Hormone Testing



Why you should take the results with a grain (or maybe a pound) of salt.

Many diagnostic tests are wonderfully useful tools of modern medicine. With a high degree of accuracy, MRIs, x-rays, and various laboratory tests can discern the presence of tumors, pinpoint the location and severity of fractures, confirm pregnancy, diagnose a wide variety of ailments from infertility to cancer, identify specific viruses and bacterial infections, measure degrees of renal function impairment, track brain waves, etc etc.

However quantifying blood hormone levels is NOT a reliable means of determining hormone deficiency and/or the need for Hormone Replacement Therapy.
First, there is no "normal" range that can be applied across the board. Everyone's "normal" hormone level is different and unique to her/him. (more)
Second, the action and interaction of hormones is far too complex for any meaningful interpretation by a blood level test. Hormones and neurotransmitter levels are in a constant state of flux, changing more rapidly than the international currency rates, making quantification an impossibility.



**********************************
BLOOD TESTS in PRACTICE

Psychiatrists do not ever attempt to measure serotonin levels when prescribing anti-depressant medication to a clinically depressed patient, despite the fact that the disorder results from insufficient levels of neurotransmitters, the body's inability to utilize them, or impaired synapse function. The psychiatric community is aware that trying to quantify these brain chemicals and monitor their actions is an exercise in futility. The correct prescribing protocol is for an (often prolonged) trial of different medications at differing dosages until the correct treatment is found, as evidenced by the patient's mood.

It is noteworthy that gynecologists rarely insist or even suggest a blood test to determine if a menopausal woman's estrogen or progesterone levels have fallen off. You know they have. Gynecologists almost universally prescribe estrogen and progesterone replacement therapy based on this biological fact alone.

AND YET these same gynecologists insist on a blood test to measure testosterone levels before (and IF) they will consider prescribing testosterone replacement for women, despite the well known fact that post menopausal women's testosterone levels drop in similar dramatic fashion to estrogen when her ovaries shut down.
**(see footnotes; bottom of page)

WHY THIS DISCREPANCY?

The reason is that testosterone is a controlled substance. Physicians are required to carefully document and justify every prescription they write for testosterone in any form to avoid scrutiny from the formidable DEA (Drug Enforcement Administration).



Yes, even that tiny 1% testosterone in Androgel prescribed to your andropausal hubby counts as a steroid and thus no endocrinologist will write him a prescription without a blood hormone test that plainly shows low levels of testosterone. Your gynecologist is in a worse pickle since no female testosterone product is currently approved by the FDA. Meeting the conditions for prescribing off-label unapproved medication on the DEA's "hit list" is onerous. So it is understandable that any doctor should want evidence in black and white on paper that the testosterone he/she prescribed is a medical necessity.

Professional Protocols.
In addition, ruling bodies within each arena of specialized medicine publish recommendations for their practitioners in the field, and the guidelines handed down to endocrinologists and gynecologists usually recommend the use of blood level hormone tests, despite their shortcomings.

Patients often request hormone testing.
"I want to believe." There is an aspect of human nature that seeks concrete fact and is uncomfortable with uncertainty. Doctors want solid guidelines and patients themselves want simple diagnostic tests that will provide definitive answers and clarity. The attraction of a tangible diagnosis on paper is powerful, even when the information on it is flawed.




Expert Opinion on
REASONS NOT TO TRUST HORMONE TESTS


Circulating Androgen Levels and Self-reported Sexual Function in Women

Susan R. Davis, MD, PhD; Sonia L. Davison, MD; Susan Donath, MA; Robin J. Bell, MD, PhD
JAMA. 2005;294:91-96. Access via PURCHASE ACCESS
Vol. 294 No. 1, July 6, 2005 http://jama.ama-assn.org/cgi/content/full/294/1/91

Traditionally, circulating hormone levels have been used as the main indicators of tissue exposure. However, intracrinology plays a pivotal role in androgen metabolism, such that the active androgens exert their effects in the same cells in which they are synthesized, without release into the pericellular compartment. DHEA and DHEAS are converted in extragonadal target tissues, such as the brain, bone, and adipose, either to androstenedione or testosterone that may then be aromatized to estrone or estradiol or converted by 5-reductase to dihydrotestosterone in the same cells. Thus androgenic effects vary according to individual variations in the amount and activity of the enzymes 5-reductase and aromatase, and individual differences in the androgen-receptor response.
With substantial androgen production and metabolism being intracrine, measurement of serum testosterone does not provide a specific measure of androgen tissue exposure or action.

