Which test for which patient?
George Gillson MD PhD
Rocky Mountain Analytical
Calgary, Alberta
gillson@rmalab.com
Disclaimer
• I don’t know what that puzzle looks like when
it’s finished
• I don’t think anybody does
• Don’t take the word of the lab as Gospel
• You must educate yourself as much as possible
to understand the nuances of each test
• Don’t be a slave to lab results
• Slavishly keep coming back to your patient
Gillson’s Corollary to O’Sullivan’s Rule
• “If you don’t know what’s wrong with your
patient before you send them to the specialist,
you won’t be any farther ahead after they come
back.”
– John O’Sullivan MD
• “If you don’t understand the lab test you are
using, you won’t understand the patient any
better after their test results come back”
– George Gillson MD PhD
There’s one thing I do know…
I am constantly asked “What is the most
accurate/”best” way to test X, Y, Z?”
• The unstated assumption is that somewhere out
there is “the test” which reveals “the truth” in
each case
• Most people probably mean: “What test should I
do to most accurately capture this aspect of the
clinical status of my patient and enable me to
make the best treatment decisions?”
Key Points to Ponder
• Was this test built with my patient in mind?
– serum estradiol was not intended for men
• Will a point sample answer my questions?
– Is the number I’m after too variable to pin down with
one measurement?
• Does the result for this test have clinical
correlation? (correlation between test result and a
symptom or symptom constellation or disease state)
More Key Points to Ponder
• If I supplement my patient with a hormone,
will this test track the dose?
• If it tracks the dose, does the number mean
what I think it means?
• Is there an interpretation?
• Does the lab take any pains to provide
“disclaimers” in the interpretation?
Estrone
Estrone Sulphate
Conjugate
Conjugated Hormones
• Conjugated hormones are hormones that have had
extra bits (conjugates) stuck on them to increase
the solubility of the overall molecule
– Extra bits (incomplete list):
•
•
•
•
Sugar e.g. glucuronide
Sulphate
Glutathione
Sulfonyl methane
• Conjugates are made in the liver and also in many
other tissues (e.g. skin, kidneys, breasts, gut
mucosa)
– Belanger A et al. J Steroid Biochem Mol Biol
1998;65:301-310
• Conjugate excretion in urine represents a significant route
of elimination for many steroid hormones
Serum Hormones
• Mostly bound hormone:
– T, E2, Pg, Cortisol are all total levels (bound +
non-bound)
– Can also measure free T and bioavailable
(loosely–bound) T by direct and indirect
methods
• Non-conjugated:
– E2, T, Pg, C, DHT, E3, E1, Aldosterone
• Conjugated:
– DHEAS, glucuronidated testosterone
metabolites, e.g. “diol-G”, estrone sulphate
Serum Hormones
• If you’re making way too much or way too little of a
particular hormone, the serum level is probably going to
reflect that
• Correlations between serum hormones and the clinical
situation exist but they are by no means the rule
• Remember this!!
• There is rarely a 1:1 map between any single hormone level
and any given symptom or sign
• Genes integrate information before deciding to turn on or off
Examples of Serum Hormone
“Benchmarks”
• Serum E2 60-90 pg/mL to prevent bone loss in postmenopause
– Calcif Tissue Int 1992;51(5):340-343. Minimal levels of serum estradiol
prevent postmenopausal bone loss. Reginster et al.
• Abolishment of VM sx at serum E2 >125 pg/mL with E2 patch
– Steingold KA et al. J Clin Endocrinol Metab 1985;61:627-632. Treatment of
hot flashes with transdermal estradiol administration.
• Erectile dysfunction, decreased sexual thoughts and decreased
morning erections are associated with serum total T in the range 810 nmoL
– Ann Endocrinol (Paris) 2014;75(2):128-131. Andropause-lessons from the
European Male Ageing Study. Huhtaniemi IT.
