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Hormone Testing in Clinical Practice: Part 3. Interpreting Your Patients’ 24-Hour Hormone Profile Results. Urinary Hormones. Part 1: Sex Hormones Estrogen Progesterone Testosterone Part 2: Adrenal Hormones Growth Hormone Thyroid Sodium/Potassium Ratio Enzyme Activity.

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hormone testing in clinical practice part 3

Hormone Testing in Clinical Practice: Part 3

Interpreting Your Patients’

24-Hour Hormone Profile Results

urinary hormones
Urinary Hormones
  • Part 1: Sex Hormones
    • Estrogen
    • Progesterone
    • Testosterone
  • Part 2:
    • Adrenal Hormones
    • Growth Hormone
    • Thyroid
    • Sodium/Potassium Ratio
    • Enzyme Activity

© 2010 Meridian Valley Laboratory

urinary hormones3
Urinary Hormones

Part 3: Case Studies

Menopause, without HRT

Menopause, with BHRT

© 2010 Meridian Valley Laboratory

3

metabolism of selected steroids
Metabolism of Selected Steroids

5

5

© 2010 Meridian Valley Laboratory

case one
Case One

Janet, a 67 year old

Post-Menopausal Woman

© 2010 Meridian Valley Laboratory

case history
Case History
  • Height: 5’4” Weight: 155lbs
  • BP: 105/70 LMP: 2005
  • Menopausal sx have worsened in past 6 months
  • Family hx of osteoporosis
  • Family hx of CVD

© 2010 Meridian Valley Laboratory

medications and supplements
Medications and Supplements

Levothyroxine 25mcg qd

Probiotics

Fish oil

Multivitamin

Ginko

Calcium Magnesium

© 2010 Meridian Valley Laboratory

8

slide9

Signs and Symptoms

  • Symptoms
    • Hot flashes
    • Vaginal Dryness
    • Night sweats
    • Foggy thinking
    • Memory lapse
    • Bone loss
    • Anxiety
    • Stress

© 2010 Meridian Valley Laboratory

slide10

Signs and Symptoms

  • Symptoms
    • Increased facial hair
    • Fatigue
    • Insomnia
    • Stress Incontinence
    • Decreased libido
    • Acne
    • Mood swings

© 2010 Meridian Valley Laboratory

24 hour urine hormone profile report
24-Hour Urine Hormone Profile Report

Doe, Jane

Doe, Jane

Doe, Jane

0001

Dr. Jonathan Wright, MD

The Tahoma Clinic

801 SW 16th Street

Renton, WA 98057

FAX: (425) 264-0071

Phone: (425) 264-0059

© 2010 Meridian Valley Laboratory

11

total volume creatinine
Total Volume & Creatinine

0.9 gm/24hr

2700 mL

© 2010 Meridian Valley Laboratory

12

estrogens
Estrogens
  • Estrone (E1)
  • Estradiol (E2)
  • Estriol (E3)
  • 2-Hydroxyestrone
  • 16α-Hydroxyestrone
  • 4-Hydroxyestrone
  • 2-Methoxyestrone
  • 2-Methoxyestradiol

Phase 1 Metabolites

Phase 2 Metabolites

estrogens14
Estrogens

Testosterone

Androstenedione

Estradiol (E2)

Estrone (E1)

4-OH Estrone

2-OH Estradiol

16α-OH Estrone

2-OH Estrone

2-CH3O Estradiol

Estriol (E3)

2-CH3O Estrone

estrogens e1 e2 e3
Estrogens: E1, E2, E3

Luteal 17-26 10.8-89.2

Follicular 27-11 7.0-110

Mid-Cycle 12-16 38-221

Post Menopausal 0-41

7.3

© 2010 Meridian Valley Laboratory

15

estrogen quotient
Estrogen Quotient
  • Estrogen Quotient
    • Originated by Henry Lemon, MD
    • Women with EQ>1 have  survival rate after BrCA
    • Estriol (E3) divided by the sum of Estrone (E1) + Estradiol (E2)

EQ = E3 / (E1 + E2)

estrogens eq
Estrogens: EQ

3.0

+

1.1

4.1

3.2 ÷

0.8

>1.0

EQ =

E3 ÷

(E1 + E2)

