done with blood or urine measurements, saliva testing is also commonly used to evaluate hormone levels. Radioimmunoassay, the same technique used for blood tests, is often used to analyze hormones from a collection of saliva. Similar to blood tests, each saliva sample represents only a snapshot.

Saliva samples are noninvasive and easy to collect with the necessary frequency. Some commercial labs offer saliva test kits for collecting several samples throughout a day or a month, so that they have more data to evaluate. One potential drawback is that saliva samples can be easily contaminated if gum disease is present, or if blood gets into the saliva sample.

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.

Proponents of saliva tests claim that only the “free” hormone is filtered from the blood into the saliva. Therefore, these tests provide a more accurate measure of the hormone that is biologically active or available to other tissues. However, 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.

How Reliable Are Hormone Tests?

A hormone test 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, women have higher levels of estrogens and progesterone than men, and women who are still menstruating have higher levels than menopausal women.

In the case of testosterone, 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. Men generally have higher DHEA and testosterone levels than women and, in both sexes, the available levels decrease with age.

The hormone tests that are currently available only measure “bioidentical” hormones: that is, only hormones which are chemically identical to those that exist naturally in our bodies. However, some hormone replacement therapies include animal-based hormones. These are not measured by hormone tests but probably affect the balance of other hormones being measured.

Hormone tests also do not measure what is happening at receptor sites. Receptor sites are the final step to actual hormone activity. For instance, birth control hormones may affect hormone measurements because they occupy receptor sites, with the result that the body may not 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.

A host of variables can distort 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 two hours of the last dose to evaluate the effects at its highest impact, or at least six to eight 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). The FSH 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.

When Should You Get Tested?

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. A hormone test, which represents a single measure (or a single day’s measure) of one or more hormones, is one of the tools available for helping assess and maintain hormone balance.  Combined with clinical observation and monitoring of symptoms, hormone testing 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.

With the availability of individually compounded bioidentical hormone therapies, hormone testing is especially helpful for determining which hormones to use and what amounts are needed. Supplementing one or more hormones will most likely have effects on other hormones. If your practitioner decides hormone therapy is appropriate for addressing your symptoms and promoting your health, hormone testing may help your practitioner determine the optimum dosage for maintaining hormone balance.

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Connections is a publication of Women’s International Pharmacy, which is dedicated to the education and management of PMS, menopause, infertility, postpartum depression, and other hormone-related conditions and therapies.

This publication is distributed with the understanding that it does not constitute medical advice for individual problems. Although this material is intended to be accurate, proper medical advice should be sought from a competent healthcare professional.

Publisher: Constance Kindschi Hegerfeld, Executive VP – Women’s International Pharmacy
Editors: Julie Johnson, Laura Strommen – Women’s International Pharmacy
Writers: Carol Petersen, RPh, CNP; Michelle Violi, PharmD – McCormick Communications

Copyright © Women’s International Pharmacy. This newsletter may be printed and photocopied for educational purposes, provided that your copy (or copies) include full copyright and contact information.

For more information, please visit womensinternational.com or call 800.279.5708.

Women’s International Pharmacy | Madison, WI 53718 | Youngtown, AZ 85363

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