Which test for which patient?

George Gillson MD PhDRocky Mountain Analytical

Calgary, Albertagillson@rmalab.com

Disclaimer• I don’t know what that puzzle looks like when

it’s finished• I don’t think anybody does• Don’t take the word of the lab as Gospel• You must educate yourself as much as possible

to understand the nuances of each test• Don’t be a slave to lab results• Slavishly keep coming back to your patient

Gillson’s Corollary to O’Sullivan’s Rule• “If you don’t know what’s wrong with your patient before you send them to the specialist, you won’t be any farther ahead after they come back.”

– John O’Sullivan MD

• “If you don’t understand the lab test you are using, you won’t understand the patient any better after their test results come back”– George Gillson MD PhD

There’s one thing I do know…

I am constantly asked “What is the most accurate/”best” way to test X, Y, Z?”

• The unstated assumption is that somewhere out there is “the test” which reveals “the truth” in each case

• Most people probably mean: “What test should I do to most accurately capture this aspect of the clinical status of my patient and enable me to make the best treatment decisions?”

Key Points to Ponder• Was this test built with my patient in mind?

– serum estradiol was not intended for men

• Will a point sample answer my questions?– Is the number I’m after too variable to pin down with

one measurement?

• Does the result for this test have clinical correlation? (correlation between test result and a symptom or symptom constellation or disease state)

More Key Points to Ponder• If I supplement my patient with a hormone,

will this test track the dose?• If it tracks the dose, does the number mean

what I think it means?

• Is there an interpretation?• Does the lab take any pains to provide

“disclaimers” in the interpretation?

Estrone

Estrone Sulphate

Conjugate

Conjugated Hormones• Conjugated hormones are hormones that have had

extra bits (conjugates) stuck on them to increase the solubility of the overall molecule– Extra bits (incomplete list):

• Sugar e.g. glucuronide• Sulphate • Glutathione• Sulfonyl methane

• Conjugates are made in the liver and also in many other tissues (e.g. skin, kidneys, breasts, gut mucosa)– Belanger A et al. J Steroid Biochem Mol Biol

1998;65:301-310• Conjugate excretion in urine represents a significant route

of elimination for many steroid hormones

Serum Hormones• Mostly bound hormone:

– T, E2, Pg, Cortisol are all total levels (bound + non-bound)

– Can also measure free T and bioavailable (loosely–bound) T by direct and indirect methods

• Non-conjugated:– E2, T, Pg, C, DHT, E3, E1, Aldosterone

• Conjugated:– DHEAS, glucuronidated testosterone

metabolites, e.g. “diol-G”, estrone sulphate

Serum Hormones• If you’re making way too much or way too little of a

particular hormone, the serum level is probably going to reflect that

• Correlations between serum hormones and the clinical situation exist but they are by no means the rule

• Remember this!!• There is rarely a 1:1 map between any single hormone level

and any given symptom or sign• Genes integrate information before deciding to turn on or off

Examples of Serum Hormone “Benchmarks”

• Serum E2 60-90 pg/mL to prevent bone loss in postmenopause– Calcif Tissue Int 1992;51(5):340-343. Minimal levels of serum estradiol

prevent postmenopausal bone loss. Reginster et al.

• Abolishment of VM sx at serum E2 >125 pg/mL with E2 patch– Steingold KA et al. J Clin Endocrinol Metab 1985;61:627-632. Treatment of

hot flashes with transdermal estradiol administration.

• Erectile dysfunction, decreased sexual thoughts and decreased morning erections are associated with serum total T in the range 8-10 nmoL– Ann Endocrinol (Paris) 2014;75(2):128-131. Andropause-lessons from the

European Male Ageing Study. Huhtaniemi IT.

• But most of the time, we are never really sure what is going on down there (at the DNA level)

Intracrinology• Serum E2 levels inversely associated with gene expression

patterns in cancerous breast tissue– BMC Cancer 2011;11:332. Serum estradiol levels associated with

specific gene expression patterns in normal breast tissue and in breast carcinomas. Haakensen VD et al

– Gene expression in breast tumours looks like that of healthy women with low serum estradiol, even in the face of high serum estradiol

• “Following the arrest of estradiol secretion by the ovaries at menopause, all estrogens and all androgens in postmenopausal women are made locally in peripheral target tissues according to the physiological mechanisms of intracrinology. The locally made sex steroids exert their action and are inactivated intracellularly without biologically significant release of the active sex steroids in the circulation.”

