Hormone level testing

This seems like it should be a wonderful tool: measure the hormones you have and just adjust your doses till you show the correct lab results. Alas, but it's not that simple (you knew we were going to say that, didn't you?). Hormone tests are inaccurate in a variety of different ways, they are difficult to interpret, and norms are so broad as to be nearly meaningless. Let's look at the problem in more detail.

"Normal" hormone levels?

Normal levels tend to be very broad because in addition to cycling up and down every moment of every day of the month, women vary a great deal in what is normal for them. Any single hormone level test is only a snapshot of what your circulating level in your blood stream is in that exact second in that particular blood vessel it was drawn from. It cannot measure the total amount of hormone you have in your system including what's in fat or stored in other forms. Even if you did have your hormone levels exhaustively checked premenopausally—which for most of us means pre-hyst—you still don't have any way to know what levels of hormones will meet your needs in your post-fertile lifestage.

Skeptical? Let's pretend for a moment that you know exactly what your hormone levels were preoperatively for every moment of the day of every day of the month, when you felt good and when you felt bad. Now, think about what you were doing with those hormones—what you needed them for. Or, in other words, what needs you were fulfilling with them such that the needs and supply balanced out causing you to feel your best. Why, a lot of those hormones were dedicated to their primary function of supporting fertility: cycling eggs up to ready and your uterus with a nice thick linking to receive them.

But now jump ahead in time to post-hyst. We're no longer fertile; we no longer have that uterus to support and cycle. In fact, being in menopause sends a signal to our bodies that we don't need a whole lot of things that were part of our reproductive lifestage any more. That means that we can cross off all of those fertility needs from our list of jobs for hormones to fill. And that in turn means we don't need as many individual hormone molecules to fill these reduced job quotas if we want everything to balance out just right between supply and demand.

And how many molecules of hormones can we cross off of those perfectly-balanced pre-menopausal values for these no-longer-needed fertile functions? Why, nobody has the slightest clue. There's no chart; there's no research study; there's no rule of thumb; there's not even a good guess that goes along the lines of X% of your hormones go to support fertility. Nobody has a clue. So what good are pre-op hormone levels in predicting post-meno needs? Not much: if we were to blindly duplicate those levels without the need, we'd be suffering sure symptoms of excess. We just can't count on numbers and expect to use them to roll the clock back.

Even more discouragingly, if you have had gynecological health problems for a considerable amount of time pre-hyst, you probably haven't been hormonally reasonable for quite awhile, especially if you were taking hormones or hormone-affecting drugs to treat your condition. You may never have known hormone balance. The times in your cycle when you were supposed to be feeling your best, may well not have been. For a lot of us, then, we are looking for hormone balance for the first time in a long time—maybe for the first time in our lives—and we have no quantifiable reference point to work against.

But nevermind all that, you say: that's water over the dam. Let's get a blood test done now and see what it says and go from there.

Ah, but wait. If you're taking hrt and have a test done, that result doesn't take into account where you are in your dose cycle: if you take a pill once a day, your dose rises afterwards and gradually falls during the day to a low at night. If you change your patch on a given day, a level drawn before the change is going to be a bit different than one drawn after it. So a single measurement doesn't tell you anything about your average level during the day or over any broad time range, but that's what has the greatest effect on how you feel (although dose dynamics are also an element of that). If you take oral hormones and have a test drawn in the morning and one drawn late in the afternoon, they will return different levels. Which one is the "true" one on which you should base your expectations?

Even then, if you look at hormone test norms, you'll see a confusing array of values, depending where you are in your monthly cycle. If you are post-menopausal, where are you in the monthly cycle? For example, one lab gives these values for adult women:
  • early follicular phase 20-65 pg/mL
  • mid follicular phase 20-130 pg/mL
  • late follicular/mid cycle phase 50-320 pg/mL
  • early luteal phase 20-100 pg/mL
  • mid luteal phase 30-200 pg/mL
  • late luteal 20-160 pg/mL
  • postmenopausal ND-30 pg/mL

This looks as though you can have more estrogen (and be "normal") when you are postmenopausal than in some times during your cycle when you were fertile. Huh? A lot of doctors use the mid-follicular phase levels, but as you can see, that's a really wide range. If it happens that you are one whose norm was up towards the 130 end of that range and you now test out at only 25: you are nominally "normal" and you might well feel like hell. Those test numbers just don't capture the relationship between feeling good and a number.

Hormone testing methods

And then there are problems relating to the method. Hormone testing is done using several methods, each of which has its drawbacks.

You can test urine for total hormone quantities. Unfortunately, this test requires collecting every drop of urine output over 24 hours, and keeping it on ice the whole time. If it's not perfectly collected and perfectly stored and perfectly delivered, the accuracy of the test diminishes proportionately. Not altogether convenient for most of us.

You can test blood levels. This is pretty straightforward—the source for the levels we quoted above calls for just 2 cc of blood. You can get it drawn at just about any hospital lab, your insurance will probably cover it, and, assuming that the lab's machine is properly calibrated and the lab tech isn't having a bad day, the results are going to be fairly accurate.

