Saliva Case Study

by Mark Newman, MS

The following is an interesting case study that highlights the challenge of using saliva testing when monitoring oral progesterone (it is also an interesting example of an independent issue when using topical hormones). A patient brought the case to me, and this educational video was created. They graciously allowed us to share it. There are some additional facts about the case below, but it is all in the short video.

This is case study that a patient brought to my attention. The patient took 340mg of oral progesterone. The patient didn’t understand how the saliva results the next morning could still be low. This actually makes sense because progesterone clears out really fast when taken orally. Circulating levels of progesterone don’t actually get very high with oral progesterone (remember you are dosing metabolites like a-pregnanolone more so than actual progesterone when the route of administration is oral). The patient also didn’t understand how her salivary E2 levels had jumped up from 2-4 to over 10. The reason is explained below (along with some other facts about the case).

• Saliva results were VERY high for E3 and somewhat high for E2…why? (see next points)
• Patient was taking a facial cream with E3. When you put E3 that close to the saliva gland, it drives salivary E3 levels (>1300 in this case!) WAY up
• VERY high E3 will actually falsely drive up salivary E2 because it cross-reacts about 0.5% with the saliva assay (so the E2 should have been 2-4, but it was 11 because of the E3 driving results up artificially)
• The lab is reporting a Pg/E2 ratio. In this case it is VERY VERY clinically misleading because of the misunderstanding of oral Pg. You should NEVER rely on salivary Pg/E2 ratio when topical hormones are used, especially if only the estrogen is topical. With oral Pg, the Pg/E2 ratio is clinically invalid as a concept.
• Using saliva testing can work for measuring endogenous progesterone if the lab is accurate (estradiol is a bigger problem because the salivary assays are not sensitive enough) but salivary progesterone should never be used to monitor oral progesterone.
• This case would have led to much less confusion with DUTCH testing to properly understand the effects of oral progesterone. Also, because we use GC-MS/MS, there is no cross-reactivity between hormones like E2 and E3.
• A facial cream with E3 in it will increase levels of the hormone in the local tissue and in saliva. It will not increase systemic E3 level all that much and urine levels will reflect this.

If you have any questions, please feel free to let us know.