So, over the last few weeks I have found myself recommending more and more a specific test called the DUTCH. A colleague of mine criticised me – saying it was my ‘new obsession’. On careful evaluation, I realised she was right.
However, sometimes there’s an entirely healthy and necessary reason behind obsessions – and, for now, I believe my obsession with the DUTCH is just that – healthy, necessary and entirely justified.
So instead of explaining to all my patients why this test is such a good thing – I thought I’d write it out…
Why Test Hormones?
To understand why I, as a practitioner, find the DUTCH so useful – let me take you on a journey – firstly through why I might test hormones to begin with, and then to show you the evolution in methods of hormone testing:
Firstly I need to explain the hormones I’m speaking about when looking at the DUTCH test and its compatriots, the Adrenal Stress Index and the Cortisol Blood test. With the latter two I am solely talking about the ‘stress’ hormones of the adrenal glad, but with the DUTCH I can also look at the sex hormones: oestrogen, testosterone, progesterone and all of their metabolites… (more on why this is important later…)
It could be argued that in order to do a thorough health analysis a practitioner might always evaluate the hormone status of their patients. However, when talking of stress hormones, typically a practitioner will reach for the testing toolkit when there are questions around tiredness, hyper-alertness or common ‘adrenal fatigue’ symptoms. This is a term that has percolated into use in modern society – typically referred to when individuals are overtrained, overtired, over-stressed and basically dead on their feet (or tired and wired, with sleep disturbances etc.).
However, the term “adrenal fatigue” is starting to fall out of favour. This is for two reasons. The first is quite simple: everyone is tired – so the low cortisol, so-called “fatigue” is so common it’s almost the norm. It’s just the way we have learned to live in our ‘always on’ society, people rarely have effective down-time practices and sleep schedules. Having ‘adrenal fatigue’ as a diagnosis doesn’t mean that much these days – particularly if the only solution is supplementing with the hormones that your adrenal is not making or with complexes that try to alter the way your hormones are being produced. This isn’t actually a ‘cure’ – it is treating the symptom, which – even if done with supplements rather than medicines – is not something I am a fan of.
The second reason behind the phrase ‘adrenal fatigue’ falling out of favour is even more important for this discussion. The phrase itself gives the impression that the adrenal glands themselves (that ‘produce’ cortisol and DHEA, adrenaline etc.) are failing due to tiredness.
However, the truth is that every hormone in the body requires two things before it will be made: firstly, the signals telling the glad to make it AND secondly, the right ‘ingredients’ (including co-factors, enzymes, nutrients etc.) to do so.
In what has been termed ‘adrenal fatigue’ we could be looking at a multitude of instigators of a heightened or slowed production of adrenal hormones – from a lack of signalling (ACTH) from the hypothalamus, to resistance to the stress states if they’ve persisted for so long, to thyroid function issues and inflammatory or immune states. “Tired adrenals” is neither diagnostic, nor accurate – this doesn’t make sense metabolically, biochemically or functionally.
The Evolution of Hormone Testing
To add complication to complexity, hormones don’t have a ‘steady state’. It is well-known that cortisol has a diurnal rhythm and therefore a one-off blood level of cortisol (even the ‘morning’ or ‘am’ blood cortisol) doesn’t show us what actually happens with our cortisol and DHEA levels throughout the course of a normal day. It doesn’t answer why we can’t sleep or get up, nor tell us what is causing our ‘tired and wired’ states.
Therefore the now incredibly popular ‘saliva’ test was invented (the Adrenal Stress Index, or ASI). This could measure the levels of cortisol throughout the day – but specifically the levels of free cortisol (i.e. the stuff that you weren’t using, the stuff that was available for the body to take up into any of its cells).
This test takes 4 samples of saliva over 12 hours and analyses 4 markers of cortisol and 2 of DHEA. Finally, as practitioners, we had a window into the level of stress/adrenal pressure/usage of cortisol (the stress hormone) our patients were going through – and the way their cycle was going over the course of their waking life. Adrenal fatigue now had stages of development – from mild, to moderate through to completely extreme (depending on the levels of the hormones and their ratio etc.) and practitioners learnt how to monitor their patients’ stress hormone dysregulation through this test.
