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FFC: Hormone testing blood vs urine

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After my bad experience with FFC, I went to a LLMD. He ordered a 24 hour urine test. After completing a seminar on hormones, he stated that urine levels are superior to blood levels.

He explained that blood levels are the least accurate because they do not separate what is bound from what is free and available for use. Urine testing measures the free form. My LLMD uses urine levels to set prescribing doses.

The FFC kept getting low measurements in my blood so they kept raising the doses. My testosterone is up 17 times more than normal. Cortisol is up 26 times greater that it should be. Pregnenelone is 13 times normal. I don't even what that hormone does other than being called the mother hormone.

My estriol is up 20 times normal. I am not taking any estrone (the bad estrogen) just using estriol and estradiol. Somehow, my body is converting one of the good estrogens to the baddie estrone.

Today, I had an office visit with a doctor that I found on this board. He was the one that prescribed the too high doses after I left FFC. He attended the same hormone seminar as my LLMD. He now thinks the urine measurement is superior to blood. Just wondering what methods are everyone's doctors are using?

The exception to this is thryoid tests. Urine tests for T4 & T4 are not acturate so blood is needed.

The FFCs rely on blood testing and then they have their optimal doses which are the upper half of the normal range. Many people have stated they were overdosed on hormones. If they are relying on blood then too high target ranges could have serious consequences.

Here's more info from: http://www.custommedicine.com.au/hormone_analysis.php

"Measuring hormone levels are essential for the proper diagnoses of perimenopause, menopause, andropause or other disease states, such as hypothyroidism and adrenal exhaustion (chronic fatigue syndrome) , which may mimic perimenopausal symptoms. Hormone level determination also enables you to closely monitor your hormones ensuring they all remain within a normal physiological range. The test results used in conjunction with any symptoms you have are invaluable tools when designing an Individual Bioidentical Hormone Replacement Therapy (IBHRT) regime.

It is very surprising, not to mention dangerous, how many women on HRT have never had their hormone levels tested. Hormonal imbalances that are not accurately identified and appropriately treated may lead to inappropriate treatments with very serious side effects so the importance of monitoring their levels cannot be overstated. A couple of examples of this are, firstly if a women presents with hot flushes the doctor may assume she is menopausal and requires estrogen when in actual fact the hot flushes were caused by high cortisol levels. By giving estrogen to her an inappropriate and possibly dangerous treatment would commense causing further hormone imbalances. Secondly, again a women presents with hot flushes which were caused by excessively high levels of estrogen which resulted in a down regulation of her estrogen receptors causing her hot flushes. By assuming it is caused by an estrogen deficiency and giving estrogen to this women would make her condition worse. These are examples of two quite common sinarios we see in our practice which emphasise the need for hormone testing.

As a generalisation I recommend that before IBHRT is commenced the levels of estriol, estradiol, estrone, progesterone, testosterone, DHEA, cortisol and thyroid (T3 and T4) be tested. The first five hormones make up the basis of IBHRT while measuring DHEA, cortisol and thyroid hormones may indicate if adrenal exhaustion or hypothyroidism are present which have been implicated in perimenopause and menopause.

