Dried Urine Hormone Testing with Dr. Carrie Jones: Rational Wellness Podcast 98
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Dr. Carrie Jones discusses Dried Urine Testing for Hormones with Dr. Ben Weitz.
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Podcast Highlights
0:58 What is the best way to measure hormones? Serum testing is the gold standard and is the most cost effective, often covered by insurance. However, hormones fluctuate throughout the day and in the Functional Medicine world we have come to appreciate the value of also measuring the hormone metabolites, so doing 24 hour urine testing is one good option. The downside of 24 hour urine testing is that you have to carry around carrying around a large container of urine that must be kept in the fridge between samples. Testing hormones via dried blood or saliva offer the advantages of being done at home by patients instead of requiring a blood drawer, which can be tricky if you are trying to get their sample done at a particular point during their cycle, which could be a weekend. Also saliva seems to be a better way to monitor topical hormones, since these don’t always show up well in the blood. Dried urine seems to offer some of the advantages of urine testing with the ease of a saliva or dried spot. It can also measure hormones at particular points during the day or month.
4:17 Dr. Jones explained that dried urine testing (DUTCH) offers ease and convenience with the benefits of being able to also look at metabolites. If you are a practitioner focused on estrogen, you want to know which metabolite your estrogen is going to turn into, which urine testing offers. With testosterone and DHEA, if you’ve got somebody you’re concerned about their acne, their male pattern baldness, their prostate issues, their PCOS, urine can tell you which androgen pathway they are going down. DHEA and testosterone can go down primarily the more androgenic alpha or the less androgenic beta pathway or it can be split 50:50 down both pathways. If testosterone is primarily going down the alpha pathway of androsterone, dihydrotestosterone (DHT), and 5 alpha Androstanediol, this will tend to contribute to PCOS in a woman and to cystic acne, male pattern baldness, and prostate issues in a man. If a patient tends to be more alpha dominant, we’ll also see this in their progesterone metabolites. What pushed you more down the alpha pathway can be genetic, but the following factors can be modified to change this: 1. Inflammation, 2. Insulin, and 3. Stress. We can also look at the following supplements that are natural 5-alpha blockers: 1. saw palmetto, 2. stinging nettle, 3. zinc, 4. EGCG from green tea, 5. reishi mushroom, and 6. pygeum africanum. These are often found in prostate formulas, but they work for women as well.
9:23 Some people have criticized dried urine testing as having no studies to validate it, but the scientist who developed the DUTCH test, Mark Newman, recently published a study validating the testing of the estrogen and progesterone metabolites via dried filter paper and mass spectometry, which was shown to be comparable to serum: Evaluating urinary estrogen and progesterone metabolites using dried filter paper samples and gas chromatography with tandem mass spectrometry (GC-MS/MS)
10:08 When it comes to estrogen metabolites, we have the 2, 4, and 16-hydroxyestrone pathways. We used to measure the 2:16 ratio as the holy grail of breast cancer risk with the 2 as safe and the 16 as carcinogenic. But later studies showed this simple concept doesn’t really hold up. Dr. Jones explained that the 2 and 4-hydroxy estrones are considered catechol estrogens, which means that they form adducts. The 2 is safer because when it becomes an adduct and if it doesn’t get methylated and go through phase two detoxification in the liver, then it can bind to DNA and form an adduct. It will stay in the DNA and wait for the DNA repair system to excise it. When the 4 becomes becomes an adduct, it breaks out of the DNA and leaves a hole, and the more 4 adducts you have, the more holes in your DNA. Your DNA repair system then is put under pressure to fix all these holes, so the risk for mutation goes up. The 16 pathway doesn’t increase the risk for DNA adducts, but it can increase proliferation, so it is good for bones, but bad for breasts. It can lead to heavy periods and their breasts may tend to get large and tender during the periods. It probably doesn’t increase the risk of breast cancer, but if you have breast cancer, it’s proliferative, so it may add fuel to the fire, so you definitely don’t want a lot of 16.
13:06 The key when looking at these metabolites is how do we fix the estrogen metabolism so that we decrease cancer risk without over methylating? Dr. Jones said we should do SNP gene testing to look for variations in the MTHFR and COMT genes, which will give us some idea. While the DUTCH test does include the 2-methoxy Estradial and Estrone but unfortunately, at this time, it is not possible to accurately measure the methoxy/methylated forms of the 4 and 16 estrogen metabolites, so there is no way to know for sure. DUTCH does include the Methylmalonate (MMA), so this can give you some idea of the B12 status, which is an indicator of methylation.
