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Testing Options for Sex Hormone Assessment and Clinical Intake

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Copyright© 2020. Health Training Associates, LLC. All rights reserved.

(Hormone Mastery Course Lecture for Module #3)

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Disclaimer

The material contained within this document/presentation and subsequent support documents for the Hormone Mastery Course (HMC) is not intended to replace the

services and/or medical advice of a licensed health care practitioner, nor is it meant to encourage diagnosis and treatment of disease. It is for health education purposes only based on the clinical experiences of its authors. Health Training Associates, LLC., Kurt N.

Woeller, D.O., Tracy Tranchitella, N.D. or any of its associates and members do not accept legal responsibility for any problems arising from your personal experimentation with the health education information described herein. Any application of suggestions

set forth in the following portions of this document/presentation and other support documents of the HMC (or other courses from Integrative Medicine Academy) is at the

reader/listener’s discretion and sole risk. As a health practitioner you are solely responsible for implementing treatment strategies for your patients or clients.

Implementation or experimentation with any supplements, herbs, dietary changes, medications, and/or lifestyle changes, etc., discussed in this course, including support

documents and member forum, is done so at your sole risk. As an individual you accept full responsibility for using/implementing any health education information discussed in this course and understand that experimentation with supplements, medications,

herbs, dietary changes, etc. needs to be discussed with your (or your child’s) personal physician first.

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Support Documents For Module #3

• Hormone Testing – What To Use When (pdf)

• Signs & Symptoms of Estrogen Def. & Excess (pdf)

• Signs & Symptoms of Progesterone Deficiency & Excess (pdf).

• Signs and Symptoms of Testosterone Deficiency & Excess (pdf).

• Female Health History Questionnaire (handout)

• Male Health History Questionnaire (handout)

• Lecture slides (pdf)

• Lecture slides - note taking (pdf)

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Lecture Overview

• What are the most appropriate sex hormone tests?

• Clinical pearls for testing accuracy

• Taking a complete history regarding sex hormones and evaluating the whole patient/client.

• Recognizing the signs and symptoms of hormone excess and deficiency.

• Case study with high progesterone

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Tracy Tranchitella, N.D.

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Naturopathic and functional medicine doctor for 20+ years.Lab advisor for BioHealth Laboratory.

Co-Founder of Integrative Medicine Academy.

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What Are The Most Appropriate Sex Hormone

Tests?

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Measuring Sex Hormones -Why Test?

• Symptoms of different imbalances overlap:• Example: Low progesterone can present as excess

estrogen or “estrogen dominance.”

• Validate the levels of each hormone

• Compare relative ratios of hormones

• Compare levels to age-range specifics

• Distinguish between follicular, ovulatory and luteal phases of the cycle.

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Measuring Sex Hormones:Which Test is Best?

• There is no single test that is appropriate in all situations because of the number of different variables that can influence test results, especially with hormone supplementation.

• Variables to consider:• Type of hormone being used: synthetic, natural, BHRT

• Mode of delivery: oral, topical, sublingual, buccal, vaginal, injectable, pellets

• Absorption rate and availability

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Overview of Labs

• ZRT Laboratory – saliva, dried urine, dried blood spot, serum. Menstrual cycle mapping in dried urine.

• Meridian Valley – dried urine and 24-hour urine.

• Precision Analytical – dried urine, saliva for CAR only. Menstrual cycle mapping.

• Labrix (Doctor’s Data) – saliva for hormones, urine for neurotransmitters.

• Genova – saliva, serum, urine for hormone metabolites, cycle mapping.

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Measuring Sex Hormones:Types of Testing

• Saliva • Pro:

• Multipoint measurements in a single day or throughout a menstrual cycle.

• Easy collection at home

• Topical hormones represented well with adjusted reference ranges for topical application.

• Oral hormones are also represented well

• Con:

• Subject to contamination from blood, supplements, sublingual or trans-buccal hormones.