Blood Tests 'v' Saliva Tests 'v' Urine Tests

(1) Blood tests commonly used to determine hormone levels will measure the total amount of hormones in serum. This type of hormone testing is considered the least accurate of all methods available. These serum tests are unable to distinguish the protein-bound, and therefore inactive form of the hormone, from its free and biologically active form, thus giving only a rough estimate of your hormone levels. This may lead to inappropriate diagnosis as quite often total hormone levels are within normal limits but once the free and active levels are tested deficiencies are identified. In addition hormones attached to red blood cell receptors are not measured as these tests only measure what is present in serum. This is a significant problem monitoring levels if you are using transdermal hormone creams with the hormones binding to red blood cells once absorbed through the skin and therefore not being measured by serum analysis. In addition serum test results only reflect hormone levels outside the cells in the serum and do not reflect levels else where in the body. Clinical trials performed by the American Academy of Anti-Aging on over 300 patients revealed that every patient whom hormone levels were deemed at optimal levels by serum blood tests had in actual fact excessive levels based on saliva tests. The doses used to achieve optimal serum levels were higher than standard physiological doses which was all that was required to achieve optimal levels by saliva tests. In every case the patients doses were reduced until saliva tests reflected optimal levels. In our own practice we see this same phenomena on a regular basis with those patients being monitored by serum blood tests, that is their current doses are too high! In addition serum tests are unable to detect progesterone level increases when used as a creams for weeks when in fact saliva testing shows it to appear within 2 hours. And finally serum tests are not available for estriol and estrone in Australia. Therefore two very important estrogens will go undetected when using serum analysis and quite often we see test results where estradiol is normal however estrone is elevated whichis a problem that would go undetected by blood tests.

(2) 24 hour urine hormone test which is very accurate and should be used when ever available however due to the collection of 24 hours of urine has obvious compliance problems

(3) Saliva testing measures the free and therefore biologically active form of several of the major hormones in saliva - estriol, estradiol, estrone, progesterone, testosterone, DHEA and cortisol. Saliva tests have been proven to be an accurate reflection of hormone levels present inside cells, where the hormone action takes place, whereas blood tests measure hormones outside the cells. It is considered to be the gold standard for hormone analysis by the World Health Organisation (WHO). Despite the WHO's recommendation to use saliva hormone testing it is often neglected by medical practitioners, many whom refuse to order such tests as they are not informed of the differences. In these cases blood test will do as they still give us an indication of your hormone levels although they may not be as accurate.

Saliva hormone testing is a less painful and a more accurate way of determining your hormone status which can be performed in the comfort of your own home. The tests may be ordered by your doctor, or alternatively we can arrange them for you with a consultation if your doctor refuses to do so. Saliva hormone testing involves a test kit being sent to your home with printed instructions. Saliva samples are taken at a uniform time of the day for more meaningful comparisons and placed into provided containers at one or more specific times of the day, then sent directly to the laboratory for analysis. The results are then sent back to whom ever ordered the tests for interpretation and to determine the appropriate therapy.

Timing of Tests
The best time of the day to collect a sample for any baseline hormone analysis is in the early morning (except for 24 hour urine analysis), and the best time of the month is between days 20 to 23 of a 28 day menstral cycle (day one is first day of mensus). This is when progesterone levels are apt to be highest (luteal phase) during the entire cycle.

When doing subsequent follow up tests to monitor levels while on any hormone replacement it is best to take the sample midway between doses so an overall daily average is measured. This is very important in order to obtain useful results.

Many doctors are critical of any form of hormone testing as they claim hormone levels fluctuate so testing is therefore useless. This is true, hormone levels do naturally fluctuate on a monthly cycle. However if that cycle is clearly understood the tests should be performed on a specific day of the cycle (luteal phase) as mentioned above where we are well aware of the appropriate hormone levels for that day. If periods are irregular it is more difficult to accurately assess hormone levels with just one sample. Therefore take samples on two different occasions before starting IBHRT to increase the chance that testing will reveal natural biological variations.

What to Test For
Your current signs and symptoms will help determine exactly what tests are appropriate to preform. Therefore the types of tests required is very individual however generally I would recommend a urine or saliva test for estriol, estradiol, estrone, progesterone, testosterone, DHEA, and cortisol. Thyroid hormones (T3, T4, Reverse T3) are determined by either blood tests or 24 hour urine excretion tests. All of these ideally should be measured before you start any IBHRT which will give you a good baseline assessment of your overall hormone status. From these initial results it can be determined which hormones need supplementation and the appropriate starting dose of each hormone.

It should be clarified that test results must be used in conjunction with signs and symptoms and not be totally relied upon 100% for a diagnosis and latter on to determine appropriate dosages. There is always a general optimal physiological level we try to achieve with tests however these levels can vary in some patients and this must be taken into account and can only be done so by also using symptoms to go by. Every day I am sent hormone test results from people wanting my advice on how to adjust their hormone doses. I cannot responsibly offer any advice without an appropriate background into their signs and symptoms to help make a final decision.

