Which Hormones Need Testing?

The major sex hormones to assess are estradiol, progesterone and testosterone.

 

The main adrenal hormones are DHEA and cortisol. These five hormones will provide crucial information about deficiencies, excesses and daily patterns, which then result in a specifically tailored treatment approach and one far more beneficial than the old “shotgun" approach.

 

 

 

 

Below is a brief description of each of these five hormones:

Estrogen: there are three forms made by the body: estrone, estradiol and estriol. The form used in past hormone replacement therapies is estradiol, often in the form of concentrated pregnant mare’s urine (premarin). It is a proliferative (causes growth) hormone that grows the lining of the uterus. It is also a known cancer-causing hormone: breast and endometrial (uterine) in women and prostate gland in men. It will treat menopausal symptoms like hot flashes, insomnia and memory-loss. With the bio-identical formulas estriol is matched with estradiol (biest) to provide protective effects and additional estrogenic benefits. The other major protector in keeping estradiol from running amok is progesterone.

Progesterone is called the anti-estrogen because it balances estradiol’s proliferative effects. It is considered preventive for breast and prostate cancers as well as osteoporosis. In addition too little progesterone promotes depression, irritability, increased inflammation, irregular menses, breast tenderness, urinary frequency and prostate gland enlargement (BPH).

Testosterone is an anabolic hormone (builds tissue) that is essential for men and women. The proper level of testosterone is necessary for bone health, muscle strength, stamina, sex drive and performance, heart function and mental focus.

DHEA is an important adrenal gland hormone, which is essential for energy production and blood sugar balance. DHEA is a precursor to other hormones, mainly testosterone.

Cortisol is your waking day hormone (highest in the morning and lowest at night). It is necessary for energy production, blood sugar metabolism, anti-inflammatory effects and stress response.
Some of the common imbalances identified through testing include estrogen dominance, estrogen deficiency, progesterone deficiency, androgen (testosterone and DHEA) excess or deficiencies, adrenal dysfunction and adrenal fatigue.

 

ESTROGEN AND PROGESTERONE:

Estradiol and progesterone are 2 hormones that are often tested together. At Labrix when you test these 2 hormones together we also provide you with a Pg/E2 ratio. This ratio allows you to determine if the patient (male or female) has “Estrogen Dominance". Estrogen dominance is a risk factor for breast cancer and osteoporosis in females and prostate gland enlargement and cancer in males.

The term “Estrogen Dominance" is less related to the amount of circulating estrogen and more related to the ratio of estrogen to progesterone in the body. Menopause and PMS are not the result of estrogen deficiency; although, estrogen levels do decline during the latter phases of a woman’s reproductive cycle. More relevant is that the estrogen levels drop by approximately 40% at menopause or during periods of stress while progesterone levels plummet by approximately 90% from premenopausal levels. It is the relative loss of progesterone that causes the majority of symptoms termed estrogen dominance. The disproportionate loss of progesterone begins in the latter stages of a woman's reproductive cycle, when the luteal phase of the menstrual cycle begins to malfunction. The malfunction is initiated when the corpus luteum, the primary source of progesterone, begins to lose its functional capacity. By about age 35, many of these follicles fail to develop creating a relative progesterone deficiency. As a result, ovulation does not always occur and progesterone levels steadily decline. It is during this period that a relative progesterone deficiency, or what has become known as Estrogen Dominance, develops.

 

Typical Symptoms of Estrogen Dominance Include:

  • Irritability/Mood Swings
  • Depression
  • Irregular Periods
  • Heavy Menstrual Bleeding
  • Vaginal Dryness
  • Water Retention
  • Sleep Disturbance
  • Hot Flashes
  • Headaches
  • Fatigue
  • Short-term Memory Loss
  • Weight Gain


The Progesterone/Estradiol (Pg/E2) reference ranges are optimal ranges determined by Dr. John R. Lee MD. While they are not physiological ranges, they are optimal values for the protection of the breasts, heart and bones in women, and the prostate in men. Salivary values within these ranges have been shown by Dr. Lee to decrease both breast and prostate cellular proliferation, thereby providing protection to these vital tissues.