© 2010 Meridian Valley Laboratory

17

promotion of estriol e3
Promotion of Estriol (E3)

Estrone (E1)

16-OH Estrone

+Iodine (↑ E1→E3)

Estriol (E3)

2 16 ratio
2/16α Ratio

Testosterone

Androstenedione

Estradiol (E2)

Estrone (E1)

+Obesity

+DIM

+Hypothyroidism

+Indol-3 Carbonyl

+Pesticides

4-OH Estrone

+Cimetidine

+Exercise

+Flax

16α-OH Estrone

+Soy

– Pesticides

+Ω-3 Fatty acids

– Alcohol

+Progesterone

– High Fat Diet

Estriol (E3)

+ Promotes this enzyme

― Inhibits this enzyme

2-OH Estrone

estrogens 2 16 ratio
Estrogens: 2/16 Ratio

1.4

÷

0.7

=

2.0-4.0

1.9

÷

2-OH E1

16-OH E1

© 2010 Meridian Valley Laboratory

20

4 oh estrone
4-OH Estrone

Testosterone

Androstenedione

Estradiol (E2)

Estrone (E1)

4-OH Estrone

16α-OH Estrone

Estriol (E3)

2-OH Estrone

estrogens 4 oh e1
Estrogens: 4-OH E1

<0.25

© 2010 Meridian Valley Laboratory

22

estrogen methylation
Estrogen Methylation

Estradiol (E2)

Estrone (E1)

2-OH Estradiol

2-OH Estrone

+Vitamin B12

+Methionine

+Magnesium

Methylation

+Folate

+Betaine

+SAMe

+Zinc

2-CH3O Estradiol

2-CH3O Estrone

estrogens methylation
Estrogens: Methylation

0.9

<0.1

© 2010 Meridian Valley Laboratory

24

slide25
Treatment Recommendations

Biest 1.25mg qd applied to vaginal labia

Recommendations

© 2010 Meridian Valley Laboratory

25

progesterone
Progesterone

Cholesterol

Pregnenalone

Progesterone

17-OH Pregnenolone

Mineralocorticoids

Pregnandiol

17-OH Progesterone

Androstenedione

Glucocorticoids(Cortisol, et.al.)

Testosterone

Estrogens

progesterone27
Progesterone

95

© 2010 Meridian Valley Laboratory

27

slide28
Treatment Recommendations

Progesterone 25-50 mg qd applied to vaginal labia

Recommendations

© 2010 Meridian Valley Laboratory

28

androgens
Androgens

Cholesterol

Pregnenolone

17-OH Pregnenolone

Androsterone

DHEA

Androstenedione

Etiocholanolone

Testosterone

Estradiol

Estrone

© 2010 Meridian Valley Laboratory

29

testosterone
Testosterone

Testosterone

5β Reductase

Aromatase

5α Reductase

5β-DHT

Estradiol

5α-DHT

5β- Androstanediol

5α-Androstanediol

androgens31
Androgens

25 Low

0.6 Low

6.4

9.8 Low

552

474 Low

© 2010 Meridian Valley Laboratory

31

testosterone32
Testosterone

Testosterone

–Myomin*

–Chrysin

+Cortisol

– GLA

5β Reductase

Aromatase

–Progesterone

+Vit C deficiency

– Zinc

–Aromatase Inhibitors

5α Reductase

+Low T3

– Saw Palmetto

–Grape Seed Extract

+Insulin

– Progesterone

– Quercitin

+Growth Hormone

–Spironolactone

5β-DHT

Estradiol

5α-DHT

5β- Androstanediol

5α-Androstanediol

* Myomin is a product consisting of 4 herbs: Aralia dasyphylla, Curcuma zedoria, Cyperus rotundus, and Smilax glabra

slide33
Treatment Recommendations

DHEA 10mg SL spray

Recommendations

© 2010 Meridian Valley Laboratory

33

adrenal hormones
Adrenal Hormones

Cholesterol

Pregnenolone

Progesterone

DHEA

Mineralocorticoids

Glucocorticoids(Cortisol, et.al.)