• Values can appear very high especially with TD progesterone

• No hormone metabolites

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Measuring Sex Hormones:Types of Testing

• Serum• Pro:

• Widely accepted amongst conventional physicians

• Broad and refined reference ranges

• Can measure peptides: FSH, LH, prolactin, insulin, thyroid hormones, SHBG, CBG.

• Con:• No distinction between bound and free hormones

(testosterone is the exception)

• Estriol not commonly measured

• Transdermal progesterone does not measure well, chance of overdosing to reach therapeutic level

• No metabolites in standard serum testing16

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Measuring Sex Hormones:Types of Testing

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• Wet Urine• Pro:

• Measures output in 24 hours, so avoidance of peaks and valleys

• Measures hormone metabolites

• Can measure hormones secreted at night – GH, Melatonin

• Provides direction for modifying metabolism of hormones

• Measures metabolites of Phase I and II liver metabolism

• Measures adrenal metabolites and mineralocorticoids, so indicates reserve function.

• Con:

• No clear measure of diurnal pattern

• Results affected by kidney or liver issues; also dehydration or excess hydration. Creatinine is used to measure kidney status.

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Meridian Valley Lab24-Hour Urine Hormone Profile

• Estrogens – Estrone, Estradiol, Estriol, metabolites, enzymes and estrogen ratios.

• Progesterone – 5-Beta-Pregnanediol

• Androgens – DHEA, Androsterone, Testosterone, metabolites and enzymes.

• Glucocorticoids – Cortisone, Cortisol and metabolites.

• Mineralcorticoids – Aldosterone and metabolites.

• Enzymes - 5-Alpha Reductase, 11-Beta-HSD II

• GH, Oxytocin, Melatonin, Thyroid, Sodium, Potassium

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Measuring Sex Hormones: Types of Testing

• Dried Urine Testing (DUTCH)• Pro:

• Can measure hormone metabolites; most of the same pros as wet urine testing.

• Can be time specific like salivary testing – diurnal rhythm of cortisol.

• Measurements of hormones are taken at specific points during the day rather than a total over 24 hours

• Cons:

• Not always reflective of tissue levels of hormones when supplementing. Shows what body is eliminating.

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Measuring Sex Hormones:Types of Testing

• Dried Blood Spot (DBS)• Pro:

• More reflective of tissue uptake than serum for patients on topical hormones.

• Can easily measure hormones that tend to be too large for saliva – thyroid, insulin, FSH, LH.

• More convenient than serum testing

• Reference ranges similar to serum ranges

• Female and Male Hormone Panels; can include thyroid

• Best option for those using hormones in a troche or SL form.

• Con:• Patient accuracy and compliance with testing

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Sample of DBS result

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Steroid Hormone Testing in Different Body Fluids Following Different Routes of Administration

1) Overestimation: metabolites interfere with immunoassays2) Underestimation: hormone levels not reflective of tissue uptake3) Overestimation: requires range adjustment4) Overestimation: direct contamination of oral mucosa/saliva5) Overestimation: direct contamination of urine6) Overestimation: if fingertips are contaminated with hormones

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Clinical Pearls For Testing Accuracy

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Measuring Sex Hormones:Getting a Baseline

• Baseline levels (without exogenous hormones) can be taken using any form of testing.

• Best to measure hormones first thing in the morning when they are highest.

• Serum testing may be more appropriate if measuring additional markers, hormone and otherwise.

• Serum testing is more likely to be covered by insurance.

• Other forms of testing may be more limited if screening for a variety of markers.

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Timing Is Everything

• When to collect samples for the best information:• Cycling Female – Test days 18, 19, 20 or 21 of a 28-30 day

cycle. For longer cycles, push the test days ahead by one day:

• Example: Cycle length is 31 days; collections days should be done on days 19, 20, 21 or 22 of the cycle. Catch mid-luteal phase when both E and P peak.

• Irregular Cycles – wait for next menses and try to follow example from above.

• Menopausal – collections can occur anytime

• Men – collections can occur anytime

• Mapping the Whole Cycle – start collecting on day 2 (BioHealth) or day 7 (ZRT) of the cycle and collect QOD until menses.

