It is a very common question and it makes perfect sense: you’re not feeling great, your hormones seem all over the place, shouldn’t you get them tested?
You may have asked your doc this very question at your last appointment and you may have been met with a host of confusing, dismissive responses. Or you may have been given a lab slip to test on a random day of your cycle and left wondering what the result even means.
This is so often the case as many women are demanding to have their concerns heard and requesting more testing. It’s unfortunate women have to fight so hard to get answers and to not have their concerns dismissed. Gaslighting of women in medicine is very much alive and well, but women are taking a stand.
Women have more testing in their hands than in years past, however, as I always say on the Dr. Brooke Show: your testing is only as good as the interpretation of your results. So we can demand testing, but without a provider able to interpret this test in light of your history, goals, and current symptom presentation as well as being very up to date on modern menopause medicine, you are likely still left with little direction towards strategies to feel better.
Alternative providers are guilty of adding to this confusion for women as well. There is a lot of misinformation around more functional medicine type testing too (i.e. the popular DUTCH test). This article will help you sift through both sides of the issue.
Common Provider Responses To “Can You Test My Hormones”?
#1 If you’re a woman in your 40s or 50s and having symptoms you think might be related to your hormones, this question has likely been met with one of these responses:
- Women’s hormones vary too much so there’s no point in testing them.
- Sure, here’s the lab order — with no specific day indicated for testing.
#2 If you are using HRT or about to start using HRT and you’ve asked for testing, you have likely heard:
- We don’t base dosing off testing so there’s no need to run any tests.
- Sure, I’ll run them but if your estrogen isn’t low then you don’t need to start estrogen. Or sure, I’ll run them but there won’t be a change in dose even though you have all these low estrogen symptoms unless your test shows low estrogen.
#3 If you’re seeing a more alternative minded coach or clinician you may have been told this when you asked for hormone testing:
- Blood tests are worthless so we only do urine or saliva testing for women’s hormones.
- DUTCH testing is the only way to diagnosis hormone issues like perimenopause.
#4 When you’ve asked your OBGYN or family practice doc about testing for hormones via saliva or urine you’ve most likely received this response:
- That’s ridiculous and not accurate, blood testing is the gold standard.
A LOT to unpack here, grab a cup of tea….we’re going through this point by point.
#1 You Don’t Need Testing & Timing Doesn’t Matter
First, yes women’s hormones fluctuate wildly during perimenopause this is true. It is not true though that testing is unhelpful.
Also, timing of testing matters – even with fluctuations.
Testing needs to be done on appropriate days: day 3 or 5 for estrogen (when levels should be their lowest) and again on day 19 OR if you know when you ovulate 7-10 days after that. We should test estrogen both days.
This day 19-day 21 window is when progesterone should be highest. This is the best time to test progesterone and it is ideal to test estrogen then as well so we can glean not only an appropriate level or not but also the ratio of estrogen compared to progesterone day 19.
Progesterone is the first hormone to fall during perimenopause and this decline can be seen as early as age 35. So knowing both a progesterone level when it should be it’s highest about a week after ovulation shows us the health of your corpus luteum (the follicle that ovulated and then became the producer of progesterone in your ovaries if you don’t become pregnant). If it’s low we know ovulation either didn’t happen or progesterone output was not sustained and we can address that. As well if progesterone is low or high compared to expected values for estrogen on day 19 we can address that as well. In this last scenario you may be experiencing symptoms of what’s called estrogen dominance, where estrogen isn’t necessarily high but it feels high because progesterone is so low. Symptoms can look like breakouts, heavier bleeding, an earlier period, water retention or mood issues.
With my patients, I often review their progesterone to estrogen ratio (P:E2). I cover that topic on this episode of the Dr Brooke Show.
So yes, there is a lot of variationin levels throughout a cycle – espeically in perimenopause – but put together with your symptoms, testing can be helpful to better support you through this phase of fluctuating hormones.
On the other hand, androgens are more consistent throughout the month and there is merit in testing both total and free testosterone as well as DHEA-S to assess if you need more support with these two hormones in addition to estrogen and progesterone. Blood testing is the more accurate way to test adrogens, while urine markers for estrogen and progesterone have been shown to correlate accurately to serum levels, they do not correlate as closely for testosterone.
Note also, that saliva testing is not considered accurate for any sex hormones.
So yes, blood testing is useful however, it is not the end of the story as hormones break down into metabolites that have hormone activity as well and often the cause of your symptoms or imbalances if a result of these vs. just a hormone level being too high or too low on any one day. Those we can see with more functional medicine testing like the DUTCH test (more on that below).
#2 The Levels Of Hormones On Testing Don’t Matter
Currently, most HRT prescribers do not base starting estrogen or upping your dose of estrogen on a lab value, instead prescribing is largely based on symptoms of low estrogen such as:
- Depression or mood issues
- Joint pain
- Brain fog or memory loss
- Less frequent periods or much lighter periods
- Hot flashes or night sweats”]
If you are experiencing symptoms of fluctuating or low estrogen during perimenopause and your doctor insists that you can only start estrogen when you are no longer having a period or if your estrogen is overtly low on a blood test, they are simply not up to date on current menopause medicine and the latest research on HRT.