TestosteroneEstrogens

© 2010 Meridian Valley Laboratory

glucocorticoids
Glucocorticoids

Cholesterol

Pregnenolone

Pregnanetriol

Progesterone

17-OH Progesterone

11β-OH Androsterone

Cortisol

11β-OH Etiocholanolone

Cortisone

Allo-Tetrahydrocortisol

Tetrahydrocortisol

Tetrahydrocortisone

© 2010 Meridian Valley Laboratory

glucocorticoids36
Glucocorticoids

182

83

45

© 2010 Meridian Valley Laboratory

36

cortisol cortisone
Cortisol & Cortisone

+Insulin Resistance

+Human Growth Hormone

+Testosterone

+Obesity

Cortisone

+Licorice

Cortisol

11β-HSD I

11β-HSD II

© 2010 Meridian Valley Laboratory

glucocorticoids38
Glucocorticoids

2094

1061

1055

4210

646

239

© 2010 Meridian Valley Laboratory

38

slide39
Treatment Recommendations

Adrenal Support: Sodium Ascorbate 2g BID

Pantothenic Acid 250 mg BID

Vitamin A 40,000 IU QD

B6 50mg QD

Chromium 6000 mcg daily for 30 days then taper to 2000 mcg

Adrenal cortical extract

Adaptogenic herbs

Recommendations

© 2010 Meridian Valley Laboratory

39

mineralocorticoids
Mineralocorticoids

Cholesterol

Pregnenolone

Progesterone

Deoxycortisone

Corticosterone

Aldosterone

5α-THB (Allo-Tetrahydrocorticosterone)

THA (11-Dehydrotetrahydrocorticosterone)

THB (Tetrahydrocorticosterone)

© 2010 Meridian Valley Laboratory

mineralocorticoids41
Mineralocorticoids

Normal Diet: 6.0-25.0

Low Salt: 17.0-44.0

High Salt: 0.0-6.0

3.8

234

64

65

130-600

30-240

62-293

© 2010 Meridian Valley Laboratory

41

mineralocorticoids42
Mineralocorticoids

Cholesterol

Pregnenolone

Progesterone

Deoxycortisone

Corticosterone

+ ↑↑Acute Stress

-↑Salt

+ ↑↑Acute Stress

THA (11-Dehydrotetrahydrocorticosterone)

-↑Stress

-↑Chronic Stress

-↑Chronic Stress

-Dehydration

+ Pregnenolone

-Spironolactone

5α-THB (Allo-Tetrahydrocorticosterone)

Aldosterone

+ ↑↑Acute Stress

THB (Tetrahydrocorticosterone)

-↑Chronic Stress

© 2010 Meridian Valley Laboratory

growth hormone
Growth Hormone

Hypothalamus

GHIH

Somatostatin

GHRH

+

GH

Somatotropin

Anterior Pituitary

Adipose Tissue

Growth Factors

Muscle

Cellular Repair and Regeneration

Bone

Skin

Cartilage

Kidney

© 2010 Meridian Valley Laboratory

human growth hormone
Human Growth Hormone

1065-4722

638 Low

© 2010 Meridian Valley Laboratory

44

growth hormone45
Growth Hormone

+ Secretagogues

+ Glutamine (Older people)

+ hCG

+ Arginine (Younger people)

+ Melatonin

+ Resistance Training

+ Thyroid

+ Vigorous Exercise

+ Progesterone

+ Adequate Protein

+ Estrogen

+ Deep Sleep

+ Testosterone

– Sedentary Lifestyle

– Inadequate Protein

– Poor Sleep

– Insufficient endogenous hormones

© 2010 Meridian Valley Laboratory

slide46
Treatment Recommendations

Growth Hormone Support: Get adequate sleep

Aerobic and resistance exercise

Paleolithic diet

Secretogogue- Glutamine 2g QD

Recommendations

© 2010 Meridian Valley Laboratory

46

thyroid hormones
Thyroid Hormones

768

871

470-1750

430-3200

© 2010 Meridian Valley Laboratory

47

urine minerals
Urine Minerals

40-220

26-150

62-293

155

48

3.2

© 2010 Meridian Valley Laboratory

48

slide49
Treatment Recommendations

Increase dietary potassium: avocados

bananas

leafy green veggies

Recommendations

© 2010 Meridian Valley Laboratory

49

5 reductase activity
5-Reductase Activity

© 2010 Meridian Valley Laboratory

50

slide51
Treatment Recommendations

5α Reductase inhibition to decrease facial hair and acne:

Zinc 60mg QD with 8mg Cu

GLA 300mg BID-TID

Saw Palmetto 160 mg BID

Recommendations

© 2010 Meridian Valley Laboratory

51

slide52

11-Hydroxysteroid Dehydrogenase I & II

© 2010 Meridian Valley Laboratory

52

slide53
Lab findings on 24 Hour Urine Hormone test

Low total Estrogen

Suboptimal Estrogen Quotient

Low Pregnandiol (Progesterone)

Low DHEA

Low Testosterone

Low Adrenal metabolites (Cortisol and Cortisone)

Low Aldosterone

Low Growth Hormone

Summary

© 2010 Meridian Valley Laboratory

53

slide54
Lab findings on 24 Hour Urine Hormone test

Low normal Thyroid

High normal Sodium/Potassium ratio

High 5α Reductase activity

Low Cortisol/Cortisone ratio

Summary

© 2010 Meridian Valley Laboratory

54

slide55
Treatment Recommendations

Biest 1.25mg qd applied to vaginal labia

Progesterone 25-50 mg qd applied to vaginal labia

DHEA 10mg SL spray

Adrenal Support: Sodium Ascorbate 2g BID

Pantothenic Acid 250 mg BID

Vitamin A 40,000 IU QD

B6 50mg QD

Chromium 6000 mcg daily for 30 days then taper to 2000 mcg

Adrenal cortical extract

Adaptogenic herbs

Recommendations

© 2010 Meridian Valley Laboratory

55

slide56
Treatment Recommendations

Growth Hormone Support: Get adequate sleep

Aerobic and resistance exercise

Paleolithic diet

Secretogogue- Glutamine 2g QD

Increase dietary potassium: avocados

bananas

leafy green veggies

5α Reductase inhibition to decrease facial hair and acne:

Zinc 60mg QD with 8mg Cu

GLA 300mg BID-TID

Saw Palmetto 160 mg BID

Recommendations

© 2010 Meridian Valley Laboratory

56

slide57

Recommendations

Follow up

  • Repeat test in 3-6 months
  • Consider adding Testosterone 2mg qd applied to the vaginal labia one month after adding in DHEA to improve libido and increase hGH

© 2010 Meridian Valley Laboratory

slide58
Robin, a 51 year old

Post Menopausal Woman

Case 2

© 2010 Meridian Valley Laboratory

58

case history59
Case History
  • Height: 5’7” Weight: 180lbs
  • BP: 106/74 LMP: 2007
  • Premarin for 2 yrs
  • Switched to BHRT 1 year ago
  • Current conditions: hyperlipidemia, depression, fibromyalgia, MS
  • Family hx of CVD, breast CA, osteoporosis

© 2010 Meridian Valley Laboratory

medications and supplements60
Medications and Supplements

Armour thyroid 30mg qd

Progesterone 100mg po qd

Biest 0.625mg/0.1ml days 1-25

Vitamin D

Vitamin E

© 2010 Meridian Valley Laboratory

60

slide61

Signs and Symptoms

  • Symptoms
    • Hot flashes
    • Vaginal Dryness
    • Night sweats
    • Foggy thinking
    • Memory lapse
    • Anxiety
    • High triglycerides
    • Sugar cravings
    • Water retention
    • Heart palpitations

© 2010 Meridian Valley Laboratory

slide62

Signs and Symptoms

  • Symptoms
    • Stress
    • Increased facial hair
    • Fatigue
    • Tearfulness
    • Insomnia
    • Weight gain
    • Irritability
    • Decreased libido
    • Fibrocystic Breasts

© 2010 Meridian Valley Laboratory

total volume creatinine63
Total Volume & Creatinine

1.7 gm/24hr

1600 mL

© 2010 Meridian Valley Laboratory

63

estrogens e1 e2 e364
Estrogens: E1, E2, E3

51.8

Luteal 17-26 10.8-89.2

Follicular 27-11 7.0-110

Mid-Cycle 12-16 38-221

Post Menopausal 0-41

© 2010 Meridian Valley Laboratory

64

estrogens eq65
Estrogens: EQ

8.4

+

4.3

12.7

39.0 ÷

3.1

>1.0

EQ =

E3 ÷

(E1 + E2)