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Timing Is Everything: Sample Collection For Patients Using Exogenous Hormones

• The timing of sample collection relative to the last dosage of exogenous hormones is important to avoid peaks and troughs of hormone levels:• Oral Hormones – if taken once a day (every 24 hours),

collect samples at the 12-hour mark. If taken twice a day (every 12 hours), collect 6 hours after the last dosage.

• Topical Hormones – if applying once a day, collect samples 12 hours after last application. If applying twice a day, collect samples 6 hours after last application.

• Troches/Sublinguals – collect samples 4 hours after last dosage. Best to do DBS.

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Timing Is Everything: Sample Collection For Patients Using Exogenous Hormones

• Injectables – collect samples mid-way between injections. • Example: Injection every month, collect samples 2

weeks after last injection.

• Pellets – collect samples mid-way between placement of pellets. For example: If the pellets are replaced every 12 weeks, collect samples at 6 weeks.

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Taking a Thorough and Complete History

Evaluating the Whole Patient

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Relating Test Results to the Clinical Picture

• Start with a thorough patient history

• Have a good working knowledge of signs and symptoms of excess and deficiency of each hormone. Refer to Support Documents for this module.

• Consider crossover symptoms

• Evaluate HPA axis function (module #1 and #2) and thyroid (module #3) as part of a comprehensive hormone evaluation.

• Inquire about sleep, diet and various lifestyle influences that can affect hormone output (module #1).

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Getting a Good HistoryStart From the Beginning

• Gathering information about your patient’s menstrual history can reveal many things about their current issues.

• A good history can reveal long standing menstrual issues that have manifested in many different conditions over the life of the patient.

• It is important to go back to the onset of menarche to fully grasp the entire menstrual history of your patient.

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Gathering a Thorough HistoryWhat You Need to Know

• Age of Menarche

• Regular or Irregular Cycles/Menopause

• Length of Cycle, Flow, LMP• Athletics

• Body Type

• Oral Contraceptives

• PMS Symptoms/PMDD

• Hormone-Driven Conditions• Family History

• Best Time of Cycle• Concurrent Symptoms

• Surgeries and Diagnostics

• Pregnancies

• Lifestyle Factors

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Going Back to the Beginning

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• Menarche should begin 2-3 years after breast buds appear (thelarche).

• Evaluate for primary amenorrhea if no menses by age 15 or 3 years after thelarche.

• Menses tends to be irregular during adolescence due to an immature HPO axis resulting in anovulatory cycles that tend to be long.

• By the third year after menarche, 60-80% of cycles will be 21-45 days long.

• Cycles longer than 90 days should be evaluated

• Conditions associated with a menstrual cycle that extends beyond the normal parameters listed above may include: PCOS, thyroid disorders, stress, eating disorders and over-exercising resulting in very low body fat (hypothalamic amenorrhea).

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Cycle Length and Frequency

• Beyond the 3 years after menarche, have the cycles been regular?

• What is the length of the cycle with day one being the first day of menses and the last day being the day before the next menses.

• How long does the menses last and what is the amount of flow? • Normal would be the use of one pad or tampon every 3-6

hours.

• Interruptions in regular cycles related to illness, weight loss, athletics?

• Last menstrual period/age of menopause

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Athletics and Body Type

• Are they tall, lean and have small breasts? Later menarche? These women tend to have lower estrogen due to lower body fat and athletic build.

• Are they full-figured, shapely and have larger breasts? Earlier menarche? These women tend to be higher in estrogen.

• Are they somewhere in between? This may be the majority of women who have an average level of estrogen.

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Athletics and Body Type

• Athletic women tend to have lower body fat and less estrogen reserve.

• Women with more body fat can produce more estrogen via aromatase activity within adipose tissue converting androgens to estrogen.

• Increased belly fat occurs in menopause in an effort to increase the ability for adipose tissue to create more estrogen.