The problem is that a blood test measures total serum estrogen. A woman taking conjugated estrogens, such as Premarin, or the potent synthetic ethinyl estrogen won't see those estrogens show up in her lab results because the standard test measures only estradiol and perhaps a couple other major estrogens, like estrone. Similarly, testing does not reflect that portion of total functional estrogen that may exist in the form of various metabolites, even though they may be active in supporting estrogen needs.

Another problem with estrogen measurement is bioavailability. A great portion of systemic circulating estrogen is bound to SHBG, a protein that locks it up so it can't be used. Well, what's the point of measuring estrogen that you can't use? Right. The problem is, the test can't distinguish even though your body can. Unless you also measure SHBG, you don't know what proportion of that estrogen is bound and which portion is free. Even measuring total SHBG doesn't tell the whole story, since it binds with a number of hormones and so you don't know how much of its capacity counts against the estrogen total.

Getting confused? Hang on, it gets worse yet.

You can also measure hormones levels in saliva. This is newer testing, generally done by private, for-profit labs. It is not accepted as legit by some doctors and most insurance companies. The labs are unregulated, so there is no independent measure of their performance or uniform, third-party standards to which they must adhere. You have to take the word of someone who makes a profit from selling you a service that this service is accurate. On the other hand, you can purchase your own saliva testing kits online or at health stores, which allows you access to testing when your doctor refuses your request for testing. Some compounding pharmacists who sell saliva kits won't work with hormone patients unless they buy a kit. Kits run from about $50 for a single hormone to $200 and more for a multiple-hormone "panel."

Since many of the companies that do testing also sell hormones or supplements or "programs," it is also reasonable to look closely at their recommendations and interpretations. While some of the labs can be quite helpful in interpreting results, others are fraught with delays, "bad reagents" and other problems. With all due respect to the labs, this is a real "buyer beware" situation.

There is also a problem with saliva testing for progesterone. Although the labs are unable to explain it, it is looking more and more as though saliva tests for progesterone return erroneously high results in women using creams. This is something that has become clearer over the past decade, as enough women have used both progesterone cream and the saliva tests to provide a reasonable sample. At first, these high results led some practitioners to recommend against use of progesterone creams because they "don't clear the system," or to tell women to stop using their progesterone because they were experiencing catastrophic overload, even though those women had no particular symptoms of progesterone excess. Some of these warnings are still up on the internet, still in use by practitioners, and continue to cause women to fear use of progesterone creams. While some of these high results are clearly backed up by signs of excessive progesterone in the women using it, many women feel just fine while testing out thousandsfold high. Many of these women also have blood tests within the normal range. So what is going on?

No one has come up with a convincing answer yet. It has been suggested that somehow the saliva tests are responding to metabolites that aren't active as progesterone in the body but still affect the test. Nonetheless, several enterprising manufacturers of progesterone creams advertise special formulations promising better delivery methods that don't cause this terrible build-up as measured in saliva tests. Since we also know plenty of women using conventional creams who are clearly showing beneficial effects and no signs of excess, we find we are just plain skeptical. Until we see something scientifically convincing, we can't wholeheartedly embrace saliva testing for progesterone.

The fact that the test manufacturers simply haven't convincingly addressed this problem in the ten or so years that it's been well known suggests that they don't have a good answer but do continue to have a profitable market. And if there is that flaw in that test, we are not convinced that the other saliva hormone tests might not have flaws of their own, given that they are essentially measuring different things than the blood tests do. There is no answer for this question of reliability until you can identify the source and extent of that discrepancy, and that has not happened. Saliva testing sounds good, but until it meets more rigorous scientific standards, we just don't feel that it is an acceptably valid technique.

When is testing helpful, then?

So, now that we've bashed all these tests, why did we say pages and pages ago that testing does have its place? Just what would that place be?

Well, even though a test can't tell you when you are "right," it can be of some use in demonstrating where you are wrong.

If you are taking HRT and still experiencing signs of deficit, testing our with extremely low hormone levels bolsters the argument that you need to try a different delivery method. If you are in agony with signs of excess estrogen, demonstrating elevated levels may substantiate the need to decrease your dose, regardless of how that dose compares with the "norm." In other words, hormone testing comes into greatest usefulness in demonstrating great deviations from the normal range.

The other most useful situation for hormone level testing is if you feel bad but are unable to determine in which direction your imbalance has taken you. The symptoms aren't always clear, especially when we're beginning to learn what our body is trying to tell us. Similarly, some doctors are better than others at tuning; some simply feel that any complaint about hormone symptoms means we need to change brands or routes or raise our doses. Sometimes we're just lost. While testing won't tell us we're within sight of our goals, it may help point the direction in which that goal may lie. And that may be enough to get us moving again.

So testing has both its uses and its limits. So long as you know one from the other, you can use test results wisely—and sparingly of your cash—in guiding the balancing process.