16:39 Dried Urine Testing can be used to map out a woman’s cycle and DUTCH calls it Cycle Mapping. You basically urinate on a piece of paper almost every morning of your cycle and let it dry and then mail it in. It’s really great for women who have cycle irregularity. Maybe they’ve had a partial hysterectomy or an ablation or they have the Marina IUD and so they have ovaries that function, but they don’t bleed, so they don’t quite know where they are in their cycle. It’s helpful for women with fertility issues (PCOS) or whom have symptoms all month long.
19:12 Dried urine testing can be an effective way to monitor bioidentical hormones, though no testing is effective if somebody is on the birth control pill, the patch, or the ring because of the mechanism of action of those synthetic hormones. It works well for monitoring oral progesterone, DHEA, vaginal estrogen, bioidentical estring (which is a prescription ring but it’s estradiol), the estrogen patch that menopausal women use, and pellet therapy. Topical hormones can be a challenge for dried urine testing. Part of the problem with monitoring hormone levels in women or men who take topical hormones depends upon where they apply it, which can drastically change how much gets absorbed and systemic levels. Topical hormones are problematic for any type of hormone testing, even for saliva testing.
21:05 With salivary cortisol testing you’re looking at free cortisol at 4 times during the day. With dried urine cortisol testing you get metabolized cortisol, free cortisol, and cortisone, which is the inactive form. If cortisone is higher it usually means that you are in a long term state of stress or you have recently been sick.
23:43 Dr. Jones explained that there is no such thing as adrenal fatigue or burnout, since the adrenals never run out of cells and never stop being able to make cortisol. Rather, the adrenals receive signals from the brain, the hypothalamus, to make less cortisol. It is a feedback and receptor issue. When Functional Medicine practitioners recommend adaptogenic herbs to help the adrenals, like ashwaganda, rhodiola, or eleutherococcus, these may be helping but not just because they support the adrenal glands. They support not just the adrenals, but they are thyroid supportive, immune supportive, neuro supportive, GI supportive etc. Adrenal glandulars may work not just because they support the adrenals, but because they provide nutrients like amino acids and other nutrients that support many glands in the body and not just the adrenals.
28:00 The cortisol awakening response (CAR) is what happens during the first 30 minutes upon awakening. Your cortisol is supposed to go up at least 50% in that first 30 minutes. When you open your eyes in the morning your brain signals your adrenals to make cortisol, which goes up in the first 30 minutes. It shows your body’s response to stress. If you’re too high or too low, then you’re not going to get the rest of your day right either. And then after 60 minutes it starts to fall back down. Most saliva testing companies require you to spit into a tube and fill it up before getting out of bed without drinking any water, which can be difficult and even stressful to do. But the DUTCH CAR test only requires you to place a cotton swab in your mouth to collect saliva, which is much easier to do. The DUTCH Adrenal test can also help with insomnia, so if you awake in the night, you collect a saliva sample when you awake. If you are using DUTCH for both adrenals and hormones–the DUTCH Complete test, then the rest of the cortisol and cortisone samples after the CAR will be with dried urine. Here is a paper that I found helpful in understanding the utility of the Cortisol Awakening Response: Daily life stress and the Cortisol Awakening Response: testing the anticipation hypothesis.
Dr. Carrie Jones is a Naturopathic Physician with a Master’s in Public Health and over 12 years experience in Functional Medicine. Dr. Jones is the Medical Director for Precision Analytical, creators of the DUTCH, dried urine hormone test. The website is DUTCHTest.com and the phone number of the lab is 503-687-2050.
Dr. Ben Weitz is available for nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or go to www.drweitz.com.
Podcast Transcripts
Dr. Weitz: This is Dr. Ben Weitz with the Rational Wellness podcast, bringing you the cutting edge information on health and nutrition. From the latest scientific research and by interviewing the top experts in the field. Please subscribe to the Rational Wellness podcast on iTunes and YouTube and sign up for my free ebook on my website by going to drweitz.com. Let’s get started on your road to better health. Hello Rational Wellness podcasters. Thank you so much for joining me again today. For those of you who enjoy listening to the Rational Wellness podcast, please go to iTunes and give us a ratings and review, that way more people will find out about the Rational Wellness podcast.