TESTOSTERONE:

Testosterone is often tested because the patient talks of low libido. Declining testosterone levels are the number one cause of low libido in males, and plays a contributing factor in females.

Declining testosterone levels are commonly seen in men beginning in the fourth decade of life. Suboptimal or low testosterone levels in males are often associated with symptoms of aging and are referred to as “Andropause" or male menopause.

Testosterone is an important anabolic hormone in men. It increases energy, prevents fatigue, helps maintain normal sex drive, increases strength of all structural tissues such as skin/bone/muscles; including the heart and prevents depression and mental fatigue. Testosterone deficiency is often associated with symptoms such as night sweats, insulin resistance, erectile dysfunction, low sex drive, decreased mental and physical ability, lower ambition, loss of muscle mass and weight gain in the waist. The primary cause of this increase in girth is visceral fat, not excessive subcutaneous fat (fat under the skin).

The visceral fat cells are the most insulin resistant cells in the human body. As a person ages hormone levels change in favor of insulin resistance. The insulin levels rise while progesterone, growth hormone and testosterone decline. The visceral fat cell begins to collect more fat in the form of triglycerides. A vicious cycle is initiated, which if not interrupted with natural hormone balancing will lead to abdominal obesity, diabetes and high cholesterol levels. This phenomenon is known as “Metabolic Syndrome". In males, metabolic syndrome results in lower testosterone levels, however, in females metabolic syndrome results in high testosterone levels and a phenomenon known as Polycystic Ovarian Syndrome (see below).

Stress management, exercise, proper nutrition, dietary supplements, and androgen replacement therapy have all been shown to raise androgen levels in men and help counter male metabolic syndrome symptoms. The “trick" is to know how much testosterone is required for each individual male. This is where knowing the salivary testosterone levels come into play. Initial salivary testing and following salivary monitoring are crucial for determining the most optimal prescription.

Metabolic Syndrome and Polycystic Ovarian Syndrome (PCOS) in females results in the same visceral fat pattern, insulin resistance and triglyceride formation as in males, however, the female patients with PCOS and metabolic syndrome had high levels of testosterone and often DHEA. This results in a typical symptom pattern seen in women with metabolic syndrome – acne, increased facial and body hair, hair loss on the head, trunkle obesity and infertility. Salivary testosterone and DHEA levels are diagnostic for this syndrome and follow up testing is key for monitoring treatment. It is important to note that women do not need to have their ovaries to have metabolic syndrome. The adrenal glands in women who have a predisposition to metabolic syndrome can produce above normal levels of testosterone and DHEA.


DHEA AND CORTISOL:

DHEA is often thought of as an adrenal hormone and in fact it is, however, DHEA is also made in the ovaries. When we measure DHEA we are eliciting information about both the adrenal glands and the ovaries. This is particularly important when DHEA levels are high. High levels of DHEA can mean that the adrenal glands are increasing DHEA production on response to stress or high glucose levels, or that the ovaries are increasing the production of DHEA as part of the PCOS cascade. High levels of DHEA are often seen years before a female develops metabolic syndrome and should be used as a risk factor marker for insulin resistance.

Low levels of DHEA are seen in evolving “Adrenal Gland Fatigue" (hypoadrenia). As acute stress becomes more chronic, the constant demand by the body for adrenal gland hormones begins to wear out the adrenal glands and DHEA and cortisol levels fall. It is for this reason that DHEA is often measured in combination with cortisol levels. Cortisol is a hormone produced by the adrenal glands in response to stress and blood sugar levels. Cortisol secretion has a diurnal rhythm. Normal cortisol levels should be highest one hour after waking in the morning and drop gradually throughout the day. Measuring the diurnal rhythm with 4 cortisol levels throughout the day gives a very accurate measure of adrenal gland function and their ability to cope with stress. Adrenal fatigue occurs in stages. The stage at which a patient is at can be determined by looking at the diurnal cortisol graph and DHEA levels. Symptoms of evolving adrenal gland fatigue include fatigue, sleep issues, inability to cope with stress, anxiety, nervousness, irritability and allergies.