• J Steroid Biochem Mol Biol. 2014 Jun 9. pii: S0960-0760(14)00115-0. doi: 10.1016/j.jsbmb.2014.06.001. [Epub ahead of print] All sex steroids are made intracellularly in peripheral tissues by the mechanisms of intracrinology after menopause. Labrie F.

Serum Hormones• Serum testing is inexpensive, and has been around for

decades…but so have some of the reference ranges…

• No interpretation is provided• Harder to control collection time in serum due to need to

book appt at drawing station e.g. first hour after waking levels

• You cannot get certain analytes e.g. unbound (free) E2 or unbound (free) Cortisol in serum

• Serum testosterone ranges may be outdated and serum assays have not been upgraded for testing both genders

• You cannot safely track dosing of hormone CREAMS with serum

Serum Hormone Levels after Topical Hormone Cream

• You can drive serum levels up to the physiologic range with topical hormone creams if you work at it

• It takes supraphysiologic doses of hormone to do it• Examples:

– 50 to 200 mg/d of testosterone in cream base to elevate serum total testosterone to high normal male range (normal testosterone output in a male is 5-15 mg/day)

– Progesterone dose hundreds of mg/day (cream) and E2 dose 5-15 mg/day (E2 as BiEst cream) to produce physiologic serum hormone levels (e.g. Wiley Protocol) (normal Pg output is 25 mg/day, and E2 output is less than 1 mg/day)

Serum Hormones• Serum is a poor choice for profiling and averaging• Is there a typical “serum testing candidate”?

– I think it mostly revolves around the patient’s ability to pay for testing

– In my mind, serum has few other advantages– It is the least attractive option and use of serum leads to

serious errors when tracking cream and oral supplementation

– Hormones applied to the skin as cream break the usual “traffic rules”

– Serum assays often can’t tell metabolites from parent hormones

One functional unit of a saliva gland

A major salivary gland may contain hundreds of ducts in an encapsulated structure

Minor salivary glands are not encapsulated

Hormone molecules are too big to enter the endplate through “Cracks in the walls”

Hormones partition from the acinar cell membranes into saliva

The salivary level is a tissue level and is probably a “fat biopsy” under some circumstances…

Opportunity for local storage in fat

Saliva and Serum• Salivary hormone levels numerically reflect the free hormone

component in serum, when the person makes their own hormone• e.g. in serum, 10% of the cortisol is free, the rest is bound to

albumin and cortisol binding globulin• Free AM cortisol in serum =A.M. serum total cortisol 100 ng/ml

x 0.1 = 10 ng/ml • A.M. salivary cortisol 2-15 ng/ml

Total serum cortisol and salivary cortisol are generally well-correlated

Yonsei Med J 2007;48:3793-88. Salivary Cortisol and DHEA Levels in the Korean Population: Age-Related Differences, Diurnal Rhythm, and Correlations with Serum Levels. Ahn RS, Lee YJ, Choi Jy et al.

In postmenopause, severity of low E2 complaints starts to kick up when E2 < 1.5 -1.8 pg/ml

*Hot flashes, night sweats, brain fog, memory problems, depression

*

Clinical correlation of Salivary Endogenous E2 levels

Salivary T after application of Androgel to various body parts

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Time after application (minutes)

Tes

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25 mg Androgel to L foot 25 mg Androgel to supraclavicular area

25 mg Androgel to L forearm 25 mg Androgel to R Buttock

25 mg Androgel to Abdomen

The closer the application site is to the head, the higher the “wave”

0 10 20 30 40 50 60 70 80100

1000

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Peak Salivary T vs Distance from Application Site

Approximate distance from application site to saliva gland (inches)

Pea

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Abdomen and Buttock

Forearm

Supraclavicular

Foot

This implies that some component of what is seen in saliva gets there literally by travelling over the body surface, in some situations

What winds up here reflects applied dose/body burden, but does not reflect clinical picture

Saliva numbers may be a surrogate fat biopsy in some cases!