Our topic for today is dried urine testing for hormones with Dr. Carrie Jones. While conventional medical doctors typically measure hormones only in serum, in the functional medicine world, we’ve come to appreciate some of the advantages of measuring hormones in urine so we can capture the hormone metabolites to see if and how these hormones are being processed by the body. However, hormones fluctuate throughout the day so measuring 24 urine is a way to capture that. But it requires carrying around a large container of urine that must be kept in the fridge between samples. We’ve also come to appreciate some of the advantages of testing hormones via dried blood and saliva since it can be done at home by patients instead of requiring a blood draw which is especially tricky if you’re trying to get a patient to get their sample done at a particular point during their cycle, maybe that’s going to be a weekend day or at a particular time of the day since hormones fluctuate throughout the day. Dried urine seems to offer some of the advantages of combining urine testing with the ease of a saliva or dried spot. Now look, there are advantages and disadvantages of every form of hormone testing. Serum testing has some advantages since it’s most likely to be covered by insurance and it may be the most cost effective. But 95 to 99% of hormones measured in serum are tightly bound by binding proteins which doesn’t reflect the unbound or free hormones that are available to the tissues. And serum testing cannot measure estrogen or androgen or adrenal metabolites. And it also does not appear to be a good way to monitor men and women who are taking hormones topically.
Saliva testing may be a better way to monitor levels of hormones taken topically, however, some of the problems with saliva testing include that it appears to be less consistent, it’s adversely affected by eating, drinking, gum chewing and tooth brushing which can result in micro-damage and can result in elevated salivary testosterone levels for up to an hour after brushing. Even in the absence of visible signs of bleeding.
24 hour urine testing has the advantage of being able to measure hormone metabolites over the course of the day though these will essentially be averaged. The disadvantages of urine testing include that it’s only measuring hormones that have been excreted and it’s not a direct measure of bioavailable hormones. An analogy would be, measuring how much food people eat by going through their trashcans. Also, urine testing cannot measure thyroid hormones.
Dr. Carrie Jones is a naturopathic physician with a Masters in public health and over 12 years of experience in Functional Medicine. She’s the medical director for Precision Analytical, the creators of the Dutch dried urine testing. Dr. Jones, thank you so much for joining me today.
Dr. Jones: Thanks for having me on. That was definitely one heck of an introduction. You sure covered all the key highlights. I think we’re done. That’s it. I love it.
Dr. Weitz: Good. Why would a Functional Medicine practitioner want to do dried urine testing versus serum or saliva or 24 hour urine?
Dr. Jones: Definitely well one of the big things that you touched on was ease and convenience. If a lot of people are afraid to get their blood drawn. A lot of people can’t come with the saliva to do a saliva test. To spit in a tube. They don’t want to carry the jug around 24 hours and collect every single last drop of urine they make and so the dried urine test was created for this happy medium. You get to do it multiple times in the day. You don’t have to spit. You don’t have to get your blood drawn or your finger poked and it’s little pieces of paper that you urinate on so convenience is huge and pretty much everyone can manage that. To urinate on a piece of paper. But the second thing is what you also mentioned are the metabolites. One of the things you said is that urine doesn’t have bioavailable but in fact it does. It’s the bioavailable that actually, that comes through as the free. That’s what comes through, not the bound. ‘Cause if it’s bound it can’t be metabolized, so it’s only the bioavailable that can. It does.
But, metabolites are super important if you’re looking for pathways. If you’re a practitioner focused on estrogen and you want to know which pathway, which metabolite your estrogen is going to turn into, urine is the way to do it. You can’t get it in blood and you can’t get it in saliva. Just like testosterone or DHEA, if you’ve got somebody you’re concerned about their acne, their male pattern baldness, their prostate issues, their PCOS, and you’re looking to see if they’re going down that sort of androgen pathway of naughtiness then urine is the way to go. Saliva and serum will tell you your testosterone in the moment, your DHEA in the moment but that could be normal, however it’s going down the pathway with all the side effects.
Dr. Weitz: Okay, well why don’t we explore that? Because I think a lot of people are at least somewhat aware that the metabolites of estrogen can affect cancer risk but I think a lot of folks are not quite aware what the advantages of looking at testosterone metabolites are.