In addition to demonstrating that the measurement of testosterone is not useful for the diagnosis of the proposed female androgen insufficiency syndrome, our findings also do not support a diagnostically useful role for the measurement of DHEAS.
This is because despite the increased likelihood that women with low sexual function have a low DHEAS level, the majority of women with a low DHEAS level did not report low sexual function.

"Our results are not in conflict with testosterone being used pharmacologically to treat hypoactive sexual desire disorder (low testosterone)....
Rather, our data, taken together with what is already known about the intracrine physiology, suggest that sex steroids influence female sexual function, but that there is no serum androgen level that defines female androgen insufficiency ....and levels of these hormones should not be used for the purpose of diagnosing androgen insufficiency in women."
**********************************
Excerpt from: Official Recommendations of ISSAM
(The International Society for the Study of the Aging Male)
http://www.issam.ch/

The accepted value for testosterone in andropause is defined to be 2 standard deviations below normal values for young men (317 ng/dL total testosterone, 7.34 ng/dL freetestosterone,15and 86–231 ng/dL for bioavailable testosterone). The normal ranges and methods vary widely, and physicians are urged to consult with their local laboratories for the applicable values in their clinical practice environment.
The actual value in an individual does not tell the whole story, for the following reasons: the history of what has been a normal continued testosterone level for a given patient in previous years is almost always unknown; the sensitivity of different target organs (brain, muscle, bone, etc) varies; there are other, unmeasured hormones contributing to the condition (testosterone is a major factor but not the only one); and there may be unrecognized molecules (endocrine disruptors) blocking the normal action of testosterone.


Factors Influencing Variability in Presentation of Andropause & Attendant Testosterone Values:

Normal ranges vary widely
History of individual normal testosterone is unknown
Sensitivity of target organs (brain, muscle, bone, etc) varies
Other unmeasured hormones contribute
Potential, unrecognized endocrine disruptors

This variability in symptoms presents difficulties in giving a simple clinical picture.

**********************************
Excerpted from The Testosterone Syndrome
by Eugene Shippen, MD and William Fryer 1998

...in all honesty, the significance of your hormone levels is difficult to assess. Here are the reasons why:

There are wide normal ranges.

It is not easy to predict the accuracy of a single measurement since hormones are subject to daily cycles (the circadian rhythm), monthly cycles, seasonal variations, and short-term ups and downs in blood level resulting from pulsatile release.

Hormone levels can be drastically affected by medications.

Nutrition, stress, and illness will all affect hormonal output.

Aging will decrease hormonal output, as we've noted, but though the level of decline in a large body of people is quite predictable, the rate at which testosterone, human growth hormone, or DHEA will decline in a given individual is deeply unpredictable.




My Personal Experiences With Hormone Tests

By now you must have figured out that I do not regard hormone tests with any degree of credence. Actually my contempt for these tests runs deeper.


My experience with the shortcomings of this diagnostic tool began a decade ago with my dog. A beautiful happy collie at age 5, his health began to deteriorate. He became lethargic, developed chronic skin lesions, brittle falling hair, and weight loss. The veterinarians diagnosed his problems



as food and plant allergies and put him on a series of prescription diets, treating his symptoms with prednisone and anti-histamines. By age 6 the poor creature resembled a concentration camp victim.

A dog breeder advised me to have his thyroid tested and I followed her advice. The prevalence of hypothyroidism in certain breeds of dogs was just becoming known at this point in history. My veterinarian was enthused about exploring this avenue and my hopes rose, then sank when the thyroid panel test (same test used in human medicine) came back in the normal range. It seemed another dead end.

However my astute vet said "no wait, these tests can be VERY ambiguous. Let's try him on thyroid hormone replacement first." I will always be grateful for his words of wisdom.

On thyroxine my thin sickly pet recovered permanently from his skin problems, grew a new shiney coat, gained weight, energy, and recovered his sunny disposition and enthusiasm for life.