Saliva Hormone Testing• Painless and convenient• Easy to generate profiles and time-averaged

values• Parallels non conjugated, non protein-bound

hormone in blood for endogenous hormones• Good interpretation from some laboratories• Fewer analytes measured wrt urine or serum• Relatively young assay compared to serum

and saliva; more method-dependent variation between labs compared to serum

Saliva for Hormone Profiling• If you need to take multiple “sightings”,

saliva is the best option as it is painless, simple and can be done at home– e.g.erratic bleeding, one period every three months. What

is happening the rest of the time?– e.g. bleeding that won’t stop (perimenopause, teens)– e.g. demonstrate effect of contraceptives (to show a 23

year old patient they have the hormone levels of a 75 year old)

– e.g. symptoms that vary throughout the month such as breast tenderness or migraines

You will get these same curves whether you measure in blood, urine or saliva

Much easier to do in saliva though!

Textbook monophasic cycle. 24 yrs old with regular menses.

Next menses started here

This was her 2nd or 3rd day of light spotting

35 y.o.Can’t conceive x 3 yrsRegular mensesFeels cold all the time

35 y.o.Can’t conceiveRegular mensesFeels cold all the time

Saliva “Ice Cores”

• Saliva is a great way to get average levels across time, when it makes sense to do so

• e.g. noncycling or erratically cycling women, postmenopausal women, males, average bedtime cortisol

• Spit an equal amount into one collection tube on multiple occasions, keeping the tube in the freezer in between times

• You can easily get 5 or 10 “layers” of saliva in a 10 mL tube

Do try this at home• Make sure you spit the same amount each

time. Mark the tube at equal intervals• Make sure you sample at the same time

relative to waking each time• Keep in freezer between samples• I don’t recommend this approach often

enough!• It will definitely improve the quality of the

test result and there is no easy way to do this in urine or serum

What’s wrong with a Day 21 single tube saliva test?

• Nothing… if someone is cycling regularly• If the hx is consistent with estrogen dominance

month over month, a low Pg Day 19-21 confirms• Saliva E and T ranges are tailored for women• The value of the interpretation that accompanies a

saliva test is significant, especially for relative newcomers to the field

• There is zero added value for serum testing

What about saliva testing for males?• The main value I see is that you get a much better

“sighting” of estradiol in saliva and it relates well to the clinical picture (in my experience)

• Serum tests only report total estradiol, which is subject to the SHBG level (just like total serum testosterone)

• As is the case for serum testosterone in women, many labs haven’t retooled their serum estradiol assay to work for men

YoungerOlder

XX

X

X

Serum Cortisol “Day Curve”

Salivary Cortisol Day Curve

X

X

XX

Psychosom Med 2003;65:836-841. Peeters F, Nicholson NA, Berkhof J.

• Can answer questions like:• “Why can’t my patient fall asleep?”

high bedtime cortisol• “Is my patient’s cortisol generally high

(or low) all day?”• “Why does my patient “crash” by

lunchtime?

steep drop in cortisol from waking to lunch

Is Salivary Cortisol the “Gold Standard” for Cortisol Measurement?

• There is no gold standard but saliva is the method of choice for many researchers.

• Questions remain…– Obese patients have normal or low salivary cortisol (and

normal serum cortisol) but can excrete elevated levels of cortisol and cortisol metabolites in urine

– Males in particular may sometimes have a disconnect between salivary cortisols and clinical status (low salivary cortisols and patient feels fine)

Is Salivary Cortisol the “Gold Standard” for Cortisol Measurement?

• If your clinical impression doesn’t match the saliva cortisol results, then seek corroboration from urine or hair

• “Mismatches” are not an indictment of saliva testing or any other kind of testing

• The tests measure what they measure• We simply don’t understand the bigger picture• Always look back to your patient!