• But most of the time, we are never really sure what is going on
down there (at the DNA level)
Intracrinology
• Serum E2 levels inversely associated with gene expression
patterns in cancerous breast tissue
– BMC Cancer 2011;11:332. Serum estradiol levels associated with
specific gene expression patterns in normal breast tissue and in
breast carcinomas. Haakensen VD et al
– Gene expression in breast tumours looks like that of healthy women
with low serum estradiol, even in the face of high serum estradiol
•
•
“Following the arrest of estradiol secretion by the ovaries at menopause, all
estrogens and all androgens in postmenopausal women are made locally in
peripheral target tissues according to the physiological mechanisms of
intracrinology. The locally made sex steroids exert their action and are
inactivated intracellularly without biologically significant release of the active
sex steroids in the circulation.”
J Steroid Biochem Mol Biol. 2014 Jun 9. pii: S0960-0760(14)00115-0. doi:
10.1016/j.jsbmb.2014.06.001. [Epub ahead of print] All sex steroids are made
intracellularly in peripheral tissues by the mechanisms of intracrinology after
menopause. Labrie F.
Serum Hormones
• Serum testing is inexpensive, and has been around for
decades…but so have some of the reference ranges…
• No interpretation is provided
• Harder to control collection time in serum due to need to
book appt at drawing station e.g. first hour after waking
levels
• You cannot get certain analytes e.g. unbound (free) E2 or
unbound (free) Cortisol in serum
• Serum testosterone ranges may be outdated and serum
assays have not been upgraded for testing both genders
• You cannot safely track dosing of hormone CREAMS with
serum
Serum Hormone Levels after
Topical Hormone Cream
• You can drive serum levels up to the physiologic range
with topical hormone creams if you work at it
• It takes supraphysiologic doses of hormone to do it
• Examples:
– 50 to 200 mg/d of testosterone in cream base to elevate serum
total testosterone to high normal male range (normal
testosterone output in a male is 5-15 mg/day)
– Progesterone dose hundreds of mg/day (cream) and E2 dose 515 mg/day (E2 as BiEst cream) to produce physiologic serum
hormone levels (e.g. Wiley Protocol) (normal Pg output is 25
mg/day, and E2 output is less than 1 mg/day)
Serum Hormones
• Serum is a poor choice for profiling and averaging
• Is there a typical “serum testing candidate”?
– I think it mostly revolves around the patient’s ability to
pay for testing
– In my mind, serum has few other advantages
– It is the least attractive option and use of serum leads to
serious errors when tracking cream and oral
supplementation
– Hormones applied to the skin as cream break the usual
“traffic rules”
– Serum assays often can’t tell metabolites from parent
hormones
One functional
unit of a saliva
gland
A major salivary gland may
contain hundreds of ducts
in an encapsulated
structure
Minor salivary glands are
not encapsulated
Opportunity for local storage in fat
Hormone molecules are too big to enter the endplate through “Cracks in the walls”
Hormones partition from the acinar cell membranes into saliva
The salivary level is a tissue level and is probably a “fat biopsy” under some
circumstances…
Saliva and Serum
• Salivary hormone levels numerically reflect the free hormone
component in serum, when the person makes their own hormone
• e.g. in serum, 10% of the cortisol is free, the rest is bound to
albumin and cortisol binding globulin
• Free AM cortisol in serum =A.M. serum total cortisol 100 ng/ml
x 0.1 = 10 ng/ml
• A.M. salivary cortisol 2-15 ng/ml
Total serum cortisol and salivary cortisol are generally well-correlated
Yonsei Med J 2007;48:3793-88. Salivary Cortisol and
DHEA Levels in the Korean Population: Age-Related
Differences, Diurnal Rhythm, and Correlations with
Serum Levels. Ahn RS, Lee YJ, Choi Jy et al.
