This is a question I have been asked several times over the past week and it seems that when I dig into the professional opinions and blogosphere chatter (never actually the same thing), this seems to be a common area of confusion. So I thought I’d produce an update to my blog from seemingly ages ago wherein I declared “Why I Choose The DUTCH”.
Blood Tests vs. Functional Tests
Firstly, many people come to me with their blood tests from their doctor and state that they’re “not good enough” so they want further testing. Well, for a start, this is not an entirely accurate statement. Blood hormone levels, particularly for sex hormones, for the hormone stimulating messengers and for sex hormone binding globulin (SHBG) are invaluable. For these latter two, blood levels are literally the only way to test for FSH and LH – the hormones which stimulate the production of sex hormones, and SHBG can tell you how much of the sex hormones are being ‘bound’ up and are unavailable for use.
When we say blood values, we typically mean serum (rather than packed erythrocytes/red blood cells) and we also tend to be referring to “Total” levels of hormones – which means the amount of hormone available for use plus the amount of hormone bound to proteins like SHBG. Whilst you can test for the free fraction of hormones, it is normally only done by request.
These blood panels are what you will often see in conventional medicine settings. And they are far from useless. They show us so much about the level of hormone being produced, the amount of it that is being bound and the potential pituitary involvement impacting upon the signal being sent out to stimulate the production of hormones to begin with.
In so doing, blood really provides a fairly accurate insight into the cascade of hormones – i.e. the signals, the binding, the usage, the free and available etc. It is like being able to see both what’s happening and have some insight into where the hormonal dysregulation might be stemming from (which might actually be anywhere other than directly a hormone issue).
And yet blood is a snapshot in time. It cannot accurately assess the spread or fluctuations of hormones with diurnal rhythms (cortisol, DHEA) or monthly cycles (female sex hormones). It can be taken at a specific time of day, or a specific day in the cycle, but accurately pinpointing the desired timing can be a bit like guesswork on behalf of the patient and practitioner.
This is the precise reason why Saliva, and then Urine testing became popular in Functional clinics. Interested in insights as to how the body functions, these tests are taken over a spread of a day (or even the whole female menstrual cycle for the DUTCH Cycle Mapping) and give a bigger picture of how an individual’s hormone production ebbs and flows in the normal course of a day/month.
Urine and Saliva Are Not The Same
And so, in response to the need for accurate reflection of what really happens in the body, both saliva and urine tests have been offered up as viable alternatives.
The problem is that, at the risk of stating the obvious, urine and saliva aren’t the same substances.
More importantly, they also aren’t even measuring the same thing to get results. They are both painting a similar picture of hormone health, but one is using watercolours and the other spray paint, if you like.
Saliva tests can only assess the free fraction of hormones because it’s literally the ‘stuff’ available freely in the body (and hence free in the saliva). This shows you how much of that hormone you have available for use, and the science indicates that this is a fairly accurate measure which gives us a useful idea of what the body is capable of hormonally at any moment in time.
Urine tests assess the metabolites of hormones, as I went to great lengths to explain in my previous article on this topic. As such, it is like reverse inference of what must have been produced because we can see the waste products.
On the surface, therefore, this would appear that saliva should be more accurate – test what’s there rather than what’s left over from a biochemical process? Right?
Well, the truth is that it really depends on what you’re trying to see.
In Functional Medicine the whole point is learning how well the body is functioning. In this way, the remnants of biochemical pathways are actually incredibly illuminating for detailing how well the body is performing certain essential tasks. This is the whole principle of the Organic Acids Test, for example.
So seeing metabolites, or hormonal waste products, can show us far deeper into the hormonal picture. It can show us the breakdown of all forms of oestrogen, for example, because each version (estriol, estrone, estradiol) leave slightly different ‘waste’ behind. Yes, saliva can show you all of the different oestrogens produced, but because of the way these hormones are used by the body, the ‘free’ fraction is a less accurate picture of what was originally produced. Urinary metabolites show us ALL of the hormone you have made, not just the free fraction and so can be relied upon to accurately depict the spread of sex hormones being produced.
Remember that saliva is only showing us what’s available for use. Many things can mean that certain free hormone levels are low. Knowing something is low in saliva is not the same as knowing that the production of that hormone is low. You need to know whether it’s being produced and then used, produced and then bound (so no longer ‘free’), or produced and metabolised quickly due to some other metabolic issue.
So urine – and metabolites – win, therefore?
Ah, well – here is an issue. One of the main points of hormones is their cycling nature. They are literally the messengers which take us on the ebbs and flows of life. Whether through the course of a day or the course of a month, hormones are designed to fluctuate.
However, many things influence the moment at which we metabolise and excrete these hormones – beyond purely hormonal issues: the thyroid, liver and kidneys become part of this process. It could also theoretically be factored in that excess sweating (exercise, sauna use, summertime) means that there are higher fluid outputs elsewhere which would minimise the hormonal metabolite output in the urine. All of these factors which cannot particularly be measured will affect the level of metabolites excreted in the urine.
There is no real evidence that I have found which shows that the cycling rhythms are dependable using DUTCH testing. It’s not that they’re not, just that when you are checking for how a body metabolises a hormone (and trusting this value to show you how much of that hormone is produced) you are invoking a host of other factors which aren’t an issue when testing free hormones in saliva. In contrast, simply assessing hormone levels in spit is a very accurate way of testing these fluctuations.
Therefore, if your concern is to gain an insight into hormonal rhythms, in particular the diurnal nature of your cortisol and DHEA output, then the chances are that salivary testing is good enough for you.