Saliva Summary• Saliva is the best “workhorse” option for baseline

testing for males and females (endogenous hormones)

• Ranges and sensitivity tailored for male and female sex steroids

• You can learn a lot from the interpretation• Easiest way to profile and get averaged data• Easiest way to generate day curves• If you want to look at conjugates, they are not

available in saliva (exception DHEAS)• If you want a more detailed look at mass balance,

saliva is not for you

Yes Virginia, You can measure Cortisol in Hair

• First citation I have dates to 2005• Flurry of citations since then… • Each follicle is like a mini adrenal gland, making its

own cortisol• But in synchrony with the suprarenal glands…• Hair cortisol has been correlated to saliva and serum

• Use to corroborate with other cortisol tests when the other results don’t match the clinical picture

• Use with shiftworkers and people routinely crossing time zones

24 Hour Urine Steroids• Most of the steroid hormones in urine are

conjugated, because urine is mostly water and won’t dissolve unmodified steroids (cortisol excepted)

• Captures hormone output during one complete diurnal cycle

• e.g. 7 AM 7AM + 24 hrs• Is thought to reflect total production of a given

hormone, if the parent hormone and all the major metabolites are tracked

• Serum and saliva can’t do this

24 Hour Urine Steroids• Somewhat cumbersome…• People forget to collect some of their output,

especially at night falsely low levels• People feel the urge to drink 5 litres of water per

day, even if they don’t live in the Sahara excessively dilute sample

• This is still a point sample since it is only one day• Info about diurnal variation is lost• All labs doing this give an interpretation

What are we measuring in urine?

-The kidneys are encapsulated. -Unlike saliva, they can only receive chemical information via blood-If it doesn’t show in the blood, it won’t show in the urine

The problem we have in serum with hormone creams also plagues urine steroid testing

Hydrolysis entails a loss of information

Urine Hormone Testing Measures Conjugates

Conjugated hormone

Unconjugated hormone

Urine Steroids• Just remember that labs report the hormones

using their PARENT names• For the most part, those molecules entered

the kidneys as conjugated derivatives

• So urine “estradiol” is not the same entity as salivary estradiol or serum estradiol and can only be compared qualitatively

Hormone bound to SHBG or other carrier protein

Hormone “gospel”: conjugated hormone is what the body is tossing out

Why would the body go to the trouble of making excess hormone just to toss it out?

Bioavailability of Conjugated Steroids• Numerous citations indicate that steroid conjugates

(sulphates and glucuronides) can be taken up into cells by various transport proteins– MRPs (multidrug resistance proteins)– OATs (organic anion transporters)

• It would make sense that potent hormones circulate in an inactive form, and are activated in situ as needed– Estrone sulphate in breast tissue converted to E2– T4 glucuronide in renal tissue– DHEAS as per Labrie (intracrinology)

“Family Tree”

“Grandma”

Chief Advantage of Urine Testing

Estrogens

17-ketosteroids

Mineralocorticoids

17-hydroxysteroids

Progestogens

A

B C

I J

D

K

EF

H

G

Sometimes we want to know: A + B + C + D + E + F + G + H + I + J + K

Sometimes we need to look at things like: J/G and (F + E)/G

Mass Balance/Distribution

Estrone Sulphate (E1S)

Estradiol

Estrone

Hydroxyestrones-OH

Methoxyestrones-OCH3Methoxyestradiols-OCH3

Hydroxyestradiols-OHR-CH3 R-CH3

R-H R-HCOMT COMT

A strongpoint for urine testing is the ability to look at estrogens in detail

Extent of formation of these endproducts may reflect methyl donor sufficiency

Estradiol

Estrone

Estrone Sulphate (E1S)

16 hydroxyestrone

Estriol

2 hydroxyestrone4 hydroxyestrone CYP1A2 CYP1A1

CYP1B1CYP3A5

CYP3A7CYP3A4CYP1A1

There is some very shaky literature suggesting that 16OHE1 promotes breast cancer

Older literature suggested that a low ratio: 2OHE/16OHE increased future risk of breast cancerNot supported by meta-analysis

It’s probably a good idea to have lots of this, no matter what

Estradiol

Estrone

Estrone Sulphate (E1S)

16 hydroxyestrone

Estriol

2 hydroxyestrone4 hydroxyestrone

CYP1B1CYP3A5

Accumulates in breast tumour cells

Irreversibly damages DNA

Damages oncogenes

? Several authors suggest looking at the ratio 4OHE1/2OHE1

Estrogen Quotient (EQ)

• EQ = E3/(E1 + E2)• Studies by Henry Lemon in the 70’s indicated that

in populations with a low incidence of breast cancer, urinary EQ > 1

• Caucasians normally have a urinary EQ <1 and are at increased risk for breast cancer relative to other races (e.g. Japanese eating traditional diet)