Clinical correlation of Salivary Endogenous E2 levels
*
*Hot flashes, night sweats, brain fog, memory problems, depression
In postmenopause, severity of low E2 complaints starts to kick up
when E2 < 1.5 -1.8 pg/ml
Salivary T after application of Androgel to various
body parts
The closer the application site is to the head, the
higher the “wave”
Tesosterone
(pg/ml)
100000
10000
1000
100
10
Time after application (minutes)
25 mg Androgel to L foot
25 mg Androgel to supraclavicular area
25 mg Androgel to L forearm
25 mg Androgel to R Buttock
25 mg Androgel to Abdomen
3000
2500
2000
1500
1000
500
0
1
Peak Salivary T vs Distance from Application Site
100000
Supraclavicular
Peak Salivary Testosterone (pg/ml)
10000
Forearm
1000
Abdomen
and Buttock
100
Foot
10
1
0
10
20
30
40
50
60
Approximate distance from application site to saliva gland (inches)
70
This implies that some component of what is seen in saliva
gets there literally by travelling over the body surface, in some
situations
80
What winds up here
reflects applied dose/body
burden, but does not
reflect clinical picture
Saliva numbers may be a surrogate fat biopsy in
some cases!
Saliva Hormone Testing
• Painless and convenient
• Easy to generate profiles and time-averaged
values
• Parallels non conjugated, non protein-bound
hormone in blood for endogenous hormones
• Good interpretation from some laboratories
• Fewer analytes measured wrt urine or serum
• Relatively young assay compared to serum
and saliva; more method-dependent variation
between labs compared to serum
Saliva for Hormone Profiling
• If you need to take multiple “sightings”,
saliva is the best option as it is painless, simple
and can be done at home
– e.g.erratic bleeding, one period every three months. What
is happening the rest of the time?
– e.g. bleeding that won’t stop (perimenopause, teens)
– e.g. demonstrate effect of contraceptives (to show a 23
year old patient they have the hormone levels of a 75 year
old)
– e.g. symptoms that vary throughout the month such as
breast tenderness or migraines
You will get these same curves whether you
measure in blood, urine or saliva
Much easier to do in saliva though!
Textbook monophasic cycle. 24 yrs old with regular menses.
Next menses
started here
This was her 2nd or 3rd
day of light spotting
35 y.o.
Can’t conceive x 3 yrs
Regular menses
Feels cold all the time
35 y.o.
Can’t conceive
Regular menses
Feels cold all the time
Saliva “Ice Cores”
• Saliva is a great way to get average levels across
time, when it makes sense to do so
• e.g. noncycling or erratically cycling women,
postmenopausal women, males, average bedtime
cortisol
• Spit an equal amount into one collection tube on
multiple occasions, keeping the tube in the freezer
in between times
• You can easily get 5 or 10 “layers” of saliva in a
10 mL tube
Do try this at home
• Make sure you spit the same amount each
time. Mark the tube at equal intervals
• Make sure you sample at the same time
relative to waking each time
• Keep in freezer between samples
• I don’t recommend this approach often
enough!
• It will definitely improve the quality of the
test result and there is no easy way to do this
in urine or serum
What’s wrong with a Day 21
single tube saliva test?
• Nothing… if someone is cycling regularly
• If the hx is consistent with estrogen dominance
month over month, a low Pg Day 19-21 confirms
• Saliva E and T ranges are tailored for women
• The value of the interpretation that accompanies a
saliva test is significant, especially for relative
newcomers to the field
• There is zero added value for serum testing
What about saliva testing for males?
• The main value I see is that you get a much better
“sighting” of estradiol in saliva and it relates well
to the clinical picture (in my experience)
• Serum tests only report total estradiol, which is
subject to the SHBG level (just like total serum
testosterone)
• As is the case for serum testosterone in women,
many labs haven’t retooled their serum estradiol
assay to work for men
Serum Cortisol “Day Curve”
X
X
X
X
Salivary Cortisol Day Curve
• Can answer questions like:
• “Why can’t my patient fall asleep?”
 high bedtime cortisol
• “Is my patient’s cortisol generally high
(or low) all day?”