Hypothalamic Pituitary Axis (HPA) Dysregulation is due to chronic stress with the resultant excess cortisol production and down regulation of cortisol receptors in the hypothalamus. In other words the negative feedback loop that normally shuts down the production of ACTH release is blunted and cortisol production by the adrenal glands is uncontrolled. If this continues, hypoadrenia always evolves. The symptoms of HPA and hypoadrenia are essentially identical but salivary testing easily distinguishes the two. This is crucially important as treatment of each can be very different.

Measuring cortisol and DHEA levels will also diagnose complex diseases such as Addison’s Disease and Cushing’s Syndrome. Addison's disease occurs when the adrenal glands do not produce enough of the hormones cortisol and DHEA. The disease is also called adrenal insufficiency, or hypocortisolism. It has however, no relationship to end stages of “adrenal gland fatigue" described above. The two illnesses have very different mechanisms of action. Most cases of Addison’s disease are caused by autoimmune destruction of the adrenal cortex. Symptoms include chronic fatigue, weight loss, loss of appetite, muscle weakness, and hyperpigmentation of the skin.

Cushing’s Syndrome results in excessive production of cortisol by the adrenal glands. Symptoms include rapid weight gain of face, trunk and back of neck, hirsutism, depression, anxiety and panic attacks.

 

Why Use Saliva?

Saliva testing is an easy and noninvasive way of assessing your patient's hormone status and balancing needs and is proving to be the most reliable medium for measuring hormone levels.

Appreciating the reliability of saliva testing is based on understanding the difference between steroid hormones in saliva and serum. This difference is based on whether or not the hormones are bound to proteins in the medium used for testing. The majority of hormones exist in one of two forms: free (5%) or protein bound (95%). It is only the free hormones that are biologically active, or bio-available, and available for delivery to receptors in the body. Those which are protein bound do not fit those receptors and are considered non-bioavailable. When blood is filtered through the salivary glands, the bound hormone components are too large to pass through the cell membranes. Only the unbound hormones pass through and into the saliva. What is measured in the saliva is the bioavailable hormone, the clinically relevant portion which will be delivered to the receptors in the tissues of the body.

Salivary hormone levels are expected to be much lower than serum levels, as only the unbound hormones are being measured. When health care providers measure serum hormone levels and prescribe hormone replacement therapy based on those results, patients are often overdosed. If the patients are then tested using saliva, the results are extraordinarily high, and confusion results from a lack of correlation between the two methods.

This discrepancy becomes especially important when monitoring topical, or transdermal, hormone therapy. Studies show that this method of delivery results in increased tissue hormone levels (thus measurable in saliva), but no parallel increase in serum levels. Therefore, serum testing cannot be used to monitor topical hormone therapy.

Saliva Measures the "Unbound" Biologically Active or Free Hormone Levels in the Body:

When blood is filtered through the salivary glands, the bound hormone components are too large to pass through the cell membranes of the salivary glands. Only the unbound hormones pass through and into the saliva. What is measured in the saliva is considered the "free", or bioavailable hormone, that which will be delivered to the receptors in the tissues of the body.

Serum Measures the "Protein Bound" Biologically Inactive Hormone Levels in the Body:

In order for steroid hormones to be detected in serum, they must be bound to circulating proteins. In this bound state, they are unable to fit into receptors in the body, and therefore will not be delivered to tissues. They are considered inactive, or non-bioavailable.

Only Saliva Testing Measures Topically Dosed Hormones:

The discrepancy between free and protein bound hormones becomes especially important when monitoring topical, or transdermal, hormone therapy. Studies show that this method of delivery results in increased tissue hormone levels (thus measurable in saliva), but no parallel increase in serum levels. Therefore, serum testing cannot be used to monitor topical hormone therapy.


Where Should I Start?
 
We believe the bare minimum for assessing hormonal status and endocrine function is the eight hormone panel; Estradiol, Progesterone, Testosterone, DHEA, and four cortisols.
 
As clinicians with over twenty five years of experience in working with natural hormone balancing and bio-identical hormone replacement we believe the reasons for this are well-established and prove out clinically… the intricate balance and direct relationship between adrenal gland function and sex hormone balance. It will frequently be seen that when the estrogen, progesterone and testosterone are showing deficiencies and excesses, the adrenals have already been working overtime to attempt to compensate for the strain to reproductive systems… and other functional roles.
 