I shudder to think what would have been the outcome if my vet had not dismissed the test results and prescribed the trial of hormone replacement. I have also read that a quite large percentage of people, esp women, go undiagnosed or are wrongly diagnosed, and continue to suffer from hypothyroidism.

This was written on a forum by a final year veterinary student (now a practicing veterinarian):
Thyroid question
Our dermatology professor calls this "the blonde frizzies" :-) A couple of her dogs tested in the normal range for thyroid BUT she put them on thyroid supplementation and their skins and coats improved (they had some hair loss and skin problems). . .
RESPONSE TO TREATMENT *IS* a way to diagnose hypothyroidism if the blood tests are not conclusive. I know someone else . . . Her dogs have a problem but since their *bloodwork* is normal, she says it must be OK ... that's probably another reason that vets are a bit reluctant to go through the testing . . . the results can be extremely variable and influenced by so many other factors that the test might not give you anything you can "hang your hat on."
**********************************

Still naive and still somewhat of a believer, my next encounter with hormone tests was at the gynecologist's office.


My own health had been steadily declining over the course of 10 years, despite the prescribed estrogen/progesterone pills that were supposed to reverse the ills of menopause. However I was finally beginning to put together the puzzle pieces.



I learned from the book No More Hot Flashes...And Even More Good News by Dr Penny Wise Budoff that the the bioavailable amount of oral hormones is very low and that estrogen tablets could be inserted vaginally for a far better result. Making this change to my HRT regimen vanquished the hot flashes and vaginal atrophy/dryness. A big improvement. (It also caused a return of periodic mentrual bleeding.) But still the "brain fog" and crashed libido persisted.

Then I learned from a television documentary produced by CBC (Canadian Broadcasting Corp) that low dose testosterone replacement therapy will restore libido and cognitive abilities in menopausal women. It was time for my annual checkup in any event so I called for an appointment and inquired over the phone as to their prescribing policy for female testosterone replacement therapy. The reply was that yes, they did occasionally prescribe compounded testosterone cream if blood tests indicated a deficiency of this hormone.

At the initial visit they drew blood and pronounced that the return of my period was likely due (as I had surmised) to excess estrogen. As a precaution an ultrasound was ordered, but it revealed no uterine abnormalities. The doctor recommended that I cut the tablets in half or quarters for vaginal use. And he also handed me some sample estrogen patches to try.

Within the week the blood test results were in. In direct opposition to what I and the doctor knew to be true, the document claimed that my levels of estrogens were LOW, but my testosterone levels were sufficient. Perhaps they should have measured my ring and index fingers before pronouncing my testosterone levels to be in the "normal" range. Normal for whom, that is the question. (Based on these false numbers, they handed me more estrogen patches but declined to prescribe testosterone.)

Another blood test was ordered. And another and another, every other week. Finally a random test supplied the desired result of showing testosterone levels in the low range and on the basis of this test I was given a jar of compounded testosterone gel that gave me back my life. It restored my sex drive and cognitive functions, as well as curing a host of symptoms I had never connected with a lack of this male hormone, ie backaches, migraines, etc.

This episode cost me 4-6 months of prolonged suffering and delayed my treatment for months.




**Footnotes:
The adrenal gland may continue to produce a minute amount of androgenic hormones, but this is predictably a drop in the bucket. Some of the adrenal androgens may convert into estrogen as well, but no doctor is going to claim that this source of estrogen is sufficient to stem the ills of menopause. When the hormone factory shuts down, it shuts down, and all the bodily deteriorations of old age will follow if these hormones are not replaced. In addition, if estrogen is supplemented, it is a known medical fact that adrenal testosterone production slows down.

Here lies another quandry: on laboratory reports, the scale of "normal" female hormone blood levels is broken down into categories according to age and cycle. The last of these categories is "post-menopausal". In other words (attributing a hypothetical measure of accuracy to these tests for the sake of argument) at age 55, your testosterone level is likely to fall within the "normal" range for a post-menopausal woman. This is the hormone level of a dying woman, but it is considered "normal". This fact adds to a physician's difficulties in justifying testosterone replacement therapy to the DEA.



You may be required to undergo hormone testing in order to obtain testosterone or other hormone replacement. treatment. My suggestion is if you have hormone test results in front of you saying one thing, and your body is telling you something entirely different, trust the latter!