• “Why does my patient “crash” by
lunchtime? Older
steep drop in cortisol from
waking to lunch
X
X
X
X
Younger
Psychosom Med 2003;65:836-841.
Peeters F, Nicholson NA, Berkhof J.
Is Salivary Cortisol the “Gold Standard”
for Cortisol Measurement?
• There is no gold standard but saliva is the method
of choice for many researchers.
• Questions remain…
– Obese patients have normal or low salivary cortisol (and
normal serum cortisol) but can excrete elevated levels of
cortisol and cortisol metabolites in urine
– Males in particular may sometimes have a disconnect
between salivary cortisols and clinical status (low
salivary cortisols and patient feels fine)
Is Salivary Cortisol the “Gold Standard” for
Cortisol Measurement?
• If your clinical impression doesn’t match the
saliva cortisol results, then seek corroboration
from urine or hair
• “Mismatches” are not an indictment of saliva
testing or any other kind of testing
• The tests measure what they measure
• We simply don’t understand the bigger picture
• Always look back to your patient!
Saliva Summary
• Saliva is the best “workhorse” option for baseline
testing for males and females (endogenous
hormones)
• Ranges and sensitivity tailored for male and
female sex steroids
• You can learn a lot from the interpretation
• Easiest way to profile and get averaged data
• Easiest way to generate day curves
• If you want to look at conjugates, they are not
available in saliva (exception DHEAS)
• If you want a more detailed look at mass balance,
saliva is not for you
Yes Virginia, You can measure Cortisol in Hair
• First citation I have dates to 2005
• Flurry of citations since then…
• Each follicle is like a mini adrenal gland, making its
own cortisol
• But in synchrony with the suprarenal glands…
• Hair cortisol has been correlated to saliva and serum
• Use to corroborate with other cortisol tests when the
other results don’t match the clinical picture
• Use with shiftworkers and people routinely crossing
time zones
24 Hour Urine Steroids
• Most of the steroid hormones in urine are
conjugated, because urine is mostly water and
won’t dissolve unmodified steroids (cortisol
excepted)
• Captures hormone output during one complete
diurnal cycle
• e.g. 7 AM 7AM + 24 hrs
• Is thought to reflect total production of a given
hormone, if the parent hormone and all the major
metabolites are tracked
• Serum and saliva can’t do this
24 Hour Urine Steroids
• Somewhat cumbersome…
• People forget to collect some of their output,
especially at night  falsely low levels
• People feel the urge to drink 5 litres of water per
day, even if they don’t live in the Sahara 
excessively dilute sample
• This is still a point sample since it is only one day
• Info about diurnal variation is lost
• All labs doing this give an interpretation
What are we measuring in urine?
-The kidneys are
encapsulated.
-Unlike saliva, they can
only receive chemical
information via blood
-If it doesn’t show in the
blood, it won’t show in the
urine
The problem we have in serum with hormone creams
also plagues urine steroid testing
Urine Hormone Testing
Measures Conjugates
Hydrolysis
entails a loss
of information
Conjugated hormone
Unconjugated hormone
Urine Steroids
• Just remember that labs report the hormones
using their PARENT names
• For the most part, those molecules entered
the kidneys as conjugated derivatives
• So urine “estradiol” is not the same entity
as salivary estradiol or serum estradiol
and can only be compared qualitatively
Hormone “gospel”: conjugated hormone is what the body is tossing out
Why would
the body go to
the trouble of
making
excess
hormone just
to toss it out?