Dr. Jones: Yeah, so when the body makes either DHEA or testosterone, obviously just like estrogen, it can push it into other metabolites. Most everyone’s familiar with the metabolite DHT, dihydrotestosterone. You can check it in serum but there’s other ones and they all have fancy big names. I don’t know who decided to name them but it’s things like etiocholanolone, androsterone, 5-alpha, androstenediol, these crazy names. But basically what they do as a family is they tell us when you make DHEA or you make testosterone, which side does it go down? Is it pretty much split 50/50 or does it go down the androgenic alpha side primarily? Or the less androgenic beta side? Let’s say you’ve got somebody like I was saying with PCOS or you’ve got a man who has cystic acne, he’s got male pattern baldness, he’s maybe having some prostate issues and you do a serum testosterone or you do serum even DHEA and it’s normal. You’re like, well that’s weird, he has all these symptoms. When you know this pathway, when you can look to see if his androsterone, his DHT, his 5-alpha, androstenediol are elevated then you know this gentleman or even this female is going right down that alpha pathway, causing all these symptoms and more importantly you can do something about it. You can intervene and try to help.
Dr. Weitz: If the testosterone is going down that pathway of DHT, that’s going to increase risk of male pattern baldness, that’s going to increase prostatitis, does that increase prostate cancer risk as well?
Dr. Jones: The research is interesting when it comes to prostate risk, prostate cancer risk for DHT. There’s some of the testosterone metabolites yes, they can increase. Not all of them but some of them, yeah. It’s good to follow.
Dr. Weitz: What are the best ways to push it the other way?
Dr. Jones: Well lifestyle factors is a big one. What pushed you down the alpha sometimes is genetic. Some people are just genetically alpha folks and we’ll see this as well in their progesterone. Men and women of course both make progesterone but if their alpha progesterone’s more dominant, we know they’re just an alpha person. But, other things like inflammation, insulin, stress. We’ll sort of see those common themes will push the alpha more. Working on addressing that helps but then we look at we call 5-alpha blockers. They’re natural supplements like saw palmetto, stinging nettle root, zinc, EGCG, that’s in green tea, reishi mushroom, pygeum which is known as pygeum africanum. All these things help lessen the load on the alpha side and kind of push it a little bit more towards the beta side. It works in men just as much as it works in women. I tease women all the time, you’re going to see these products in prostate formulas, you’ll probably need the same formula, just pay no attention to the title.
Dr. Weitz: Yes. I recently interviewed Frank Nordt from Reine Labs. They do 24 hour urine testing. He said, “There’s no scientific validation for dried urine testing.”
Dr. Jones: It’s not true. In fact we have a great study that just came out.
Dr. Weitz: I read it. [Here is the paper: Evaluating urinary estrogen and progesterone metabolites using dried filter paper samples and gas chromatography with tandem mass spectrometry (GC-MS/MS)]
Dr. Jones: It’s public. No, there’s research coming and we have another one coming behind that as well.
Dr. Weitz: What did that paper show?
Dr. Jones: That one was in particular for estrogen and progesterone in blood and it showed that it has great correlation. Dried urine when you’re looking at estrone, estradiol, comparing it to serum, had great correlation. You can effectively use it for hormones.
Dr. Weitz: Cool. When it comes to women’s hormones, I’d like to touch on the metabolism of estrogen and what increases risk of breast cancer. For years we used to measure the 2 to 16 ratio and we thought was the holy grail and more two was safe. That was anti-carcinogenic and 16 was bad and 4 we weren’t quite sure about. And then they started being a bunch of papers that seemed to show that it really wasn’t valid. 16 wasn’t necessarily correlated with anything and then it seems like more of the interesting research has been with the four as potentially being related to cancer but I did a quick literature search and I saw several papers from 2017 that seemed to be validating the two to 16 ratio again. Where do you think we are?
Dr. Jones: Here’s the thing with cancer that what originally said the 2, 16. The 2 and the 4 are considered catechol estrogens which means they can form adducts. A-D-D-U-C-T-S, adducts. The reason the 2-hydroxy is considered safer is that when 2 becomes an adduct, if it doesn’t get methylated, if it doesn’t go through phase two, and it binds to DNA and forms an adduct, like a very obedient child, it just stays in the DNA. It’s not supposed to be there but it stays there and it waits for your DNA excision, your basically your DNA repair system to come in, notice it’s a problem, and then fix it. Whereas the 4, the 4 pathway, when it becomes an adduct with the DNA, it’s a very naughty child and it breaks out of the DNA and leaves a hole. And when the four adducts break off and the more 4 adducts you have breaking off, the more holes you have in your DNA. Now your DNA repair system is like, crap, I’m full of holes and it has to increase repair so to speak and the risk for mutation goes up. It’s like a factory that’s been given a double, triple, quadruple order and yet you don’t have the people, the machines, the what have you, to make it happen so mistakes happen. Things get missed. Things slip through that quality assurance maybe before would have been fine. Now you have this increased risk for mutation.