If you combine this with a test for sex hormones you can start to build a picture. This is because the adrenal and sex hormones need a lot of the same ingredients, so if your adrenals are hogging all of those ingredients to produce massive amounts of cortisol then your sex hormones have no building blocks and so don’t get made. Combining adrenal and sex hormones just makes sense and shows you more of what’s happening in the ‘hormone soup’ that is a human being.
The New Kid On The Block
Many labs offer combined testing for hormones – and you can always do an Adrenal Stress Index and a separate sex hormone panel. So why go DUTCH?
The DUTCH test is urine. You may think “well that’s messy”, but really you saturate 4 or 5 bits of filter paper over the course of 12 hours (including overnight) and then let them dry and post them off (postage = one 1st class stamp). Simple.
But from these small bits of filter paper, the Precision Analytical lab uses phenomenally intricate mass spectrometry with crazily accurate reference ranges (even including allowing for menopausal women AND those taking supplemental hormone therapies).
And what I get as a practitioner is a window – into not only the level of cortisol you’re producing, but (because it’s looking at cortisol AND its metabolites) I can see how much cortisol you’re metabolising, your DHEA levels in relation to this, your ratio of cortisol to cortisone (the active vs. storage form) – I can see your sex hormones, what your pregnenolone (broadly speaking, one of the ‘ingredients’ above) is up to and where it’s being directed – including seeing the levels of your different types of oestrogen, the metabolites of testosterone and what your androgen balance is like, whether you’re methylating some of the oestrogen correctly and a whole host of other things beside.
In short, I can tell how stressed your body really is – and exactly what is being affected by that stress. Quite cool is that I can interpret from this whether your thyroid is OK, how well your liver function might be working, and if you’re taking replacement hormones, I can see whether these are actually helping or harming your function. As a Functional Medicine Practitioner this test really, genuinely and usefully shows me how your hormonal systems arefunctioning. See a sample report here.
Is the ASI Useless Then?
So where does this leave the saliva test? Well, in my opinion, probably not as clinically useful any longer – and that’s not as reckless as it sounds. There is a specific reason for this…
A saliva test measures free cortisol, as I said. It doesn’t, however, tell me how much total cortisol you’re making, how much you’re metabolising and whether there is a load of cortisol you’re storing instead. It could be that you make a lot, but metabolise a lot of cortisol. It may be (and I see this regularly) that you look as if you have high cortisol but actually your level of metabolisedcortisol is low – which shows me that your adrenals are fine (producing a moderate or ‘normal’ amount) but there’s something going on with the way you’re handling the cortisol produced so you’re not clearing it, leaving it floating around in your system. This is very different from you being ‘over-stressed’ and needing to ‘calm down’ – it’s much more to do with thyroid function and how well you’re generally metabolising things. This is so different for a clinician that it renders the ASI looking actually a little unhelpful.
And so I am, I admit, obsessed with the DUTCH. Basically because it gives me so much more bang for my buck as a therapist – and I feel I can help my patients more because it shows me a whole picture, rather than just a small pixel of information from the hormonal status of a person.
I am ready to be wrong about anything in my practice – this is a new(ish) test and has perhaps not earned its stripes, and at twice the price of an ASI I recognise that a DUTCH Complete test may be out of reach of some people. Even then, however, I don’t know that I would choose to run an ASI on my patients now – because whilst the information it provides can help, it does not always give me a clear enough picture to definitively know how best to help my patients.
So for now – in an ideal world – if I could run four tests as a starting point for ALL of my clients (in addition to any bloods from their GP) it would be these:
1 – Urinary Organic Acids Tests (probably this one here – I just love the way the lab keeps up to date with the way it evaluates the data
2 and 3 – Two stool tests (because I don’t love the way some labs’ stool testing can miss things)
4 – and, now, a DUTCH Complete Hormones.
This would probably tell me all I needed to know for the vast majority of my clients – and more than that, give me proper clinical tools and a direction with which to go in to make demonstrable differences to their health and their life.
And that’s what I love about the evolution of testing within Functional Medicine – the more I can do with less testing, the more I genuinely believe it is better and more practical for me AND my patients.
(***Here ends the justification of my obsession…***)