Interpreting Test Results
A major problem with interpretation of test results is that medical practitioners with little experince in hormonal matters often observe results that lie at the low end of the so called “normal range” and determine that no hormone imbalance or deficiency exists thus determine no action is required. A major problem is that laboratory test “normal” ranges are defined and standardised according to statistical norms instead of physiological optimal levels. That is, mathematics rather than patient symptoms define “normal” hormone levels.

Instead of using “normal” laboratory ranges we prefer to use optimal ranges which as a general rule lie within the upper one third of the normal laboratory range. This general rule is only a guide as it does not take the appropriate balance between certain hormones into account which is also very important. Therefore it is important that someone with experience and knowledge on appropriate hormone balance views your test results for an accurate diagnosis. Often there is a marked improvement in symptoms when levels at the low end of the normal range are increased to the upper end of the normal range with supplementation. For a more detailed explaination on the shortfall of using "normal" laboratory ranges - click here

Once you have started IBHRT it is essential to retest your hormone levels after four to six weeks to ensure your hormone levels remain within the upper one third of the normal physiological range and also to ensure the supplemented hormones are absorbed and utilized by the body. If you use lozenges to deliver your hormones you must have blood tests as saliva test will be adversely affected if performed within 36 hours after your last dose. The best time to retest for oral and transdermal doses is half way between consecutive doses so an overall daily average is measured. After your hormone levels have stabilized to suitable levels continue to retest at least annually for the rest of your life.

Estrogen Metabolism Monitoring
In addition to saliva/urine analysis we also recommend that both men and women have their 24 hour urine estriol, estradiol, estrone, 2-hydroxy-estrone, 4-hydroxy-estrone, 16-hydroxy-estrone levels checked. The goal is to assess and reduce any potential risk of disease by monitoring which estrogen metabolites are being produced, the relationship between metabolites, and how replacement affects metabolite levels. For more information on an unfavourable estrogen metabolite balance possibly causing breast and prostate cancer please refer to appropriate sections."

[This Message was Edited on 08/02/2007]


New Member
Hi Munch,

Please don't take the following commentary on the article you posted as a flame. There's a lot of writing out there that makes assertions that benefit from verification.

>>It is considered to be the gold standard for hormone analysis by the World Health Organisation (WHO).>>

I believe this statement takes WHO's positition out of context. WHO recommends saliva tests for certain *diseases* -- notably AIDs antibodies & antibodies affecting fertility. Go to the WHO main website & do a search.

>>serum tests are unable to distinguish the protein-bound, and therefore inactive form of the hormone, from its free and biologically active form...>>

Most hormones can be tested in serum for total (incl. bound)hormone, OR the free hormone (active) form. It depends on what's ordered. I'

>>... serum tests are not available for estriol and estrone in Australia. Therefore two very important estrogens will go undetected..>>
But you can have these levels measured by blood/serum in the US.

>>In addition hormones attached to red blood cell receptors are not measured as these tests only measure what is present in serum. >>

Interesting point. However, those hormones attached to RBCs won't be present in saliva or urine (typically). Moot point, IMO.

>>24 hour urine hormone test which is very accurate and should be used when ever available ..>>

Accuracy is highly dependent upon handling & lab standards. The handling starts with the patient collection process, the patient's measuring of total urine volume, the adequacy of homogenization of sample (portion of total sent to lab). Most steroids are heat-sensitive so storage/handling is of the utmost importance. Depending on the lab (usually these are small operations, not a standard lab like Quest), various metabolites (hormone breakdown products) are measured, sometimes by dubious methods. Then there are issues like reliability/ reproducibility of result, validity of "reference ranges," etc. Literally hundreds of variables affect lab results.

I've been there, done that, all the diff methods. You can spend thousands on the testing. When all is said & done, we are best off listening to our bodies first, and considering lab findings as adjunct info.