Hormone bound to
SHBG or other
carrier protein
Bioavailability of Conjugated Steroids
• Numerous citations indicate that steroid conjugates
(sulphates and glucuronides) can be taken up into
cells by various transport proteins
– MRPs (multidrug resistance proteins)
– OATs (organic anion transporters)
• It would make sense that potent hormones circulate
in an inactive form, and are activated in situ as
needed
– Estrone sulphate in breast tissue converted to E2
– T4 glucuronide in renal tissue
– DHEAS as per Labrie (intracrinology)
Chief Advantage of Urine Testing
“Grandma”
“Family Tree”
17-ketosteroids
Progestogens
17-hydroxysteroids
Mineralocorticoids
Estrogens
Mass Balance/Distribution
A
D
B
F
H
C
E
G
I
J
K
Sometimes we want to know: A + B + C + D + E + F + G + H + I + J + K
Sometimes we need to look at things like: J/G and (F + E)/G
A strongpoint for urine testing is the
ability to look at estrogens in detail
Estradiol
Estrone
Hydroxyestradiols-OH
Estrone Sulphate
(E1S)
Hydroxyestrones-OH
R-CH3
R-CH3
COMT
COMT
R-H
R-H
Methoxyestradiols-OCH3
Methoxyestrones-OCH3
Extent of formation of these
endproducts may reflect methyl
donor sufficiency
Estradiol
Estrone
Estrone
Sulphate
(E1S)
It’s probably
a good idea
to have lots
of this, no
matter what
CYP1B1
CYP3A5
4 hydroxyestrone
CYP3A7
CYP3A4
CYP1A1
CYP1A2
CYP1A1
16 hydroxyestrone
There is some very
shaky literature
suggesting that
16OHE1 promotes
breast cancer
Estriol
2 hydroxyestrone
Older literature suggested
that a low ratio:
2OHE/16OHE increased
future risk of breast cancer
Not supported by metaanalysis
Estradiol
Estrone Sulphate
(E1S)
Estrone
CYP1B1
CYP3A5
4 hydroxyestrone
2 hydroxyestrone
?
16 hydroxyestrone
Accumulates in breast
tumour cells
Irreversibly damages DNA
Damages oncogenes
Estriol
Several authors
suggest looking at
the ratio
4OHE1/2OHE1
Estrogen Quotient (EQ)
• EQ = E3/(E1 + E2)
• Studies by Henry Lemon in the 70’s indicated that
in populations with a low incidence of breast
cancer, urinary EQ > 1
• Caucasians normally have a urinary EQ <1 and are
at increased risk for breast cancer relative to other
races (e.g. Japanese eating traditional diet)
• Lemon postulated:
– if the urinary excretion of estriol (E3) can be increased
relative to the other estrogens, this will decrease the risk
of breast cancer (make EQ >1)
EQ Calculated from Saliva Results
• You can measure E1, E2 and E3 in saliva and
calculate an EQ
• Remember that you are building that EQ using
different molecules compared to urine
• Urine conjugates
• Salivanon-conjugates
• Does it matter?
• Yes. You get the opposite results in saliva
• There is no published data on the salivary EQ
Urine HormoneTesting
• You might want to make this a first-line,
baseline test for a patient with a family
history of breast cancer, or a history of
longstanding breast tenderness (to get the
estrogen data)
• You might want to do this as a baseline test
on an overweight male (to get the estrogen
data)
• Do this test to explore cortisol metabolism in
more detail
Salivary Cortisol
End-stage adrenal fatigue
Saliva Cortisol
• But…when
salivary cortisol is
at odds with the
clinical picture, you
need to do some
other confirmatory
testing
This patient feels fine
Urine Cortisol Metabolites
-You would not attempt to treat this person with adrenal support or
cortisol, based on these results!
-But you wouldn’t have done it based on saliva either, as you are
treating the patient, not the lab results!