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Evaluating The Whole Patient

• Observe or Inquire about:• Vitals – BMI, Pulse Rate, Blood Pressure

• Waist Circumference – Goal < 35”

• Waist/Hip Ratio – Goal < 0.8

• Hair and Skin – facial hair, scalp hair

• Neck/Thyroid – presence of goiter

• Abdomen – shape/striae

• Cognitive Function – mood, concentration, affect

• Skin – dry, acne, pigmentation, brittle nails, pallor

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Oral Contraceptives

• Has your patient taken oral contraceptives in the past? How long were they on them? Were they given for birth control or another reason?

• Other reasons might include: regulate cycle, acne, heavy menstrual flow, fibroids, endometriosis, severe pain and cramping during menses or severe PMS symptoms.

• Testing while the patient is on Oral Contraceptives will not be useful as both estrogen and progesterone will be low on hormone testing. You will not see the endogenous production of female hormones in their natural output because the contraceptives suppress the cycle.

• If the patient discontinues the Oral Contraceptive, waiting 2-3 months before testing hormones is advised.

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PMS Symptoms

• Evaluating PMS symptoms can offer insight into relative hormone deficiencies and excess.

• Symptoms within the first half of the cycle may be related to rising estrogen.

• Symptoms midcycle may be due to the steep drop in estrogen after ovulation.

• Symptoms within the second half of the cycle may be related to progesterone deficiency or poor distribution.

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Hormone-Driven Conditions

• Endometriosis

• Uterine Fibroids

• Breast Cancer

• Endometrial Cancer

• Uterine Cancer

• Polycystic Ovarian Syndrome (PCOS)

• Acne

• Hirsutism

• Fibrocystic Breasts

• Gallbladder Disease

• Infertility

• Migraines

• Serial Miscarriages

• Cervical Dysplasia

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Family History

• Inquire about mother, grandmother and siblings

• Need to know specifically if these family members have a history of hormonal based cancers: breast, endometrial, uterine, ovarian.

• Other conditions as mentioned in the previous slide.

• Inquire about thyroid conditions, osteoporosis, heart disease and dementia.

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Best Time In Her cycle

• Ask your patient when in her cycle she feels the best:• During or shortly after menses: she feels best when

both estrogen and progesterone are low.

• During the week after menses: she feels best when estrogen is on the rise.

• Mid-cycle: she feels best when testosterone is rising, and estrogen is falling.

• First week after ovulation: she feels best when estrogen and progesterone are rising.

• Week before menses: she feels best when both hormones are dropping.

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Concurrent Symptoms

• Ask your patient if she has any symptoms that present themselves at the same time during each menstrual cycle:• Headaches

• Bowel Changes

• Bloating

• Cramping/Pain

• Mood Changes

• Try to match hormonal fluctuations to recurrent conditions by testing.

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Surgeries and Diagnostics

• Hysterectomy

• Oophorectomy

• Cholecystectomy

• Lumpectomy

• Mastectomy

• Mammography

• Thermography

• Pap smear

• Laboratory Studies:

• thyroid, adrenal• peptide hormones

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Pregnancies

• Number of pregnancies?

• Full-term, early-term, premature?

• Miscarriages? DNC?

• Complications of pregnancy?

• Complications of childbirth?

• In Vitro Fertilization?

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Lifestyle Factors

• Diet

• Exercise

• Sleep

• Alcohol

• Work

• Smoking

• Medications

• Supplements

• Perception of Stress

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Understanding Signs and Symptoms of Excess and Deficiency of Hormones

Using a Systemic Endocrine Approach

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Evaluating the Endocrine System As A Whole

• Understand that more than one hormone imbalance can cause the same symptom:• Example: hot flashes can be caused by low estrogen or high

cortisol. Low thyroid and/or high cortisol can present as low testosterone.

• Evaluate the adrenals (HPA Axis), thyroid and sex hormones to get a complete picture of endocrine sufficiency, excess and deficiency.

• Excess sex hormones may present with common symptoms of deficiency due to down-regulation of receptors. This commonly occurs with over-supplementation.