AM cortisol levels represent the maximum output of cortisol for the entire 24 hour period and initiates and maintains waking day activity and function. DHEA has equally important duties and is often referred to as the "anti-aging hormone" because it is central in its role for disease prevention and health optimization. Measuring DHEA and AM cortisol is your first glimpse into the status of the endorcrine balance and function. As we age and our production of sex hormones is changing, the adrenals will maintain a central role in sustaining optimal health and function. Aging is often first noticed when our sexual function diminishes and menopause or andropause have begun. While it is obvious that we want to test the estrogen, progesterone and testosterone at this stage, it is not so apparent but equally important to look at the foundation for this endocrine balance: cortisols and DHEA.

 

Most Common Profiles Ordered

Comprehensive Panel: estradiol, progesterone, testosterone, DHEA, am, noon, evening and pm cortisol
Total: 8 tests

The Comprehensive Hormone Panel is the starting point for initial assessment of hormonal status and endocrine function and includes estradiol (E2), progesterone, testosterone, DHEA and four cortisols. This panel is useful with male and female patients because it looks at the full diurnal cortisol pattern; it is especially important in patients who are experiencing the following symptoms in addition to the symptoms listed for the Basic Hormone Panel:

  • Weight gain
  • Multiple chemical sensitivity
  • High blood sugar
  • Elevated lipids (cholesterol and/or triglycerides)
  • Insomnia
  • Chronic fatigue
  • Fibromyalgia


Short Comprehensive Panel: estradiol, progesterone, testosterone, DHEA, and am and pm cortisols
Total: 6 tests

This assessment is useful in men and women whose primary symptoms are related to sex hormone imbalances (elevated or depressed E2, P or T). The abbreviated adrenal panel that includes DHEA and the AM and PM cortisol levels provides a brief assessment of the level of involvement of adrenal dysfunction. Additionally, this condensed panel (like the Basic Hormone Panel) is often used for re-evaluation 2-3 months after hormone replacement has begun to monitor therapeutic values. The Short Comprehensive Panel should be ordered if the patient is suffering from:

  • Fatigue
  • Sleep Disturbances
  • Family history of breast cancer
  • Brain fog


Basic Hormone Panel: estradiol, progesterone, testosterone, DHEA, and am cortisol
Total 5 tests
The Basic Hormone Panel provides a basic evaluation of the sex hormones and a brief glimpse at adrenal function with the AM cortisol level. This panel is useful when retesting patients who have begun hormone therapy, but we encourage use of the Comprehensive Panel for initial evaluation. The Basic Hormone Panel is the minimal test recommended for symptoms that include:


Men Experiencing:

  • Decreased libido
  • Erectile dysfunction
  • Loss of stamina
  • Decrease in mental sharpness
  • Reduced muscle size
  • Tearful episodes or increased moodiness
  • Metabolic syndrome
  • Prostate enlargement or cancer
  • Hot flashes
  • Irritability

Women Experiencing:

  • Hot flashes
  • Anxiety/Depression
  • Night sweats
  • Breast tenderness
  • Irritability
  • Forgetfulness
  • Irregular menstrual cycles
  • Vaginal dryness
  • Urinary incontinence
  • Uterine fibroids
  • Increased facial / body hair
  • Acne


Vitamin D

Vitamin D is a fat soluble vitamin and pro-hormone that exists in several different forms. Ergocalciferol (Vitamin D2) is not produced in the body and comes from plant sources whereas cholecalciferol (Vitamin D3) is found in cold water fish such as salmon, mackerel and sardines, is fortified in milk and is manufactured in the skin with adequate exposure to the suns UVB rays.

The New England Journal of Medicine estimated that 30-50% of children and adults in the US are at risk for vitamin D deficiency and 32% of healthy adults age 18-29 were measured as Vitamin D deficient at the end of a winter in Boston. This is likely a consequence of inadequate dietary intake that may be exacerbated by fat malabsorption coupled with insufficient exposure to UVB sunlight. Note: Synthesis from sunlight requires that the sun be greater than 45? above the horizon and most sunscreens block UVB rays. People with increased melanin (darker skin) require longer exposures to sunlight to produce the same amount of Vitamin D.