• Lemon postulated:– if the urinary excretion of estriol (E3) can be increased

relative to the other estrogens, this will decrease the risk of breast cancer (make EQ >1)

EQ Calculated from Saliva Results• You can measure E1, E2 and E3 in saliva and

calculate an EQ• Remember that you are building that EQ using

different molecules compared to urine• Urine conjugates• Salivanon-conjugates• Does it matter? • Yes. You get the opposite results in saliva• There is no published data on the salivary EQ

Urine HormoneTesting• You might want to make this a first-line,

baseline test for a patient with a family history of breast cancer, or a history of longstanding breast tenderness (to get the estrogen data)

• You might want to do this as a baseline test on an overweight male (to get the estrogen data)

• Do this test to explore cortisol metabolism in more detail

End-stage adrenal fatigue

Salivary Cortisol

• But…when salivary cortisol is at odds with the clinical picture, you need to do some other confirmatory testing

This patient feels fine

Saliva Cortisol

-You would not attempt to treat this person with adrenal support or cortisol, based on these results!-But you wouldn’t have done it based on saliva either, as you are treating the patient, not the lab results!

Urine Cortisol Metabolites

Endogenous Hormone Production• To a first approximation, when people are

making their own hormones, any of the popular testing modalities (serum, blood spot, saliva, urine) are able to identify significant hormone shifts (low or high)

• e.g. Day vs night, prepuberty/postpuberty, hormone secreting tumours, pituitary failure-doesn’t matter what testing modality you use, you will

pick up obvious deviations and imbalances

Endogenous hormones and baseline testing

• Use serum only if cost is an issue• Saliva for 80% of patients/Urine if more

detail needed• Saliva when profiles or averages needed or

preferred• Urine if want to take apart estrogen or

testosterone metabolites• Use a test that gives an interpretation if you

are new to the field

Testing After Supplementation• Each testing modality has significant “quirks”

depending on the hormone and the type of delivery

• The tests always measure what they measure; it is the context that has changed

• It is difficult/impossible to replicate youthful levels of hormones in most cases

• The numbers you do get are not clinically validated numbers, in the absence of other evidence

Why don’t the tests always tell the “truth”?

• When we test after supplementation, we run into what we think are “nonphysiologic” hormone levels.

• It’s the delivery that is nonphysiologic

• Your GI tract is not a gonad or an adrenal• Your skin is not a gonad or an adrenal• Your oral mucosa is not a gonad or an adrenal• Your vagina is not a gonad or an adrenal

• The tests always measure what they are capable of measuring; the plumbing isn’t the same; the rates of conjugation aren’t the same; the binding of the hormone may not stay the same

GLAND Hormone receptors??????????

NON-GLAND

e.g. mucosa

Hormone

????

?

GLAND Hormone receptors??????????

Uptake, Binding, Metabolism

New set of

questions

addedUptake, Binding, Metabolism

Other inputs

Other inputs

63 year old woman: BiEst cr 2 mg bid; Pg cr 160 mg bid

Her supplemented hormone levels have moved into the Luteal range, but it took massive doses to do it

Testing after Hormone Cream

• Serum = urine: a lot of “inertia”• It takes supraphysiologic doses to “move the needle” for

these test types with cream: Risk of overdose• Results don’t appear to be dose-dependent and don’t reflect

the clinical picture

• Saliva has much less “inertia”• Physiologic doses give supraphysiologic numbers: Risk of

underdose if try to replicate physiologic levels• The numbers display dose-dependency• The numbers track body burden but not clinical effect• Saliva has “memory” effects

The finding of a low/high level of a hormone despite an average dose of hormone might point to:

Poor absorption/excessive absorption

Non-compliance/over-compliance

Problem with composition of topical (actual dose lower/higher than labelled)

Avg Pg Result vs Evening Pg Cream Dosebid dosing only

y = 91.501x + 1.0154R2 = 0.7958

02000400060008000

100001200014000

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l)

ExcessFacialBodyHair

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Breast Tenderness

Endogenous Range

Symptom severity is not proportional to “On-cream” salivary E2 level( a score of 3 indicates severe breast tenderness)

Salivary E2 after cream supplementation (pg/ml)

Facial Hair Growth

Endogenous Range

Symptom severity is not proportional to “On-cream” salivary Testosterone level( a score of 3 indicates severe facial hair growth)

Salivary T after cream supplementation (pg/ml)

Patient uses progesterone cream 37.5 mg bid, 12 days/monthSupplemented Pg is stored and released at appropriate time

Last Pg use

Testing after Oral Supplementation• Lots of conjugated metabolites forming within 2

hours of ingestion in GI tract as well as liver• Results are dose-dependent• Urine results can go sky-high• If you adjust the oral doses low enough, you can

achieve physiologic levels in urine• This may be at the expense of clinical effect!

