Timing, Options, And The “Why” Of Hormone Testing

Photo: Lacie Slezak

You wouldn’t believe how many clients come to me with hormone issues and when I ask if their OB-GYN has ever tested their hormones, they were told, “it’s pointless, because hormones fluctuate so much.”

Or, if they were lucky enough to get tests, the doctor says, “everything looks fine.” I ask the client when in their cycle they were tested, and they often say, “I don’t know – my doctor didn’t tell me I had to go at a certain time.”

(Yes, my eyes tend to roll to the back of my head.)

While it is true that hormones fluctuate throughout both the month and the day, that doesn’t mean checking them isn’t going to give you good information. Your blood sugar fluctuates throughout the day. Would anyone say it’s pointless to take your blood sugar if you were having blood sugar issues?

A test is always going to be a snapshot (though you do have options for cycling tests that track an entire menstrual cycle), but it gives us often crucial information on steps to take to improve hormone balance. This is particularly true if you deal with menstrual issues such as debilitating PMS, fibroids, ovarian cysts, infertility, endometriosis, or are in perimenopause.

But it is true that the blood tests most doctors run are the least useful of the bunch. This is because they only test for the bound version of the hormone. We want to know the free – or bioavailable – levels of hormones at a given time. Plus, serum labs only test for one point in the day. This is why you want to turn to saliva or dried urine testing.

Because I want women to understand what hormone tests do, what the pros and cons are of each, and why you may need to go outside of your doc in order to get them done (like with a functional health coach such as myself), I’ve compiled a list of testing options for you below. 

**Why**

You don’t have PMS just because you are a woman. Fibroids don’t grow just because you are getting older. Ovarian cysts don’t appear out of the blue. Your period isn’t a crime scene because your body is just a rebel.

These things are happening because your hormones are out of balance, plain and simple.

Now, I’m not trying to imply there is some hormonal grail that you can get to and everything will be perfect forever and ever. Hormones will always be fluctuating (as I mentioned above), but when you have imbalances in your cycle, it is a clear sign that your hormones are not acting in concert with each other. There’s many reasons for this, including, but not limited to:

• Stress
• Xenoestrogens/Xenobiotics
• Overloaded liver
• Gut dysbiosis (often stemming from antibiotics, birth control, and medications)

In order to get your hormones-band back together again, you are going to have to look at all these areas in your life. But what is helpful about getting a hormone test if you are in the midst of intense hormonal symptoms is that we have a chance to get really specific, really fast.

Tests that include cortisol levels throughout the day are going to tell us how your adrenals are doing (and how much stress is impacting you). Some hormone tests will show us estrogen metabolites, which will tell us how your liver is doing in terms of detoxing estrogen. Though I recommend the GI-Map and MRT food sensitivities test to actually see what is happening in your gut, hormone testing can point to nutrient deficiencies and microbiome issues.

Plus, we actually get to see what your estrogen, progesterone, testosterone, and DHEA are doing so that we know what foods, supplements, and yes, in some cases, which bioidentical hormone therapy may be called for.

**Timing**

Generally, you want to test your sex hormones between days 19-22 of your cycle. This is because your body only produces progesterone after you’ve ovulated (day 14ish, give-or-take because every woman’s body is different). So if you test your progesterone pre-ovulation, your progesterone numbers will be tanked and you may wonder why; there’s basically no progesterone circulating at that point (unless you are taking supplemental progesterone).

Your progesterone levels peak during this 19-22 window, which gives us an idea of your highest level of progesterone. That means if it’s on the lower end of the scale, you know things usually get worse as your cycle continues.

We also want to compare those progesterone numbers to your estrogen levels. Your estrogen should be lower at this point than it was pre-ovulation, so if you see higher numbers during this point in your cycle, you know you may be dealing with an estrogen dominance situation. (Of course, your numbers could be low, which is also good information for different reasons. This is why it’s so important to work with a practitioner that understands sex hormones and the intricate relationship between them).

You may need additional testing times when infertility is an issue, or if you want to get really clear on issues like missing periods, extremely heavy periods, or periods that are all over the place. In this case, doing a month-long cycling hormone test is going to give you the most information.