 

Effects

Bioactive vitamin D binds to specific receptors in the cell (known as VDRs or Vitamin D receptors) and induces the transcription of more than 50 genes that have far reaching effects in the body including:

Osteoporosis / Calcium Balance - Vitamin D increases intestinal absorption of dietary calcium, increases re-absorption of calcium filtered by kidneys and mobilizes calcium from bone when there is insufficient dietary calcium. We have long known the influence vitamin D had in formation of bone, as evidenced by the incidence of rickets with low Vitamin D levels.

Anti-Cancer – Vitamin D inhibits proliferation and stimulates the differentiation of cells when bound to VDR receptors. Vitamin D has also been shown to induce apoptosis (programmed cell death).

Immunity – There are a significant number of VDR receptor on T cells and macrophages and there is evidence that when bound to these receptors vitamin D acts as a selective immunosuppressant and can either prevent or significantly affect many autoimmune diseases including rheumatoid arthritis, SLE, type 1 diabetes and IBD. Vitamin D can also enhance innate immunity and has been shown to be beneficial against tuberculosis and through this mechanism may be useful against additional infectious agents such as influenza.

Diabetes – The bioactive form of Vitamin D has been shown to stimulate insulin production in the pancreas in type 1 diabetics and may play a role in the pathogenesis of type 2 diabetes through its ability to impair insulin synthesis and secretion.

Blood Pressure Regulation – Vitamin D can decrease the expression of the gene that codes for rennin, and therefore play a role in controlling hypertension.

Toxicity
Vitamin D is a fat soluble vitamin that is stored in the liver and fatty tissue and is eliminated more slowly than water-soluble vitamins. Excess levels of Vitamin D can cause hypercalcemia, hypercalciuria, hypertension, constipation, fatigue and more. While adequate levels of Vitamin D are very important, you can get too much of a good thing. Monitoring therapy is important to ensure adequate, but not excessive dosage.

What to Test
Whether supplemented or manufactured in the skin, cholecalciferol (D3) is hydroxylated in the liver to form 25-hydroxycholcalciferol (25(OH) and this is the major circulating form of the vitamin. Though it goes through an additional hydroxylation (primary in the kidney) to form 1,25-dihydroxycholecalciferol before it is biologically active, the 25(OH) form is considered the most accurate measure of the amount of Vitamin D in the body, which is why testing 25(OH) is preferred.The 25(OH) Vitamin D Blood Drop test from Labrix Clinical Services; this inexpensive, quick and painless test will enable you to test and monitor Vitamin D supplementation without the inconvenience of venipuncture.

References
1. Vitamin D Deficiency. Holick MF. N Engl J Med. 2007 Jul 19; 357(3):266-81.
2. Vitamin D: Importance in the Prevention of Cancers, Type 1 Diabetes, Heart Disease, and Osteoporosis. Holick MF. Am J Clin Nutr 2004;79:362-71.
3. Overview of General Physiologic Features and Functions of Vitamin D. DeLuca HF. Am J Clin Nutr 2004;80:169S-96S
4. Vitamin D: It’s Role and Uses in Immunology. Deluca HF, Cantorna MT. FASEB J. 2001 Dec; 15(14):2579-85.
5. Vitamin D and the Immune System: Role in Protection Against Bacterial Infection. Bikle DD. Curr Opin Nephrol Hypertens. 2008 Jul;17(4):348-52.
Health Disclaimer: All information given about health conditions, treatments, products and dosages are not intended to be a substitute for professional medical advice, diagnosis or treatment. This is provided only as a suggested guideline.

About Labrix Clinical Services
Labrix was founded to address the clinician's need for precision and reliability and the scientist's demand for quality and integrity. Labrix is a CLIA registered laboratory.
Labrix Clinical Services, Inc. headquartered in the Pacific Northwest, uses state-of-the-art saliva hormone testing techniques. Labrix Medical Director, Jay H. Mead MD, is a pathologist who has served as Chief Medical Director of a number of the country's well known medical institutions. Dr. Mead has many years of clinical experience treating patients in his own integrative medicine practice.

 

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