By Jim Paoletti, BS Pharmacy, FAARFM, FIACP, Director of Education at Power2Practice
The majority of female patients that visit a practitioner for hormone evaluation are going to be in the peri-menopause or menopause stage of life. For these patients, a baseline test should include estradiol (E2), progesterone, testosterone, DHEA or DHEAS, cortisol 4 times in a day, fasting glucose and fasting insulin. For a woman who is still cycling, testing should be done between day 18 to day 21 of her menstrual cycle.
The best way to measure the sex steroids and cortisol is with saliva testing or capillary blood spot testing. Venous serum testing may not provide an accurate result for androgen in females, and urine measures metabolites only. Once a patient is on hormone restoration therapy, venous serum and urine testing may not provide accurate results for the dosage route employed, therefore it is best to get the initial base line done in a medium which can be used for follow-up testing for direct comparison.
Is she exhibiting symptoms of low thyroid function?
If the patient exhibits a significant number of moderate to severe symptoms indicating low thyroid function, thyroid testing should include TT4, fT4 direct, fT3 direct, TSH, TPO, 25-OH-Vitamin D, and ferritin.
TgAb may be included if there are systemic indications of an autoimmune reaction. Iodine can be tested initially if there is a history of nodules or goiter, or can be measured during follow-up testing if production of thyroid hormone is less than optimal. Venous serum or capillary blood can be used for thyroid testing, with the exception of iodine, which is best measured using spot urine testing.
Is she taking birth control pills?
If a patient is taking birth control pills, her endogenous production of estrogen and progesterone is suppressed. Normal endogenous production may not be restored even after the birth control pill is discontinued.
To test for endogenous production of estrogen and progesterone, patients need to discontinue the birth control pills for at least one month and preferably two months before testing. One option is to do initial testing to assess the other hormone levels and address issues there, then retest again after the patient has been off the birth control pill for an appropriate amount of time.
Has she, or is she taking oral estrogen?
If a patient has taken oral estrogen therapy for an extended time or is presently taking it, estrone (E1) should also be measured. Oral estradiol is converted to a large degree to estrone in the first pass effect. Estradiol levels may be normal for women on oral estrogens, but estrone levels are most often very high. Menopausal women who are significantly overweight should also have estrone measured, as fat tissue can serve as a source of estrone.
Once a woman is administered bi-est, a combination of estradiol and estriol, then follow up testing should also include measurement of estriol. Estriol affects the function of the stronger estrogens estradiol and estrone, so it has to be kept within normal physiologic range.
In certain cases, measuring hormones on more than one day may be beneficial. If a patient is experiencing migraine headaches on a cyclic basis, testing just prior to when migraines usually occur, during migraines, and immediately after can give a better picture of what hormone fluctuations if any are involved in the triggering of the headaches.
Does she have fertility issues?
For women with fertility issues, ZRT Laboratory offers a fertility panel, which measures a 4-point cortisol in saliva, while capillary blood measures the sex steroids, thyroid levels and SHBG, FSH and LH. Sampling is done on days 3 and 21 of the menstrual cycle. The day 3 sample is optimal for assessment of ovarian reserves with the FSH and LH tests, while the other hormones are measured mid-luteally (day 21 commonly), when the level of hormones should be optimal for a successful pregnancy.
Guidelines for testing once she has started HRT
Once a patient is on hormone restoration therapy, follow-up testing must be done with a lab that has established reference ranges based on dosage route and timing of the last dose of hormones. In general, if a patient is using a hormone cream once daily, test about 12 hours after the last dose. To do so, the patient may have to move their morning application to nightime for 2 days prior to testing. Or when interpreting the results, consider the fact that the sample was taken towards the end of the dosing interval, so resulting level will be near the low point of what is provided by the therapy. If they are using oral progesterone capsules, test 4-8 hours after the last dose.
I hope that this article helps clear up some questions about testing for a female’s hormone needs!
Looking for more information? Check out these related blogs and podcasts:
Jim Paoletti, BS Pharmacy, FAARFM, FIACP, is the Director of Education at Power2Practice and a Clinical Consultant with over 30 years’ experience creating and using bio-identical hormone therapies in both retail pharmacy and clinical practice.
Jim is a Diplomat in Functional Medicine in addition to being a former faculty member for the Fellowship of Functional Medicine.
At Power2Practice, Jim applies his wealth of knowledge and experience by hosting live webinars and creating useful content, such as blogs, podcasts and clinical support tools.