“I am experiencing many signs of perimenopause. I can’t sleep. I’m tired all the time. I’m anxious about everything and — OMG — the flooding periods. I went to my doctor and asked to have my hormones tested. He refused and told me that it wouldn’t be useful because I was too young (42) and hormone levels change constantly. He did do an FSH, and it was in the ‘normal’ range. I was offered birth control pills and an antidepressant, but I don’t want that! I know there’s something hormonal going on and I want to get to the bottom of it. Help!”
Hormone balance is essential to good health for women of all ages. Unfortunately, for women in early midlife, the scenario above is all too common. Hormone testing is dismissed out of hand as being useless. This reaction tends to come from providers who have no idea what to do with the information they might get from testing and are uncomfortable prescribing hormones at all. This leaves many women suffering needlessly.
Even though there are no perfect testing methods, my preference is a test-don’t-guess approach. Having data allows a doctor to create a plan that is customized to a woman’s specific needs and work with a woman to get bioidentical hormones on board, if that’s what she wants to do. The test-don’t-guess approach is far superior to guess-and-treat.
Unfortunately, the latter is still far too common in clinical practice. Most physicians would never prescribe a blood pressure drug or cholesterol-lowering medication without monitoring the patient appropriately. Many are, however, very willing to prescribe potent hormones without clearly understanding how the woman’s body is using them. This can result in preventable adverse effects and poor clinical outcomes — not to mention unhappy patients.
There is a lot of confusion about testing, so let’s look at some of the myths and truths.
1. Hormone testing is useless because levels fluctuate.
False. It is true that hormone testing is a snapshot in time (as are all lab tests) and that levels fluctuate, but if testing is done at the correct time in your cycle, it is useful to look at the magnitude of the imbalances that may be present and the metabolic pathways your body prefers. Yes, your estrogen may fluctuate, but if it’s way out of balance with progesterone, that imbalance is unlikely to correct itself at certain times of the day or month.
2. Blood tests are the best way to measure hormones.
False. Most doctors will order a blood test to measure hormones, but some important information can be overlooked when a blood test is used alone. There are other kinds of testing — some best for assessing specific hormone replacement therapies.
3. FSH is the best way to tell if you’re in menopause.
False. FSH is a blood test that’s commonly used to assess the hormonal status of perimenopausal women who complain of hot flashes, mood changes, or other symptoms. But here’s the problem: It gives only an indication of how hard your body is working to produce an egg. The higher the number, the closer you are to menopause. It says nothing about sex hormone production or the relative imbalances, and it can fluctuate widely during the decade before menopause.
What’s the Right Test for You?
That depends on whether you’re already on some kind of hormone replacement therapy. Matching the type of testing with the type of hormone supplementation is important because measuring with the wrong method can lead to inappropriate dosing.
– Baseline (no hormone replacement therapy)
Any testing method can be used to assess baseline levels of hormones. My favorite is DUTCH because it is easy to administer and it shows hormone metabolites. This allows a doctor to see the how your body is using hormones and whether you are eliminating them appropriately.
– Topical progesterone
Progesterone creams can be reliably assessed using only blood spot testing. This is done with a finger stick. With DUTCH or serum testing, values how only a slight increase (if any). With saliva testing, values can show very high, leading prescribers to reduce doses inappropriately. Levels can stay elevated for months after topical therapy is discontinued.
– Oral progesterone
DUTCH provides useful feedback when using oral progesterone to help with sleep. One metabolite is associated with better outcomes relative to sleep, and this is the only test that provides that information. With serum and saliva, results go up and down quickly. If oral progesterone is taken at bedtime, levels return to baseline within a few hours. Results can also be inaccurate with tests other than DUTCH due to progesterone metabolites cross-reacting with immunoassay tests.
– Sublingual hormones (troches, lozenges)
No testing methods are accurate for monitoring dosing, however, DUTCH will still provide metabolite patterns.
– Topical estrogen (gels, creams, sprays)
DUTCH is preferred over serum due to the inclusion of metabolites. If using saliva, values are variable and may not correlate with symptoms. For DUTCH, target values between the top of the postmenopausal range and the lower third of the premenopausal range correlate with improved bone density, hot flash relief, etc.
– Oral estrogen
Serum and saliva can be used to monitor oral estrogen therapy. However, DUTCH is not useful because much of the dose is stripped out in the liver, leading to lower urine excretion. DUTCH can still be used to assess metabolite patterns.
– Patches, pellets, injections
Any method (serum, blood spot, saliva, DUTCH) can be used for follow-up. Saliva may be less accurate than serum. Only DUTCH gives metabolic patterns in addition to hormone levels.
Dr. Anna Garrett is a leader in the testing and treatment of hormonal imbalances and the author of Perimenopause: The Savvy Sister’s Guide to Hormone Harmony. You can work with her no matter where you live. If you are located near a Quest blood draw center, you can get serum lab tests on your own or contact her for guidance. Learn more about Dr. Garrett at drannagarrett.com and order her book at perimenopausebook.com.