**Options**

Blood test

Pros:

• Can do at doctor’s office
• Quick and easy (as long as you don’t mind blood being drawn)
• It’s the best way to test your thyroid hormones, which have a special relationship with your sex hormones. It can also test LH, FSH, sex binding hormone globulin, and prolactin
• Insurance often covers it
• It gives you basic information of what’s going on with your sex hormones

Cons:

• Serum tests show you the bound form of sex hormones, not the free form that is in your tissues (yes, there are serum test options that look at free hormones, but they are not commonly available. Also, free testosterone is an exception, as this is easily obtained)
• What this means is that you can see normal levels of the bound hormone, but you actually have low levels of the bioavailable form of the hormone, the form you actually use – which you won’t know, because these tests don’t provide this information.
• The test happens once, at one point in the day. Our hormones rise and fall in a rhythm, so simply seeing your hormones at one point in the day doesn’t tell us a lot.
• You don’t get a chance to see the metabolites of your hormones, which we’ll get to below.

Example of a hormone blood test:

Saliva test

Pros:

• Is usually done at home
• Good for people who don’t like to have their blood drawn
• It measures the free, usable version of hormones
• It involves multiple collections over the day, so we can see cortisol rhythm, which has a huge impact on our sex hormones
• Gives you a clear picture of estrogen and progesterone
• Can assess an entire cycle
• Can assess FSH and LH as well as estrogen, progesterone, testosterone, DHEA, and cortisol
• Have the option to test or retest one hormone at a time

Cons:

• Doesn’t show hormone metabolites (particularly with cortisol, it is important to know the level of metabolites, as this is going to guide how you treat adrenal dysfunction)
• Some people struggle to produce the amount of saliva needed for the vials
• It’s not the best way to monitor hormone replacement therapy (oral forms of HRT often show up really high because it concentrates hormones in the salivary glands)
• Caffeine cannot be imbibed the day of the test
• Insurance sometimes, but often doesn’t, cover it

Example of saliva test results:

As you can see, this test shows you cortisol levels in the morning, noon, afternoon and nighttime, and shows us what the rhythm is and should be (this particular test includes the additional Cortisol Awakening Response – CAR – which can help to determine if your cortisol is doing what it should first thing in the morning). We can also see DHEA levels along with the cortisol-to-DHEA ratio, which is important as DHEA and cortisol are both made in the adrenals and can point to underlying HPA-Axis dysregulation.

The three estrogens (estradiol, estriol, and estrone) all are shown on this test, along with progesterone, testosterone, and melatonin (helpful to know if you are having issues with sleep, and often corresponds with dysregulated cortisol levels, including high nighttime cortisol).  

Urine Test

Pros:

• Offers the three main estrogens, progesterone, testosterone, DHEA, and their metabolites, and 4-point cortisol
• Shows bioavailable hormone levels
• Shows 24 hormone secretion instead of just one moment in time
• How your estrogen is metabolized gives you insight into how your liver is doing, both Phase I and Phase II detox. It also lets you know which pathway you prefer: the 2-OH pathway is considered more “protective,” while the 4-OH pathways is considered more genotoxic, or cancer-causing, and the 16-OH is considered “proliferative.” Knowing this information is extremely helpful in determining particular foods and supplementation for an individual.
• It provides additional OAT (Organic Acid Test) markers, including B12, B6, glutathione, melatonin, and oxidative stress
• Caffeine drinkers can drink caffeine up until noon on day of 5pm and 10pm testing; also drink it after final sample, which is 2 hours after waking up

Cons:

• Measures progesterone metabolites and “works it’s way back” to determine progesterone levels. This is not always seem as an accurate measurement of progesterone (vs. saliva)
• Does not assess FSH and LF
• Insurance does not cover it

Two pages from my Dutch test last year, which shows some of the plethora of information you get from this test:  

Though I know this is confusing to look at when you haven’t worked with the Dutch, a practitioner who knows the Dutch gathers a lot of information from this test beyond simply estrogen, progesterone, and testosterone levels. We can see Phase I and Phase II liver detox for estrogen, metabolites that can point to more or less androgenic symptoms, and overall cortisol, cortisone, and metabolized cortisol, among other things.

Now, I understand this is a bit complicated, and that it may bring up more questions. Feel free to add your question below and I’ll do my best to answer it!