This is an excerpt from “Awakening Athena” by Kenna Stephenson, MD. We gratefully acknowledge Dr. Stephenson for sharing her wisdom and expertise with Women in Balance. In some instances, Women in Balance has added some information.
Testing Hormone Levels
Hormone balance is essential to good health for women of all ages. Unfortunately, the accuracy of the tests used to determine hormone levels varies widely. Below are the types of tests that can be used to determine hormone levels:
Saliva testing has been used in clinical research, including studies conducted at the National Institutes of Health (NIH) for more than 30 years. Saliva testing has been available to physicians for over a decade, and Medicare and many insurance companies provide reimbursement. Over years of clinical practice, it has been shown that saliva testing is the most accurate measurement of the body’s availability of the hormones Cortisol, DHEA, Estrogen, Progesterone, and Testosterone. Saliva testing is much more specific and correctly identifies the level of hormones at the cellular level, in contrast to a serum (blood) test, which measures the level of hormones circulating in the bloodstream.
Saliva testing is not helpful, however, to monitor women who are taking hormones in a sublingual (drops or spray) or tansmucosal (lozenge or troche) format. These forms of hormone delivery concentrate the hormones in the salivary glands and the resulting saliva levels are too high to be useful.
Serum or Blood Testing
Most serum tests define the normal range of hormones very broadly, which is a distinct disadvantage to their use. After a woman’s blood has been drawn, a portion of the blood sample (the serum) is used to measure hormone levels. Most serum testing measures the level of “free” hormone (the hormone that can easily enter the cell), the level of the “total” hormone (the hormone attached to substances that carry hormones in the bloodstream), or a calculated combination of both free and total levels of hormone. It is not an accurate reflection of the bioavailable hormone (the amount of hormone that is active in organs and tissues).In addition, the results of the serum testing are often inconsistent, especially if the hormone value indicated is in the low-normal range. Serum testing is less helpful in monitoring women using transdermal (patch or cream) forms of hormones, as the hormone is bound to the red blood cell surface and does not register in the serum in very high amounts.
Many women whose serum test results are normal cannot understand why they continue to experience the symptoms of hormone imbalance. (Saliva testing, however, provides a more exact range of normal results.)
Follicle-Stimulating Hormone (FSH) Testing
FSH, another serum test, is frequently used to determine the hormonal status of premenopausal women who may complain of hot flashes, mood changes, or other symptoms. The FSH test should not be used as an accurate measure of sex steroid hormone production or as an indication of reproductive status for most women, because the level of FSH fluctuates widely during the decade before menopause.
A properly conducted FSH test requires that blood be drawn three times at 60-minute intervals beginning precisely at 8am. The FSH reference ranges are based on the average of those three levels. In many cases, only one blood sample is drawn for evaluation, usually during the appointment with the woman’s physician at a time other than 8 a.m. The vital clinical decisions about a woman’s hormonal status and subsequent treatment are usually based on that single test. When hormone imbalance is detected early and steps are taken to correct it, symptoms can be relieved, and progression to disease states may be prevented.
To correct a hormone imbalance, use the “test-and- treat approach,” which involves assessing the woman’s hormone levels and then providing individualized treatment such as customized dosages of bioidenticals hormones, if needed, and lifestyle and nutrition recommendations designed specifically for her. The test-and-treat approach is far superior to the “guess and treat” approach.
In the guess-and-treat approach, the woman reports her symptoms and the physician guesses which hormones might be out of balance before prescribing a standard dose of a hormone. If, at the follow-up visit, the woman’s symptoms have not improved or her condition has worsened, her treatment is changed to another standard dose of conventional hormone therapy. After several episodes of treatment with different hormones or changes in doses, a patient who reports no improvement is often treated with a drug to relieve anxiety or depression.
Unfortunately, the guess-and-treat approach is still far too common in clinical practice. Most physicians would never prescribe drugs such as a blood thinner or cholesterol-lowering medication without monitoring the patient appropriately. Many are, however, very willing to prescribe highly potent hormones that can induce harm, but they do not believe that monitoring the effect of treatment is important.