Responding to Claims in a Recent Review of the DUTCH Test
by Mark Newman, MS
A recent review of the DUTCH Test by Abby Langer (a registered dietician in Canada) has come to the attention of many of our longtime providers. Due to the number of questions we’ve received about the claims in this review, we want to take this opportunity to respond. While the review in question is critical of what we do, it creates an opportunity to highlight published research that speaks to common misconceptions about the DUTCH Test.
We take great care to include markers on the DUTCH Test that add clinical value and are supported by available scientific research. We make considerable efforts to publish our own research to support the validity of the DUTCH Test—exceeding any other hormone lab test in the functional medicine industry.
In fairness to the author, not all these publications were available when she wrote the piece (though her piece implies that she was unaware of any of our published work). Here we have rebutted the key points Ms. Langer makes in her review of the DUTCH Test.
Healthcare Providers and the DUTCH Test
The DUTCH Test is used by both conventional medical doctors and naturopathic physicians. In fact, MDs are the most common type of practitioner that uses the DUTCH Test. We are proud to work with over 4000 different MDs and thousands of NDs and various other healthcare providers.
The DUTCH Test offers clinically relevant markers, often overlooked by most providers. There are some markers tested that have clinical utility according to published research that have not been widely adopted by traditional medicine. Cortisol metabolites are a good example of markers included on our panels that are not commonly tested by conventional providers.
It is easy to find scenarios where the addition of cortisol metabolites offers more clarity to a trained provider. Scientific research highlights the clinical utility of cortisol metabolites, though it is true that conventional medical doctors without training on these markers do not find them useful or necessary. In some cases, they do not add clinical value. In others, profound insight can be gleaned from their addition to our panel.
Many of the markers on our panels are offered by labs like the Mayo Clinic’s lab, Quest Diagnostics, and Labcorp.
We have published validation data showing the accuracy of dried urine samples when compared to liquid urine samples. If published data proves the accuracy of dried samples, the categorical dismissal of every test found on a DUTCH profile also discounts tests used daily by traditional providers across the globe.
The Benefits of Salivary Cortisol Collection
The DUTCH test is a viable alternative to serum and saliva for testing cortisol. We believe that measuring the diurnal pattern of free cortisol has more clinical value than a single serum cortisol measurement. The scientific literature supports our position.
We have never claimed urine free cortisol (seen in the DUTCH Complete) to be superior to salivary cortisol (found in the DUTCH Plus). Our published research shows that urine is a viable alternative to saliva for the diurnal pattern of free cortisol.
We collaborate with providers and researchers who prefer urine and those that prefer saliva. Saliva is superior due to its inclusion of the cortisol awakening response (CAR).
Both the DUTCH Complete and DUTCH Plus include the measurement of cortisol metabolites to make the profile more complete. This can be helpful when patients have abnormal cortisol clearance (such as in cases of obesity, thyroid dysfunction, and others).
Much can be learned from testing cortisol four times in a day. This added benefit to the DUTCH Complete (all urine testing including free cortisol measurement) and DUTCH Plus (urine plus saliva for free cortisol measurements) is the ability to observe the up and down daily pattern of free cortisol.
Why does this matter? Consider the number one killer of Americans—heart disease.
A healthy stress response (HPA-axis) shows higher cortisol values in the morning and much lower values as the day goes on. If this pattern is abnormal, it has real consequences.
In 2006, Mathews showed that patients with flatter salivary cortisol curves throughout the day were more than three times more likely to have coronary artery calcification (CAC). CAC is an established marker of subclinical atherosclerosis and a predictor of future coronary heart disease.
The Whitehall II Prospective Cohort Study took this even further, correlating flat cortisol curves with increased cardiovascular disease mortality in a study of more than 4000 individuals. This study was published by The Endocrine Society in 2011.
Interventional cardiologist, Dr. Doreen Saltiel, MD, JD, FACC was aware of this research when we interviewed her for a response. She states, “As a result of these and other studies, I incorporated circadian rhythm free cortisol testing (both salivary and urinary) into my cardiology practice. Testing has provided insight into the importance of the stress axis in both primary and secondary prevention. I believe it is a missing piece in the ‘residual’ cardiovascular risk that still exists despite optimal medical therapy.”
Listen to Our Recent Podcast Episodes to Understand the Science of Cortisol Testing
The DUTCH Test is Backed by Peer-reviewed Research
The DUTCH Test is a valid, clinical lab test. The credibility of our testing is very important to us. We have extensively validated our testing and taken additional steps to get the data published in reputable, peer-reviewed journals.
Additionally, we have published abstracts with groups like NAMS (North American Menopause Society), ASRM (American Society of Reproductive Medicine), and published data showing clinical correlation for our testing. These efforts continue with multiple publications in 2021 and already in 2022.
Learn More About the Research Behind the DUTCH Test
Hormone testing may prove useful for patients undergoing HRT. We recently published data showing that DUTCH results increase as expected for patients taking FDA-approved estradiol gel products. To our knowledge, no other lab has done this.
We have published similar data for patches and creams in abstract form (NAMS, 2021). We hope to continue to pursue this topic, but extensive clinical studies where clinical endpoints (like bone mineral density) and testing are evaluated concurrently are needed.
It is worth noting that one critique of monitoring ERT is the variability of serum (blood) testing throughout the day. Our urine test helps to average out these ups and downs to provide a more stable target for follow up labs that are meaningful.
We acknowledge the value of hormone testing for patients on HRT is controversial. This debate is nuanced and the subject of much discussion. More research is needed for additional clarity, and we are seeking out this type of research.
The Value of Comprehensive Hormone Analysis
The DUTCH Test provides considerable value to both patient and provider. The markers on the DUTCH test are worth well over $1000 according to the current Medicare billing schedule for lab pricing. Ultimately, value is determined by how useful a provider finds the testing in their quest to help patients solve their health problems.
If reproductive or adrenal function plays a role in an individual’s deviation from health, there is a strong chance that the DUTCH Test could play a role in their journey back to wellness. We stand by the years of scientific research that implies that the markers we have chosen are relevant. We have supported these findings with our own efforts to critically research DUTCH results, and we’ve published those findings for consideration. We are happy to allow providers to consider the research and quality that supports our testing and assess the value for themselves.
DUTCH testing can guide people towards answers to their medical problems. We see many patients experiencing poor quality of life despite prior efforts to address their symptoms. Addressing underlying hormone dysfunction can be transformative in many of these cases.
A trained, evidence-based MD (or healthcare provider) may step in the gap with testing (including DUTCH) and solutions that help the patient make adjustments (lifestyle, diet, neutriceutical and/or pharmaceutical interventions) that initiate legitimate and lasting profound change. We are proud to be associated with this brand of research-backed, evidence-based medicine.
Precision Analytical welcomes serious inquiries and critical questions. There is more work to do for us to further optimize what we are testing and how to best apply it clinically. That work continues, and we will lead the charge in asking critical questions of our methods and the data produced and continue to be transparent with the findings.
To learn more about monitoring hormones with the DUTCH Test, browse our extensive video library.