Endogenous Hormone Production
• To a first approximation, when people are
making their own hormones, any of the popular
testing modalities (serum, blood spot, saliva,
urine) are able to identify significant hormone
shifts (low or high)
• e.g. Day vs night, prepuberty/postpuberty,
hormone secreting tumours, pituitary failure
-doesn’t matter what testing modality you use, you will
pick up obvious deviations and imbalances
Endogenous hormones and baseline testing
• Use serum only if cost is an issue
• Saliva for 80% of patients/Urine if more
detail needed
• Saliva when profiles or averages needed or
preferred
• Urine if want to take apart estrogen or
testosterone metabolites
• Use a test that gives an interpretation if you
are new to the field
Testing After Supplementation
• Each testing modality has significant “quirks”
depending on the hormone and the type of
delivery
• The tests always measure what they measure; it is
the context that has changed
• It is difficult/impossible to replicate youthful
levels of hormones in most cases
• The numbers you do get are not clinically
validated numbers, in the absence of other
evidence
Why don’t the tests always tell the
“truth”?
• When we test after supplementation, we run into what we think
are “nonphysiologic” hormone levels.
• It’s the delivery that is nonphysiologic
•
•
•
•
Your GI tract is not a gonad or an adrenal
Your skin is not a gonad or an adrenal
Your oral mucosa is not a gonad or an adrenal
Your vagina is not a gonad or an adrenal
• The tests always measure what they are capable of measuring;
the plumbing isn’t the same; the rates of conjugation aren’t the
same; the binding of the hormone may not stay the same
Uptake, Binding, Metabolism
GLAND
Hormone
??????????
receptors
Other inputs
Uptake, Binding, Metabolism
GLAND
Hormone
??????????
Other inputs
NON-GLAND
e.g. mucosa
receptors
63 year old woman: BiEst cr 2 mg bid; Pg cr 160 mg bid
Her supplemented hormone levels have moved into
the Luteal range, but it took massive doses to do it
Testing after Hormone Cream
• Serum = urine: a lot of “inertia”
• It takes supraphysiologic doses to “move the needle” for
these test types with cream: Risk of overdose
• Results don’t appear to be dose-dependent and don’t reflect
the clinical picture
• Saliva has much less “inertia”
• Physiologic doses give supraphysiologic numbers: Risk of
underdose if try to replicate physiologic levels
• The numbers display dose-dependency
• The numbers track body burden but not clinical effect
• Saliva has “memory” effects
Avg Pg (pg/ml)
Avg Pg Result vs Evening Pg Cream Dose
bid dosing only
y = 91.501x + 1.0154
R2 = 0.7958
14000
12000
10000
8000
6000
4000
2000
0
0
20
40
60
80
100
120
Evening Pg Dose (mg)
The finding of a low/high level of a hormone despite an average dose of
hormone might point to:
Poor absorption/excessive absorption
Non-compliance/over-compliance
Problem with composition of topical (actual dose lower/higher than labelled)
BreastTenderness
Breast Tenderness
3
Symptom severity is not
proportional to “On-cream”
salivary E2 level
( a score of 3 indicates
severe breast tenderness)
Avg Sx Score
2.5
2
1.5
1
Endogenous
Range
0.5
0
1
10
100
1000
Salivary E2 after cream
supplementation
(pg/ml)
Salivary
E2
ExcessFacialBodyHair
Facial Hair Growth
3
Avg Sx Score
2.5
Symptom severity is not
proportional to “On-cream”
salivary Testosterone level
( a score of 3 indicates
severe facial hair growth)
Endogenous
Range
2
1.5
1
0.5
0
0
50
100
150
200
250
Salivary
(pg/mL) (pg/ml)
Salivary T after
creamTestosterone
supplementation
300
Last Pg use
Patient uses progesterone cream 37.5 mg bid, 12 days/month
Supplemented Pg is stored and released at appropriate time
Testing after Oral Supplementation
• Lots of conjugated metabolites forming within 2
hours of ingestion in GI tract as well as liver
• Results are dose-dependent
• Urine results can go sky-high
• If you adjust the oral doses low enough, you can
achieve physiologic levels in urine
• This may be at the expense of clinical effect!
