Hormone Testing: Blood, Urine or Saliva?
Many of you sense there could be something off with your hormones and would like them tested by your doctor. In this article, I'll share the optimal method for testing hormones no matter your gender, and what exactly to ask your doctor to test.
So which is best: blood, urine or saliva?
Over the last 13 years I have attended dozens of medical conferences on hormone replacement to include: American Academy of Anti-Aging Medicine (AAAM), WorldLink Medical and other medical age-management presentations and trainings. Additionally, I've listened to hundreds of lectures on testing hormone levels in patients. The companies that attend these conferences specialize in lab testing and each has their own pitch as to what’s best for determining your optimal hormone levels. Some recommend saliva testing because they argue it's the level in the tissues that matter the most. Others recommend checking urine and various metabolites, and there are other doctors who recommend blood or serum testing.
What I want you to understand is that the doctors who are the best in the world at hormone replacement all check blood levels. This is what 90% of the published medical literature bases hormone replacement on. With the exception of getting a saliva cortisol level, I exclusively check blood levels. I can honestly tell you that it is not only the most accurate, but it is the best guide as to whether or not our treatments are effective enough to influence physiology.
For example, we know that in the medical literature, estradiol levels that are protective for women are in the 75 range for women; and, in men I like to see estradiol levels over 50. For testosterone, I like to see men in the 1000-1200 range, and women with free testosterone levels above 4. There is no urine or saliva level that we can point to in the medical literature to suggest what those levels should be. I have found both saliva and urine to be unreliable and a complete waste of time and money and I do not recommend either.
So what should I have checked?
For men, I recommend checking blood levels of total and free testosterone, estradiol, sex hormone binding globulin, DHEA, IGF-1, FSH, LH, thyroid (to include TSH, free T3, free T4, reverse T3), thyroid antibodies, and a morning 8am cortical level. Some doctors also check DHT (which I have never found helpful because it doesn’t change management). For women, I get all of the above in addition to progesterone. However, for women there’s a really important point I want you to understand. If you are still having any menstrual periods at all, checking estradiol, progesterone and testosterone levels is basically pointless because they will fluctuate wildly throughout the month. In the first half of your menstrual cycle your estradiol levels can be 12 and your progesterone level 0.3. At the mid-month mark, when you ovulate, estradiol can spike to 450 and your progesterone levels are still at 0.4. If your lab draw happens to be on day 20 of your cycle, as an example, your progesterone levels can go up tenfold and your estradiol levels can drop to 80! I can't tell you how many women I see who have been told they are estrogen dominant because their estradiol levels were high and progesterone levels were low simply because they checked their labs right before ovulation. In women who still have ovarian function, we treat symptoms more than lab values, with the exception of thyroid, growth hormone level and cortisol.
What about estrogen metabolites?
There are many doctors who check for estrogen metabolism because there are different pathways that dictate how estrogen is metabolized, and their doctor tells them that some of those metabolites are more likely to cause cancer with others being protective. However, that conclusion is not all based on science. What the medical literature shows is that when you give a woman estradiol and progesterone, her risks of cancer do not go up. In fact, much of the research shows protection against breast and uterine cancer. The bottom line is - don't get caught up in checking estrogen metabolites.
Differentiating normal vs. optimal
It is important to understand that for any given hormone, whether it's testosterone or thyroid, the laboratories have established reference ranges. They take the average of a population, calculate the median and go up and down (+ and -) 2 standard deviations to create the range. So, the range for testosterone is 347 to 1197 in younger patients and goes down as we age. For a 60 year old male, that range is 249-836. For thyroid, the range for free T3 is 2.0-4.4, but for a younger patient the range is 2.3 to 5.2.
As physicians, we are trained to treat the number and ignore the patient, meaning if you have all the symptoms of low thyroid, as long as your free T3 is 2.0 or higher, you’re "normal", and you don't get treatment. The same goes for testosterone in men, they go to their doctor complaining of fatigue, low sex drive, erectile dysfunction and have a level of 415 and told they're normal. That is not what the science says to do and not even what the endocrinology textbooks say to do. In Williams Textbook of Endocrinology (pg. 15), it reads, “It is important to keep in mind that there is not yet a consensus on what is normal, optimal and abnormal levels for any given hormone or metabolite and these definitions are continuously undergoing revision to reflect the latest research." I personally have prescribed testosterone to men, off label for fatigue, with "normal" levels who do absolutely fantastic.
The bottom line is if you want your hormone levels tested, there are two things to remember. First, have your levels checked by blood draw and second, have them done by a doctor like myself who understands the intricacies of treating hormone imbalances and understands that normal is not optimal.
If you would like me to personally check and review your hormone levels, simply give us a call at 877-721-0047.