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The Complex Female (and why timing in hormone testing absolutely matters)

There seems to be some strange disconnect these days between science and common sense when it comes to hormone testing in women. Countless times I've had women appear in tears because they had their hormones tested and they received devastating results when, in fact, they simply tested their hormones at an incorrect time. Other times they are put on a treatment plan that can actually make things worse because hormones weren't looked at properly. Most of the time women are handed a lab requisition at an appointment and told to go whenever and they head straight to the lab because they just want to know as soon as possible. This practice needs to stop- it is completely clinically irrelevant and can be immensely stressful to patients when they receive the wrong information.

The female body is an amazingly complex cyclical being. We can't fit it into a static box and expect to gain any reasonable understanding. Some hormones, such as testosterone, are fairly static in women (in men they can drop by as much as 1/3 just from morning to afternoon) that you can easily test any time. Estrogen and progesterone are another story, though. As you can see from the diagram, the first half of the female cycle, which begins on the first day that bleeding begins, is dominated by estrogen, whereas the second half is all about progesterone.

So what happens when a women is sent to get her blood drawn on day 2 of her cycle because she's told it doesn't matter when she goes? Her levels are going to read like she is in menopause! This is not the time to be testing! Look more closely at the cycle. Ups, downs, steep, gently graded. It's quite the roller coaster, and many women also know that these fluctuations can have all sorts of influence on the body- physically, mentally, emotionally.

When looking for the most accurate measurement of these two important hormones I first like to figure out exactly when the woman is ovulating. To do this we utilize ovulation kits, which are similar to a pregnancy test but measure a hormone called luteinizing hormone, or LH, which spikes when ovulation occurs. While pregnancy tests should be done first thing in the morning when urine is concentrated, ovulation tests should be done later in the day, between 11am-6pm and should be done the same time every day. When you begin generally depends on the cycle and I usually try to guess and start testing 3 days before we would expect it to occur. Additionally, basal body testing can be done every morning at the same time before getting out of bed and when you see an approximately one degree spike (often after a slight dip) that indicates ovulation. Once a positive test is had (if ovulation is actually occurring) then you want to count forward 5-7 days. As you can see, at this point estrogen and progesterone both peak and plateau for approx 3 days and we can get an accurate portrayal of the hormone cycle.

When testing FSH, this is typically done on days 2-4 of the menstrual cycle but this is typically done only when looking into fertility. For a typical female hormone panel I will generally test the following hormones:

1) total estrogens- this helps us look at the estrogen to progesterone ratio more easily

2) estradiol- this is the dominant estrogen in a women who has not reached peri-menopause/

menopause and deserves it's own look

3) DHEA-S- this hormone converts into both estrogens and testosterone and it's important to

understand where imbalances might be stemming from

4) testosterone, free and total- this helps look for additional imbalances in conditions like

PCOS (polycystic ovarian syndrome)

This is obviously not a complete list because each person's case is unique and needs to be evaluated individually and often times additional sex hormones, thyroid and other endocrine issues needs to be looked at, as well. Also, the way we test will vary depending on the patient, as well. A dried urine test has been found to be the most accurate way to test hormones and it's nice because you can do it in the comfort of your home and is perfect for patients who are afraid of needles. A lot of the times blood testing will be done simply because it can be covered by health insurance and cost is often a factor. In healthcare it's often about working with the patient to figure out the best ways to get information without creating additional financial or emotional stress.

Once the (accurate!) information has been obtained you are in a much better place to begin discussing treatment options! SO many issues are caused by hormonal imbalances than people can imagine. I have had husbands and partners send me flowers for balancing their wife's or girlfriend's hormones and I always tell women the word "just" is NEVER allowed when talking about hormones. If you've ever fallen in love, gazed into your newborn's eyes, or felt the loss of a loved one- all of these intense feelings are caused by hormones. We are a big walking ball of these chemicals that make us who we are. Keeping them in balance is incredibly important. Make sure you get the most accurate information to help you feel the best you can.

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