• Saliva won’t see these conjugates and parent hormone may
have returned to baseline overnight, if take hormone at
bedtime and spit next morning
Dose-Dependency of Urine E2 after Oral E2
If you dose down here, you
might get clinical benefits with
“younger” level of E2
metabolites
Hormone replacement with estradiol: conventional oral doses result in excessive
exposure to estrone. Friel PN, Hinchcliffe C, Wright JV. Altern Med Rev 2005;10:36-41.
Testing after Oral
Supplementation: Saliva
• Metabolites form almost immediately, and peak
within 2 hours of ingestion
– Saliva progesterone is down to postmeno baseline at
7AM following ingestion at 11PM the night before
– You can drive the 8 hour post-ingestion result to the
luteal range but it takes 200-300 mg
– Side effects will occur, due to metabolites
– Salivary estrogens are less predictable and may
sometimes stay 2-3x physiologic next morning
– This may indicate difficulty clearing estrogens
Testing after SL/Troche
Supplementation
• Stimulates salivation
• Possibility for rapid conjugation if this
‘juice’ is swallowed-will then look like an
oral dose if testing urine: sky-high numbers
• Depending on how rapid the absorption into
the mucosa, can look like IV-with rapid
elevation of blood levels
• Saliva will be heavily contaminated!!
Don’t do saliva testing after
sublingual hormone use !!
2/19/2011
Copyright Rocky Mountain Analytical
74
Testing after Vaginal/Labial
Delivery
• Parent hormone may
directly contaminate
urine
• Parent hormone will be
“counted” in the assay
• Hit and miss: may get
meaningless, high
results
• Some labs separate the
conjugates from the
non-conjugates
Testing after Vaginal/Labial
Supplementation
• Saliva levels do not elevate the same way
they do with hormone cream applied to
squamous epithelium
Testing after Skin Gels
• Much better penetration to blood (wrt
creams) for alcoholic gel products:
testosterone, estradiol and progesterone,
DHEA
• Better chance for metabs to show up in urine
at physiologic doses
• Progesterone gel would have to be
compounded
• Skin gels act like skin creams when tested via
saliva-supraphysiologic numbers
Pellets/Patches
• Generally slow release into systemic
circulation with daily fluctuations depending
on activity, exercise
• See fluctuating high levels in saliva possibly
indicating some fat depot effect
• More natural pattern of conjugate formation
• Opportunity for local conversion to other
hormones?
Testing After Supplementation
• Regardless of what test type you choose, avoid
“blanket testing” of every patient on hormones,
without regard to what hormones you are giving
and how they are being given,
• There is no role for this type of testing IMHO
• You cannot simply reset the gauges in every
situation when you supplement hormones
Test, supplement, retest, adjust “sliders”
(i.e. dose) based on test results?
Normalize results to youthful levels??
This approach only works in specific cases
Testing After Supplementation
• Always think about where you might be starting in the
steroidogenesis cascade
• The higher up the cascade, the greater the opportunity to
make other stuff besides the hormone you are giving
– Pregnenolone vs DHEA vs Testosterone
• If someone is taking estradiol, progesterone, testosterone,
DHEA and pregnenolone, you probably won’t be able to
make sense of what is going where, especially with
multiple routes of administration
• I see this all the time, unfortunately.
Testing After Supplementation
• You have to have very specific questions in mind
that you want answered:
– e.g. Is this patient making too much estrogen from the
testosterone I am giving him/her?
– e.g. Is this patient accumulating too much of the
hormone I am giving her?
• If in doubt, call the lab before testing.
• Anyone who is selling one testing modality for all
supplementation scenarios has not given this topic
enough deep thought, or doesn’t care
Don’t let the
lab test do
your thinking!
Remember
to treat the
Patient first!
Just be
thankful you’re
not my Dentist
CONCLUSIONS
2/19/2011
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