It is worth investigating both serum or blood testing for estrogen and progesterone, as well as metabolism of these hormones with other methods of testing – more on that below.
And again, I do not recommend presciribng DHEA or testosterone without blood testing – those two hormones SHOULD alwasy be tested before beginning using these hormones, whereas estrogen and progesterone is commonly ecommended based on symptoms as they are more in flux than our androgens like testosterone or DHEA. There is so much nuance to here and this is exactly what I do in my practice, so please reach out for more help.
#3 & #4 The Ongoing Fight About What’s Better: Blood, Urine or Saliva
I’m just gonna say this now: one is not better, they simply show different things.
Well one actually isn’t better and that’s saliva testing for estrogen, progesterone and testosterone. Saliva testing is great for assessing cortisol but not for our sex hormones. Urine and serum testing are more accurate.
But when it comes to blood testing vs. urine testing (like the DUTCH test), there is not a right or wrong here but there is a difference and you should understand what these tests can – and can’t show you , but know they both have value.
Blood testing is great for showing you a level of a hormone, say estrogen or testosterone. It’s accurate and often covered by insurance. For fluctuating hormones like estrogen and progesterone though should be checked on specific days, as I said above.
But remember, unless your testing method takes samples throughout your cycle we are indeed checking a moment in time – not that that moment in time is not useful, it is. Or at least it can be, when taken in context of the rest of your picture.
What testing like the DUTCH test shows us that is unique is breakdown products, or metabolites of your hormones: estrogen, progesterone, testosterone, etc. It shows the breakdown products of your hormones after you use them. These metabolites also have activity and this is often where your symptoms arise and where risk factors can be mitigated to a large degree. As well, it can demonstrate HOW you break down hormones, like which metabolite you make more if vs. another.
What Is The DUTCH Test?
DUTCH stands for “dried urine test for comprehensive hormones”. There are various versions of DUTCH testing which assess different biomarkers for cortisol and/or our steroid hormones.
There is an adrenal only version, the plus or complete version which include sex hormones in addition to cortisol and the Cycle Map which assesses estrogen and progesterone throughout a woman’s cycle. My preference is to always include the salivary cortisol as that is the best way for us to assess circadian rhythm.
Know what DUTCH test you are getting and what it will show you. So often I see women having spent a lot of money on these tests only to realize that wasn’t the best test option for what they wanted to evaluate.
Because urine is tested, which shows what happens to the hormone after you use it, you are able to see some interesting data for you own hormone metabolism that we can’t see on a blood test. This is important because knowing how you break down a hormone can help you understand dietary and supplemental strategies to feel better. As well it can really help fine tune dosing for HRT.
For example, if you push progesterone more towards it’s beta-pregnanediol pathway vs. the alpha pathway then you might need higher doses of progesterone to sleep better and feel less anxious. Or you might have found that even with ovulation in your 20s and 30s you didn’t feel the calming benefits of progesterone as much. Vice versa, if you push the alpha pathway preferentially you might need less progesterone or you will feel groggy the next day.
Another example of what the DUTCH test can show you is how you breakdown your estrogen or testosterone into various metabolites. This matters because these metabolites still have action in the body until they are cleared out – which you might not do so well and this test can show you that. In the case of estrogen, its metabolites can also bind estrogen receptors creating varsious side effects and risk factors that can be easily manipulated with certain nutrients and diet strategies.
Again, it’s not necessarily “better” than a serum test but it gives us very useful clinical info to better customize your regimen.
Problems + Misunderstandings About DUTCH Testing
We have data to back up that urine markers for estrogen and progesterone levels correlate to serum levels, so in that regard they are similar. However, we don’t see hormone metabolites in blood testing, so that’s useful info to get a better sense of your big picture.
It is though important to not rely on urine markers for androgens as I mentioned above. Blood testing is more accurate than the DUTCH test for levels of testosterone and DHEA, but the metabolism that’s shown in the urine markers is still very helpful. The markers on the DUTCH test can show breakdown of androgens via that can help you know if nutrients like zinc would be helpful to alleviate some high androgen symptoms or side effects from your HRT.
Critics of more functional testing like the DUTCH test are often uninformed about what we’re actually looking at either because they aren’t educated on the test or they hear misinformation around the internet of people saying inaccurate things such us:
DUTCH testing is better or more sensitive than serum testing. False.
DUTCH testing is the only way to diagnosis perimenopause False. There is no definitive test for perimenopause.
It’s important to note as well, that some practitioners that use the DUTCH test aren’t able to order blood testing due to a lack of scope or lack of a medical license and in some cases (i.e. testosterone) so they favor testing like DUTCH that they can order. This should be made more apparent, but alas: marketing.
All That To Say: Yes Testing Your Hormones Has Value
Women going through hormonal imbalances symptoms around their cycle, fluctuations of perimenopause or any symptoms related to their hormones deserve to have a wide range of options to help them see how they can feel their best, to give them all the information.
This is one argument on the internet I wish we could just put to rest. Both types of testing have merit and utility in formulating a comprehensive treatment plan for you. This is what I do, so please reach out for help!