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DUTCH Complete Overview

Understanding the Reference Ranges (General)

The reference ranges on our test are listed out in 2 places. First, they are listed on page 2 and 4 of the DUTCH Complete report, on page 1 of the DUTCH Sex Hormone Metabolite report, and on page 1 of the DUTCH Adrenal report. Next, when looking at the pictures, they are listed out as dials or gauges for each hormone. Almost all gauges have 2 stars. The left star indicates the lower range cut-off while the right start indicates the upper range cut-off. In this example, the range given is 1000-5500. The patient is on the lower side of normal at 1875.

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Reference Ranges (Female Cycling vs. Post-Menopausal)

When looking at the progesterone and estrogen metabolites for female patients, ranges are presented slightly differently. The range (as described above) between the stars represents premenopausal female ranges. Postmenopausal ranges are given (lower) in the purple band. Many female patients that are postmenopausal take some form of hormone replacement therapy. In these cases, it is helpful to see both ranges simultaneously.

Therefore if the arrow on the gauge is pointing towards the rectangular box, she is in the post-menopausal range. If the arrow is pointing in between the stars (as in the example below), she is in the range for a woman who still cycles every month. From the example below one would conclude that the patient is within range if premenopausal and quite elevated if the patient was postmenopausal (and not taking HRT).

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Reference Ranges (Fan Gauges)

The test also has fan-style gauges for 5a-Reductase Activity, Methylation Activity, and Cortisone/Cortisol metabolite preference. These fan gauges do not have actual number reference ranges however they do have upper and lower limits with an optimal range in between based on a calculation. These simply look at a ratio (5a versus 5b metabolites, 2-Methoxy-E1 versus 2-OH-E1 or cortisol metabolites versus cortisone metabolites). If the patient ratio is “average” the gauge will plot in the middle. If the ratio is above average, it will point to the right (and to the left if below average).

In this example, the patient’s 2-OH-E1 is “high normal” but 2-Methoxy-E1 is not (lower) which implies a lower rate of conversion than is typical. If 2-Methoxy-E1 was 5.3, the Methylation-activity index would be plotted in the middle (average or expected). Since the ratio is significantly lower, the index is in the shaded area, which is similar to being out of range (too low).

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How are reference ranges determined?

The determining of reference ranges is a complex and involved process. Many “healthy” or “normal” individuals are tested to determine our ranges. As an example, for estrogens we only include otherwise healthy individuals. To make the process more robust, we exclude premenopausal female patients if the progesterone values are low. Low progesterone values may imply that the patient is not really cycling regularly or may have ovarian suppression from unreported birth control or medication ingestion. Thousands of individuals have been screened and tested to properly develop all of the ranges used for DUTCH testing.

What is the Progesterone Serum Equivalent gauge on page 1 of the DUTCH complete test?

Progesterone itself is not found in the urine therefore we test the two metabolites (see question below) a-pregnanediol and b-pregnanediol. In this respect progesterone is measured “indirectly” in urine. This is standard for urine testing (although most labs only measure b-pregnanediol and miss part of the progesterone). We have done extensive testing of urine and blood and these two metabolites of progesterone in urine correlate strongly with the progesterone in your blood (serum). As a result we are able to provide an estimate of what your progesterone in the serum could be should you have your serum levels drawn. This correlation is strongest for women who are still cycling regularly. This may be helpful for providers and patients in trying to understand their progesterone levels, but this is a calculation and not an actual measurement. When progesterone is taken orally or sublingually, these values will no longer correlate to serum values.

What if I am on HRT or hormone replacement?

You are still able to use DUTCH testing when on HRT. We strongly encourage you to visit our free video library, find the route of administration you are taking (ie. oral, topical, vaginal) and watch the video in order to determine your specifics. DUTCH testing can provide useful information on hormone metabolism for any form of HRT. To get highly useful information regarding proper dosing of hormones, be careful using DUTCH testing for the following forms of HRT:

  • Oral estrogens (estradiol, estriol) – values can be artificially inflated from 1st-pass metabolites that end up in urine from gut metabolism having never been in circulation as a bioavailable hormone.
  • Sublingual progesterone, estrogens, testosterone – If these hormones are swallowed when you take them (which is difficult to avoid) a lot of the concentration in the urine will be from 1st-pass metabolism (hormone that gets metabolized in the gut and excreted in urine without making into circulation as a bioavailable hormone). It is not possible to differentiate between hormones that get into circulation and end up in urine and those that are there due to 1st-pass. This makes the interpretation difficult.
  • Transdermal progesterone, testosterone – Monitoring transdermal creams is controversial and not entirely clear (especially with progesterone and to some degree testosterone). For more information on this topic, see our video library.
What if I use the birth control pill/patch/ring/implants (not IUD)?

The birth control pill (patch, ring and implants) stops the FSH and LH surge from the pituitary to prevent an estrogen rise and ovulation (thus progesterone production) from the ovary. If you hormone test while on the pill, your estrogen and progesterone should be predictably low. That means the pill is doing its job and you are not likely to become pregnant.

If you are on hormonal birth control to prevent or decrease symptoms of certain conditions such as endometriosis or heavy bleeding, talk with your health care provider first before just stopping your birth control. If you stop your birth control you symptoms will likely return immediately. It is the healthcare provider’s role (not the labs) to decide what treatment options should be followed, but we want to make sure the lab testing provides maximum information. In some cases where birth control has been taken, reproductive hormone values have diminished value (as they are relatively predictable).