• Saliva won’t see these conjugates and parent hormone may have returned to baseline overnight, if take hormone at bedtime and spit next morning

Dose-Dependency of Urine E2 after Oral E2

Hormone replacement with estradiol: conventional oral doses result in excessive exposure to estrone. Friel PN, Hinchcliffe C, Wright JV. Altern Med Rev 2005;10:36-41.

If you dose down here, you might get clinical benefits with “younger” level of E2 metabolites

Testing after Oral Supplementation: Saliva

• Metabolites form almost immediately, and peak within 2 hours of ingestion– Saliva progesterone is down to postmeno baseline at

7AM following ingestion at 11PM the night before– You can drive the 8 hour post-ingestion result to the

luteal range but it takes 200-300 mg– Side effects will occur, due to metabolites– Salivary estrogens are less predictable and may

sometimes stay 2-3x physiologic next morning– This may indicate difficulty clearing estrogens

Testing after SL/Troche Supplementation

• Stimulates salivation• Possibility for rapid conjugation if this

‘juice’ is swallowed-will then look like an oral dose if testing urine: sky-high numbers

• Depending on how rapid the absorption into the mucosa, can look like IV-with rapid elevation of blood levels

• Saliva will be heavily contaminated!!

2/19/2011 Copyright Rocky Mountain Analytical 74

Don’t do saliva testing after sublingual hormone use !!

Testing after Vaginal/Labial Delivery

• Parent hormone may directly contaminate urine

• Parent hormone will be “counted” in the assay

• Hit and miss: may get meaningless, high results

• Some labs separate the conjugates from the non-conjugates

Testing after Vaginal/Labial Supplementation

• Saliva levels do not elevate the same way they do with hormone cream applied to squamous epithelium

Testing after Skin Gels• Much better penetration to blood (wrt

creams) for alcoholic gel products: testosterone, estradiol and progesterone, DHEA

• Better chance for metabs to show up in urine at physiologic doses

• Progesterone gel would have to be compounded

• Skin gels act like skin creams when tested via saliva-supraphysiologic numbers

Pellets/Patches• Generally slow release into systemic

circulation with daily fluctuations depending on activity, exercise

• See fluctuating high levels in saliva possibly indicating some fat depot effect

• More natural pattern of conjugate formation• Opportunity for local conversion to other

hormones?

Testing After Supplementation

• Regardless of what test type you choose, avoid “blanket testing” of every patient on hormones, without regard to what hormones you are giving and how they are being given,

• There is no role for this type of testing IMHO• You cannot simply reset the gauges in every

situation when you supplement hormones

Test, supplement, retest, adjust “sliders” (i.e. dose) based on test results?Normalize results to youthful levels??

This approach only works in specific cases

Testing After Supplementation• Always think about where you might be starting in the

steroidogenesis cascade• The higher up the cascade, the greater the opportunity to

make other stuff besides the hormone you are giving– Pregnenolone vs DHEA vs Testosterone

• If someone is taking estradiol, progesterone, testosterone, DHEA and pregnenolone, you probably won’t be able to make sense of what is going where, especially with multiple routes of administration

• I see this all the time, unfortunately.

Testing After Supplementation• You have to have very specific questions in mind

that you want answered:– e.g. Is this patient making too much estrogen from the

testosterone I am giving him/her?– e.g. Is this patient accumulating too much of the

hormone I am giving her?

• If in doubt, call the lab before testing.• Anyone who is selling one testing modality for all

supplementation scenarios has not given this topic enough deep thought, or doesn’t care

2/19/2011 83

Rememberto treat thePatient first!

Don’t let the lab test do your thinking!

Just be thankful you’re not my Dentist

CONCLUSIONS