Bang for Your Buck
DUTCH testing is FAR more expensive than salivary testing, even just checking adrenal hormones (cortisol and DHEA). But then, of course, you have to factor in that testing the free fraction of hormones to check diurnal rhythms is just testing one marker. In isolation, this may actually be presenting you with a false impression of your hormonal production.
Just looking at cortisol alone – this could be being produced and then metabolised quickly, or being produced and shifted over to cortisone (the storage version of the hormone). In both of these states, with a salivary test, your adrenal glands would look like they were flatlining. What’s actually happening is that output was fine, or even high – it was just matched by metabolism, usage or storage.
This is where metabolites excel over testing for the mere presence of hormones. Assessing metabolites you can gain a small window into the liver and thyroid function because the DUTCH test can show you a full breakdown not only of free cortisol, but also what level of cortisol has been metabolised. Simple maths can show you what the state of the body’s production of cortisol is, which may be very different to what is showing up as “free”…
Wow this is getting complex…
So, to summarise, it seems you get many, many more markers with the DUTCH, BUT they’re not necessarily as reliable because they’re inferring data from urine output which may be affected by other complications and not showing accurate timings etc…
So, Given All Of This, Why Did I Say I Choose the DUTCH?
Basically, the whole point of me writing this article is to state that a) all of these test are assessing different elements of the hormones in question and b) each test has its own validity and strength – providing it is used with the correct application.
Yet some time ago I pinned my allegiance to the DUTCH… Why did I do that?
Reason Number 1
I choose the DUTCH, still, because I hate doing tests with a single utility. Proving someone has dysregulated diurnal rhythms of cortisol through a saliva test is often superfluous to my requirements when their reporting of sensations and symptoms basically tells me that this is what’s going on for them.
So many people are stressed and suffering from some form of adrenal dysregulation – especially if chronic illness has been part of their lives for any length of time. Being ill is a stressor in and of itself – so checking to see if someone’s cortisol rhythms are affected is a waste of money, in my opinion. (Kelly Brogan, MD recently did a fab article about this linked here. And Dr Michael Ruscio regularly discusses this over on his site/podcast linked here.)
So saliva testing can tell me, often, something that I already know. Which is a waste of money.
However, with the DUTCH test I get more information. I can see upstream and downstream of hormonal dysregulation. I can, in the same test (I only ever really run the “Complete” DUTCH panel), see how all the hormones are fitting together and whether the body is both catabolic and androgenic, or whether there are some conversions not taking place which may require nutrients or other support etc. etc. – the list goes on as to the ‘extra’ insight I can get from DUTCH. Basically:
More markers, more metabolites, more data = more insight into the breadth and interwoven nature of the issues.
Reason Number 2
But the second reason that I choose not to worry about the potential confounding factors for urine analysis when it comes to diurnal rhythms is because the factors which affect metabolite output (so may compromise diurnal interpretation) can also be seen within the DUTCH Test itself.
From looking at metabolised vs. free fractions of cortisol I can see potential thyroid and liver issues, and therefore I know whether the diurnal rhythm may be slightly non-reflective of reality because there were other variables involved.
From looking at the breakdown into metabolites of the oestrogens I can see whether there’s slight methylation conversion issues which might affect the recommendations for treatment or further testing and also indicate that precision in the diurnal rhythm may be a little off.
And from using my clinical awareness of the breadth of the patient’s issues, I can usually make an educated assessment of whether what I see on paper relates to the reality of that patient’s situation.
Data is Only As Good As Your Doctor
All of which brings me to my two, final, most important points. No test is worth doing unless you have someone to interpret it – and someone who can interpret it in the correct context and in a way it can be applied.
Understanding how to use these results requires knowing all about what can – and cannot – be inferred from the results, and also knowing what data you want for each patient. Because no two health situations are the same, there is a real relevance to choosing the right tool for the job (I wrote about this with regards to diets in my blog on Whole30, linked here – and the same is true for testing). All of these tests for hormones – blood, saliva, urine – show you something. You just need to be really clear about what.
So if you’re choosing a test from the internet, that’s fine – but make sure that you trust whoever is telling you what it means. Because these tests aren’t really interchangeable, nor even comparable – so anyone who justifies their test as ‘best’ simply doesn’t really grasp the science.
Which brings me to my last thought to ponder…
DUTCH testing isn’t cheap. And to my mind, though it shows me so much more than saliva… it still isn’t always necessary. There are so many tests, and even interventions, which I would choose to do before I checked into hormones for many of my clients.
I know from my own massively dysregulated hormonal history that hormonal balance – i.e. minimised but appropriate cortisol release, timely melatonin release, cycling and balanced sex hormones etc. – is a very, very late stage reality for anyone with health issues. Simply put – chilling out and healthy babies is very low on the list of priorities for a body battling any crisis.
For this reason, there are many steps I often recommend to my clients before I dig into hormones from a testing perspective. Though some practitioners would disagree (and if money is no object I happily test up-front for clients), I regularly put hormonal balancing measures in place first – sometimes for months prior to testing, if I ever test at all.
Just listening to a patient and walking/talking/supporting them out of stress – through diet, upping healthy fats, changing exercise regimens, altering sleep hygiene etc. etc. – is often the best place to start before needing the nitty gritty on precise hormonal functions.
So yes, when I choose a hormone test I do choose the DUTCH first and foremost… but still…
But in reality, when it comes to hormones, I choose healthy life practices, really mindfully supporting people to tackle any issues – physical, mental and emotional… and in many, many cases all that’s left after that is to let the body look after, and hormonally balance, itself.
Need some hormonal attention or wondering what I do with my clients to balance their hormones without expensive testing? Just click here to contact me today and I’ll happily work with you to find a way for you to get to healthy, balanced hormones…