Munch, I hope you can soon recover from your excess hormone dosing.

Best wishes.



Yours was the sort of reply I was hoping for when I posted this topic! I am uncertain and confused about which doctor's advice to follow. I don't see how I can be overdosed on estrogens since I've got the dried up pruny crotch (and the lack of libido to match) of a much older woman. As in can you spell D-R-Y and B-U-R-N? Even my husband can feel the burning.

My compounding pharmicist says to go with blood results. Those were all done by Quest Labs. The 24 hour urine test was overnighted to Genova Diagnostics (formerly Great Smokies Lab).

The endocrinologist says to go with blood. But he asked how come my hormones don't have a brand name. I asked if bioidentical was a dirty word. Then he understood.

I think I'm one of those people that Dr. Cheney writes about losing their dynamic hormone response. Seems to me that I'm peeing everything out without utilizing it since my blood is low and my urine results are high.

I was told to read Dr Thierry Hertoghe's book "The Hormone Handbook". I also think this is the seminar that the doctor's have attended:



New Member
Oh, Munch, how I laughed at that description! Only those of who've been there can understand, and the words you put to it (low estrogen/vag issues) are certainly apt. Made my day.

IME, the libido comes back w/adequate testosterone. However, the point about receptor sensitivity issues with overdosing is not lost.

Are you losing other stuff in your urine, like protein and/or sugars? I wonder if it could be a kidney filtration thing? Just guessing/wondering.

The thing about testing hormones in blood is that the techniques have a LOT of standardization, which is helpful. And they've stood the test of time. Which is not to say they couldn't be improved on ...

Good luck with your hormone quest!


New Member
I feel for you, and I certainly know what it is to have a low libido.

I don't have much of value to add to this conversation, except that it appears that there is a lot we don't know about hormones and their effects.

I suspect it may be a while before it all shakes out.

Witness the debate over HRT.

The evidence seems to point to higher risk for clots, cancer and stroke with certain combos.. but also to show there may be benefits to short-term supplementation for women of certain ages or at a certain point in the transition from perimenopause to menopause.

IMHO, women are the guinea pigs in a huge experiment with anti-aging medicine....

Sorry, getting off point. I have been loath to tinker with my hormones, even though it does seem to part of the CFS syndrome.

I will be interested to see if my homrone levels change as my progress continues on the MCB protocol. Fingers crossed.

And good luck to you. I have followed your progress, and I have been impressed with your tenaciousness and the fact that you don't take what the docs tell you at face value.. in other words your independence of mind.

Also, thanks to SnoozQ for her input. Always interesting.



People who question my use of bioidentical hormones get the same answer. You'd take them too if your Va-Jay-Jay was cracked. In fact you buy snake oil for it too.

My 28 year old daughter was horrified when I described what was going on with my hormones. She had no idea the Va-Jay-Jay has a shelf life. Right there and then she called all of her friends (and probably put it on myspace) to warn them that this could happen to them.

She's going to use it before she loses it. Seems like that old saying might have some merit after all. This is not something my mother ever told me. Could this be why are parents eventually moved into separate bedrooms?

Isn't this existance is a living HELL? Two days ago we had our umpteenth fight about the money I've spent chasing CF & FM now I find out it's Lyme.

Where is the viagra for women? The constant male enhancement (bone) commercials during dinner are such a painful reminder that women are suffering in silence. Could the people in charge use something besides sex to sell products?

Thanks for your replies. It's nice to know I'm not alone. Have you found anything that works?
Urine is widely used to test for drug use because maximum urine test uses for pregnancy test, and stomach infection etc. It is less commonly used to test hormones overall but some doctors are recommending this test and use the 24-hour urine test to measure level of cortisol, but the test is less often used to measure the sex hormones estradiol, progesterone, and testosterone. And blood test its very important for check your level of follicle stimulating hormone and estrogen. During menopause, FSH increase your estrogen increase your estrogen levels decrease and confirming menopause. This test can detect sings of certain pituitary disorder.