The 16 pathway doesn’t increase the risk for adducts but it can increase proliferation, so good for bones, bad for boobs. It’s also bad for other things. Heavy periods. If I see somebody who has a higher 16 in their result and they report clotty periods, heavy periods, their breasts get large and tender, then I know that they’ve got this proliferative effect. If you have breast cancer, it’s proliferative so you definitely don’t want a whole lot of 16 because it’s just going to add fuel to the fire but it’s the four that really increases your risk for that adduct mutation when it’s trying to fix it, fix the hole.
Dr. Weitz: Based on looking at these metabolites, how do we know how to fix the metabolism so that we decrease cancer risk without over methylating?
Dr. Jones: Now with urine testing, you cannot tell if somebody is an over or hyper-methylator. You can only do that through SNP testing. On urine, any urine, dried urine, 24 hour urine, Frank’s urine, doesn’t matter, Rheine Labs, if somebody has quote high methylation, it just means the ratio between their ability to get from phase one, the hydroxy phase, to phase two, the methoxy phase, looks really in the favor of methylation. But does that actually mean they have the fast COMT? I don’t know. I won’t know that until you do SNP testing.
Dr. Weitz: Couldn’t we tell by looking at B12? I notice that you have a marker, B12 in some of your testing now.
Dr. Jones: We do. We have one of the, we have MMA. We have the organic acid methylmalonate, yeah, we do have that marker. And we also have HVA and VMA which are also of course broken down by MAO as well but they are broken down by COMT.
Dr. Weitz: Do you think that is a way to tell how much you’re methylating?
Dr. Jones: It’s still not absolute. It’s still not absolute. They are good markers, good indicator markers but if somebody’s like, does this mean that I have a fast COMT, I don’t know. A 100% I don’t know until I actually see your SNP test.
Dr. Weitz: But even if you have a snip, still how do you know how much?
Dr. Jones: Correct. Correct. ‘Cause you could have normal. You could have heterozygous, not even a fast COMT. You can have a heterozygous COMT but yet whatever you’re doing and something is speeding it up. And then if you knock that off, it’ll go back to normal or slow back down. Maybe if you are a homozygous fast person but on testing everything looks normal and you’re like, well it’s not manifesting. I have a fast comped but it’s not showing up on test. But if you have things on testing that look like it should be fast and you know on SNP testing you have the fast results then, there you go. You’re fast. Then it lines up, absolutely, yes.
Dr. Weitz: Now does your test measure whether the 4 is getting methylated or not?
Dr. Jones: We don’t look at the 4. We don’t look at the 4 and the reason we don’t is because the result for 4, it’s so tiny that the accuracy gets very, very messy and that’s what we find when we look at a lot of the other companies. Is that when you look at the reference ranges it’s like .000 or .00 whatever and once you get into the more than one zeroes it can be really messy, really quickly. I have heard from other people who use other companies that it’s a struggle because it often looks core but when it’s in the cancer world, that’s really concerning ’cause then you freak out, oh my gosh, my four is not methylating, I’m going to get cancer but really it might just be noise and messiness. We choose, we can run it, we choose not to run it to not mislead practitioners since we’re not a 100% when it comes to that, something that small.
Dr. Weitz: It’s too bad that there’s not some way to measure that ’cause that might be a way to decide how much methyl B vitamins to give.
Dr. Jones: Yes, yeah, yeah, exactly. Exactly. It’s definitely a work in progress in trying to figure out the best way. Yeah, most definitely.
Dr. Weitz: Right. How can we use dried urine testing to map out a woman’s cycle and what can that tell us? How can that help with fertility problems or PCOS or things like that?
Dr. Jones: Definitely. In fact, ours is called they cycle mapping. I just did mine. I do mine every January and so much like saliva, a lot of people are familiar with doing the month long saliva collection. You can do the month long dried urine testing if you’re looking for the entire month. It’s very easy. It’s very straightforward. Basically, almost every morning of your cycle, you will urinate on a piece of paper and let it dry and then by the time your next period comes and you mail everything in and the estrogen and progesterone is tracked out through the month. It’s really great for women who have cycle irregularity. Maybe they’ve had a partial hysterectomy or an ablation or they have the Marina IUD and so they have ovaries that function but they don’t bleed so they don’t quite know where they are in their cycle. Women with a lot of fertility issues. Women who have symptoms all month long. I have a lot of women that say, “I’m symptomatic at ovulation, I’m symptomatic from ovulation until my period comes.” And so you need a much bigger picture, you need all month long as opposed to just a one day snapshot. I do mine every January. This January I was doing the fasting mimicking diet so I did it at the same time I was doing the fasting mimicking diet, I was doing cortisol collection and the cycle mapping and I’m doing my washout next month. I will collect a cycle map again, I’ll be a month removed from the fasting mimicking diet to see how it looks.
