Subtleties in the Diagnosis of Endocrine System Dysfunction
by Mark Newman, MS
The DUTCH (Dried Urine Test for Comprehensive Hormones) test is currently the most comprehensive lab test available in the market. Therefore, it is not surprising that reading the patient reports can be a bit overwhelming at the beginning. In order to help you with the learning curve, Dr. Tim Hyatt, ND has written this quick article to walk you through some basic conditions to keep an eye out for when analyzing your results.
As a long time physician, I consider myself to be a holistic and functional medicine practitioner, always looking for reliable tests to confirm or deny my clinical suspicions and help patients achieve a higher level of function and performance. When it comes to diagnosis and treatment for conditions involving the endocrine system, there is often great complexity and an endless amount of choices in putting together a diagnostic workup that is revealing, but also cohesive in its entirety. Each individual test result offers insight into the function of the particular patient; with many results, we can often see how each are related and come up with a treatment plan that makes sense for the patient and helps them reach optimum function.
In the world of functional medicine, bodily fluids remain the most valuable source of information along with a thorough intake and physical exam. The most commonly used fluids are blood components, urine, saliva, and occasionally stool samples. Choosing the bodily fluid and the marker can be a challenge because there is rarely a consensus on which tests are better for diagnosing given conditions, with benefits and limitations to each.
Every day I consult with healthcare providers who are new to the DUTCH test and more often than not, they mention the complexity and amount of comprehensive information that can be gleaned from these results.
The DUTCH test has proven to be of great clinical utility for testing sex and adrenal hormones (as well as their metabolites), as it gives you insight into many other conditions, if you know where to look. Below, are a few examples of the conditions to keep an eye out for.
Over the last decade or so, the phrase “low T” has crept into the vernacular, so that just about everyone knows what it means when it rolls off the tongue. Many people are interested in their testosterone levels because they have symptoms of either too much or too little. For women, having an adequate amount of testosterone helps maintain a healthy sex drive and protection against bone loss. Having too much, however, can create symptoms of acne, hair loss and hirsutism (excess hair growth in those ‘inappropriate places’). On the other hand, most men would like to have enough testosterone to maintain traditional “male” characteristics, but not so much that they develop irritability and display aggressive behaviors. The beauty of the DUTCH test is that it tells you not only what the aggregate testosterone hormone levels are, but how testosterone is metabolized and if you process it safely or not.
Luteal Phase Deficiency or Defect (LPD)
LPD is not a well-known condition to the general public and I would venture to say that many practitioners would struggle to fully explain the ins and outs of this problem associated with the menstrual cycle. LPD occurs when the onset of menses is less than 8 days from the LH peak at mid-cycle or ovulation. This results in a very short luteal phase. LPD is associated with hypothalamic amenorrhea, infertility, low FSH, a low FSH/LH ratio, low progesterone and estrogen, elevated prolactin, thyroid disorders, PCOS, 21-beta hydroxylase deficiency, excessive exercise, anorexia and starvation, and aging.
In women who are not trying to get pregnant, it is known that low progesterone in the luteal phase is associated with symptoms of PMS, breast tenderness, heavy menstrual bleeding, insomnia, and worsened anxiety.
Currently, there is no scientific consensus on the diagnosis and treatment of LPD in association with infertility. However, testing for LPD in patients who are trying to regulate their cycle can be useful and a starting point for the implementation of natural or bioidentical therapies.
If you suspect that your patient has a LPD, and the progesterone metabolites are low, you might want to take a look at midcycle LH and FSH, and prolactin; consider the diagnosis of LPD.
In general, inflammation can be viewed as an internal or external environmental insult of some kind, brought on by genetic predispositions and/or susceptibilities in the individual coupled with epigenetics. In a more obscure sense, inflammation is associated with dysregulation of metabolism and overall organ system dysfunction.
Inflammation shares an inverse relationship to cortisol; cortisol plays an anti-inflammatory role and when levels in local tissues and serum are low, inflammation increases. We know that cortisol levels increase in local tissues as a response to local inflammation and therefore urine free cortisol, and metabolized cortisol may be elevated when inflammation is present. However, inflammation cannot be ruled out when adrenal insufficiency or Addison’s Disease is a factor because of likely HPA-axis dysfunction. These patients, instead, will show up as a very low or flat lined free cortisol and cortisone, and very low metabolized cortisol.
Fortunately, the DUTCH test can help you look for indications of inflammation. For example, increased aromatization in the conversion of testosterone to estrogens is associated with inflammation along with low DHEA-s levels, low testosterone, elevated 5-alpha reductase activity, and elevated 4-OH-E1. Keep your eyes open for these results and it should help you connect the dots in some of your complex patient cases.
Since the Thyroid gland is a major driver of the metabolism, thyroid disorders can affect virtually every system of the body. Constipation, dry hair and nails, dry skin, fatigue, poor focus, elevated cholesterol, and menstrual cycle abnormalities are several of the signs and symptoms to watch out for in hypothyroidism. Anxiety and or irritability, low body weight or sudden weight loss, insomnia, diarrhea, changes in menstrual patterns, fatigue, brittle hair and nails are a handful of the symptoms associated with hyperthyroidism.
We have known for more than a decade that comprehensive testing of the thyroid gland is appropriate in order to optimize treatment and outcomes. The importance of testing and supporting the thyroid and adrenals together cannot be overstated because the thyroid and the adrenals work in concert to support the metabolism.
Suboptimal or elevated thyroid function, especially early in the disease, can often be confused with HPA-axis or adrenal dysfunction. Sluggish HPA-axis function appear as low metabolized cortisol and higher free cortisol on the DUTCH test – so does hypothyroidism. Elevated HPA-axis function can appear as elevated metabolized cortisol and lower cortisol on the test as well – so does hyperthyroidism! This means that where symptoms of hypo and hyperthyroidism overlap with presumed adrenal dysfunction you need to consider both glands in your diagnosis.
These are just a few of the examples of how valuable the DUTCH test can be when diagnosing and treating your patients. Check back weekly for more great information!