Remember the DUTCH testing is very specific (accurate) so synthetic estrogens and progestins found in birth control are NOT seen by our testing methods. For more information on this please see this blog post.

What if I have an IUD?

The copper IUD also known as the Paragard is not made up of any hormones therefore you can test on the typical day 19, 20 or 21 of a 28-ish day cycle as the instructions request.

The Mirena IUD does have synthetic progesterone in it known as a progestin. For those women who still have a cycle with the Mirena, it can partially suppress ovulation in some women which will make progesterone levels sub-optimal or outright low. The DUTCH test is a very good way to see if the Mirena is suppressing hormones. The progestin in the Mirena often makes the lining of the uterus very thin to almost non-existent. As a result some women do not bleed when it’s time to have their period. This can make it difficult to determine exactly what day of their cycle they are on. Please call the lab to discuss your options if you are doing sex hormones as part of your testing. If you are just doing only the adrenal test, you can collect as instructed by your healthcare provider. Remember the DUTCH testing is very specific (accurate) so synthetic progestins found in hormonal IUDs are NOT seen by our testing methods.

What if I am on a steroid medication such as prednisone, steroid inhaler, steroid allergy nasal spray or topical hydrocortisone/Cortaid cream?

Cortisol is also known as hydrocortisone and is a corticosteroid (meaning it comes from the cortex of the adrenal glands). Prednisone is a synthetic corticosteroid. Prednisone and other synthetic steroids (dexamethasone, triamcinolone) are much more potent and remain circulating in the body a lot longer than cortisol. They can cause a lot of side effects such as adrenal suppression, thinning skin, and weight gain however they may be necessary in an emergency or autoimmune situation. If someone is taking a steroid medication regularly, it may disrupt and suppress the adrenal gland output of cortisol resulting in very low cortisol markers on the DUTCH test.

Be aware that a “steroid hormone” and someone taking synthetic steroids such as for body building are different. “Steroid hormone” is an umbrella term for those hormones made in the cortex of the adrenal glands (ie. cortisol) or the gonads (ie. testosterone or progesterone). Remember the DUTCH testing is very specific (accurate) so synthetic glucocorticoids like Prednisone are NOT seen by our testing methods. For more information, see this blog post.

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*The chart indicates the type of medication on the left, the glucocorticoid power (ability to act like cortisol) mineralcorticoid power (ability to act like aldosterone), duration in the body and how strong it is compared to cortisol. Short = 8-12 hours Medium = 12-36 hours, Long = 36-72 hours

What is the difference between pre-menopausal, peri-menopausal, and post-menopausal?

Pre-menopausal describes the time in a woman’s life when she still cycles on a regular basis. This occurs most commonly between her teen years up into her 40’s and sometimes 50’s.

Peri-menopausal describes the time prior to menopause where her hormones are starting to shift due to the ovaries beginning the process of shutting down and not cycling every month. She may experience a change in her cycle (no cycles, short cycles, long cycles, and irregular cycles) that had not been normal to her. She may also experience common symptoms such as insomnia, hot flashes, night sweats, brain fog, weight gain, joint pain, and vaginal dryness. This occurs most commonly between the 40’s and 50’s.

Once a woman has not had a period in 12 consecutive months, she is considered post-menopausal. She may still continue to have unpleasant hormonal symptoms, but she does not cycle anymore.

What is a hormone metabolite and what is hormone metabolism?

When looking at a DUTCH test or through this website, you may notice the word “metabolites” or “metabolized” used fairly often. When you make a hormone such as progesterone or cortisol, or when someone takes a hormone (such as in HRT), it must be processed by the body in the liver through the process of phase 1 and phase 2 detoxification before it can be excreted. This is known as hormone metabolism. As a hormone is undergoing that process, it gets changed into other forms known as metabolites. For example, during estrogen metabolism, the potent estrogen known as Estradiol (E2) goes through phase 1 detoxification in the liver where it can be changed into the estrogen metabolites known as 2OH-Estrone, 4OH-Estrone, or 16OH-Estrone. In the dried urine test, progesterone itself is not found in urine so we test the progesterone metabolites known as a-pregnendiol and b-pregnenediol that correlates well with the progesterone that is floating around in your system. The wording of these concepts can be confusing. 16-OH-E1 is a metabolite of estrone (E1). We also measure E1 itself, BUT as it appears in urine, E1 is actually in the form of E1-glucuronide or E1-sulfate. Those are commonly called “conjugates” of estrone, but some might call that a metabolite since conjugation is part of phase II metabolism. For the purpose of simplicity, we call things like 16-OH-E1, 5a-androstanediol and tetrahydrocortisol “metabolites” (of estrogens, testosterone and cortisol respectively).

What about metabolized cortisol?

On the adrenal page of our test, we measure metabolized cortisol. Just like above, cortisol has to be processed in the body and is then excreted as metabolized cortisol. On our test these markers are known individually as a-tetrahydrocortisol (aTHF), b-tetrahydrocortisol (bTHF), and b-tetrahydrocortisone (bTHE). They are the best marker of the total cortisol output from the adrenal gland (see the cortisol section for more information).

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