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Making The Connections

• Important for both practitioner and patient to understand the symptoms of excess and deficiency of all the endocrine hormones.

• Share symptoms of excess and deficiency with your patients. They will likely reveal additional symptoms they are experiencing but hadn’t thought to share.

• Relate history to symptoms of excess and deficiency to reveal a common pattern for each patient.

• A thorough history and evaluation accompanied by hormone testing will guide and direct appropriate and individualized treatment programs for each patient.

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Signs and Symptoms of Low Cortisol

• Depression/Anxiety

• Feeling Faint/Dizziness

• Low Blood Pressure

• Heart Palpitations

• Inability To Cope With Stress

• Muscle Weakness

• Difficulty Waking

• Salt Cravings

• Insomnia/Night Waking

• Energy Better In the Evening

• Need for Caffeine

• Decreased Immunity

• Increased Allergies

• Dry Skin

• Hair Loss

• Joint Pain, Back Pain

• Loss of Muscle Tone

• Fatigue After Exercise

• Dark Circle Under Eyes

• Low Sex Drive53

Signs and Symptoms of High Cortisol

• Depression

• Fatigue/Tired but wired feeling

• Weight Gain – face, back, torso

• Abdominal Obesity

• Back Pain

• Bone Loss/Osteoporosis

• Loss of muscle in arms and legs

• Thin skin

• Decreased concentration

• Swelling in hands and feet

• Hyperglycemia

• Hyperinsulinemia

• High Blood Pressure

• Immune Suppression

• Decreased Mucosal

Immunity

• Insomnia/Night Waking

• Hot Flashes/Night Sweats

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Signs and Symptoms of Hypothyroidism

• Fatigue and Muscle Weakness

• Weight Gain

• Coarse Dry Hair/Hair Loss

• Dry Skin

• Cold Intolerance

• Muscle Cramps/Achiness

• Joint Pain

• Constipation

• Depression/Irritability

• Poor Memory/Concentration

• Abnormal Menses

• Serial Miscarriages

• Decreased Libido

• Puffy Face/Fluid Retention

• Hoarse Voice/Difficulty

Swallowing

• Elevated Cholesterol

• Low Ferritin

• Decreased Heart Rate/Low BP

• Frequent Headaches

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Signs and Symptoms of Hyperthyroidism

• Change in Appetite and Weight

• Insomnia

• Nervousness/Tremor

• Fatigue

• Irritability

• Frequent Bowel Movements

• Heart Palpitations

• Heat Intolerance

• Light or Absent Menses

• Fertility Problems

• Shortness of Breath

• Dizziness

• Hair Loss

• Skin Itching/Hives

• Hyperglycemia

• Muscle Weakness

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Overlap of Hormone Symptoms

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Case Study

• 49-year old perimenopausal female

• Transdermal progesterone 30 mg BID daily

• Complaints:• Restless sleep, difficulty falling asleep

• Daytime fatigue

• Brain fog

• Digestive issues – mild bloating, reflux, poor elimination

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It’s important to understand when evaluating hormone problems such that more than one

hormone imbalance can cause the same symptom. For example, hot flashes can be caused by low

estrogen or high cortisol. Also, low thyroid or high cortisol can present with symptoms of low

testosterone. Therefore, one cannot assume a symptom is always caused by a deficiency of one

specific hormone. Adequate testing for all hormones is essential for proper assessment and eventual

hormone replacement therapy.

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Topic

The Link Between Sex Hormone Function and Thyroid Disorders:

• The link between HPA dysfunction, adrenal cortisol output problems, sex hormone imbalances and thyroid function.

• What are the similarities and differences in symptoms related to hormone dysfunction and thyroid problems?

• Why you shouldn’t assume a patient/client problems are all sex hormone problems

• How to accurately test for low thyroid and correlate that information to hormone/adrenal intervention.

Module #4

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Thank You

Kurt N. Woeller, D.O. & Tracy Tranchitella, N.D.

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HormoneMasteryCourse.comHormoneMasteryCourse@gmail.com

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