© 2010 Meridian Valley Laboratory

65

estrogens 2 16 ratio66
Estrogens: 2/16 Ratio

5.1

÷

1.4

=

2.0-4.0

3.6

÷

2-OH E1

16-OH E1

© 2010 Meridian Valley Laboratory

66

estrogens 4 oh e167
Estrogens: 4-OH E1

1.0

© 2010 Meridian Valley Laboratory

67

estrogens methylation68
Estrogens: Methylation

3.2

0.2

© 2010 Meridian Valley Laboratory

68

slide69
Treatment Recommendations

Increase Biest to 1.25mg qd for symptom relief

Recommendations

© 2010 Meridian Valley Laboratory

69

progesterone70
Progesterone

13,461 High

© 2010 Meridian Valley Laboratory

70

slide71
Treatment Recommendations

Decrease Progesterone to 25-50 mg qd

Recommendations

© 2010 Meridian Valley Laboratory

71

androgens72
Androgens

104

9.2

19.0

37.3

1254

2715

© 2010 Meridian Valley Laboratory

72

slide73
Treatment Recommendations

DHEA 10mg SL spray

Recommendations

© 2010 Meridian Valley Laboratory

73

glucocorticoids74
Glucocorticoids

345

103

71

© 2010 Meridian Valley Laboratory

74

glucocorticoids75
Glucocorticoids

4414

431

1856

6701

666

403

© 2010 Meridian Valley Laboratory

75

mineralocorticoids76
Mineralocorticoids

Normal Diet: 6.0-25.0

Low Salt: 17.0-44.0

High Salt: 0.0-6.0

8.0

132

243 HIGH

217

130-600

30-240

62-293

© 2010 Meridian Valley Laboratory

76

human growth hormone77
Human Growth Hormone

1065-4722

5496 High

© 2010 Meridian Valley Laboratory

77

slide78
Treatment Recommendations

Growth Hormone Work-up: Check IGF-1 in serum

Assess liver and kidney function

Recommendations

© 2010 Meridian Valley Laboratory

78

thyroid hormones79
Thyroid Hormones

779

516

470-1750

430-3200

© 2010 Meridian Valley Laboratory

79

slide80
Treatment Recommendations

Consider increasing thyroid dose

Recommendations

© 2010 Meridian Valley Laboratory

80

urine minerals81
Urine Minerals

40-220

26-150

62-293

180

41

4.3

© 2010 Meridian Valley Laboratory

81

slide82
Treatment Recommendations

Increase dietary potassium: avocados

bananas

leafy green veggies

Recommendations

© 2010 Meridian Valley Laboratory

82

5 reductase activity83
5-Reductase Activity

© 2010 Meridian Valley Laboratory

83

slide84

11-Hydroxysteroid Dehydrogenase I & II

© 2010 Meridian Valley Laboratory

84

slide85
Lab findings on 24 Hour Urine Hormone test

Estrogen WNL

Estrogen Quotient WNL

High Pregnandiol (Progesterone)

Testosterone WNL

Low NL DHEA

Adrenal metabolites (Cortisol and Cortisone) WNL

High Tetrahydrocortisone

Aldosterone WNL

High Tetrahydrocorticosterone

High Growth Hormone

Summary

© 2010 Meridian Valley Laboratory

85

slide86
Lab findings on 24 Hour Urine Hormone test

Low normal Thyroid

High normal Sodium/Potassium ratio

Low 5α Reductase activity

Cortisol/Cortisone ratio WNL

Summary

© 2010 Meridian Valley Laboratory

86

slide87
Treatment Recommendations

Increase Biest to 1.25mg qd for sx relief

Decrease Progesterone to 25-50 mg qd

DHEA 10mg SL spray

Growth Hormone Work-up: Check IGF-1 in serum

Assess liver and kidney function

Consider increasing thyroid dose

Increase dietary potassium: Avocados

Bananas

Leafy green vegetables

Recommendations

© 2010 Meridian Valley Laboratory

87

slide88

Recommendations

Follow up

  • Repeat test in 6 months – 1 year

© 2010 Meridian Valley Laboratory

next webinar

Next Webinar...

Monday, October 4

1pm PDT

Hormone Testing in Clinical Practice: Part 4

Cases: Interpreting 24-Hour Urine Hormone Profiles - Men