Dr. Weitz: What did you find with the fasting mimicking diet and cycle mapping?
Dr. Jones: My cycle mapping I did it last year, so all I have to compare it to was last year’s. Last year my progesterone rise is pathetic. Oh my gosh, that is pathetic. So sad. But my estrogen’s really high in the luteal phase and then this, when I just got the result back, my progesterone looks better and my estrogen’s not nearly as high which I don’t know yet if that’s my normal or if that because a year is spanned and I’ve done a lot of work. Or if that was the effect of the fasting mimicking diet. I’m waiting a month and then I’ll do it for the month of March and I’ll compare January then to March and if they look the exact same then, or maybe March will look better. Maybe March will look worse and then we’ll compare and see what’s going on. I’m collecting a lot of my own data points to see what’s happening. Including cortisol.
Dr. Weitz: How well does dried urine help us to monitor women who are on hormones?
Dr. Jones: As long as it’s bioidentical hormones, great. Obviously if it’s synthetic if like for example, they’re on the birth control pill, no testing is good if somebody is on the birth control pill, the patch, the ring because of the mechanism of action of that synthetic hormone. But, if somebody’s on oral progesterone, DHEA, vaginal estrogen, even bioidentical estring which is a prescription ring but it’s estradiol, the estrogen patch that menopausal women use. Pellets, lot of pellet therapy out there right now. Great, it works really great for that.
You did mention the topical hormone. Topical hormone can be a little bit of a challenge of course for dried urine but we find that topical hormone as you probably know, is challenging in really any testing realm. There’s no great, we can’t control topical hormone, it depends on the tissue it’s in. If you rub it in the inner thigh, if you rub it on the belly, if you rub it on your inner arm, if you’re far away from the saliva gland, close to the saliva gland, they’ve shown that the levels can definitely vary. If you rub it on topically, what it is in the endometrium, what it is in the breast tissue, what it is in that skin right there, varies. And that’s what makes it challenging, especially topical progesterone. Especially, progesterone’s just it’s own beast when it comes to the topical nature. But as far as other hormone monitoring goes, great. It’s used often.
Dr. Weitz: Right. I understand it’s not as effective for progesterone monitoring, right?
Dr. Jones: Topical. Topical. Just like saliva. Saliva has a lot of caveats with topical progesterone, yeah. But with oral progesterone, people can, we much like saliva we adjust the ranges to account for first pass.
Dr. Weitz: Okay. Let’s talk about the cortisol test. Dutch urinary cortisol test compared to the salivary cortisol test.
Dr. Jones: Yeah, very different. With salivary cortisol you’re looking at free cortisol at certain points through the day. Usually salivary does first thing in the morning, around lunch, around dinner and before bed. That gives you the free inactive cortisol. With dried urine, you get three things. You get metabolized cortisol which sort of gives you the idea of can your adrenals even make cortisol in the first place? What’s your potential? You get the free cortisol, the bioavailable ’cause that’s what comes through. And you get cortisone which is inactive. I can tell you, can you make it? How much is free in the pattern? And then, what’s getting deactivated? Because some people might have really low free cortisol and it’s not a production problem, it’s a deactivation problem. And the treatment’s different. It’s nice to see. And some people have everything. They don’t make it. They don’t have a lot of free. Whatever they do make, they deactivate and then those people are tired.
Dr. Weitz: What do you do if it’s deactivated? What’s it mean for your cortisol to be deactivated?
Dr. Jones: Your body always preferentially makes cortisol and it can deactivate it to cortisone. Not hydrocortisone, what everybody’s used to. Hydrocortisone, the topical that you get at the pharmacy, that’s actually cortisol, it’s just a pharmaceutical naming thing. Cortisone is inactive. It’s the inactive form of cortisol and the body can flip it back and forth depending on the location, the receptors it’s around and the need of the body. You may, if you systemically have an up regulation in the enzyme that deactivates cortisol then you’re going to have a lot more cortisone. Your body is not going to have a lot of cortisol available.
We see this a lot with chronic long term sort of stress states where the body is trying to get you to slow down. When it’s like, my analogy is like the body is tired of you burning the candle at the both ends so it will force you to slow down. It will convert to cortisone. The other time we see it all the time is immediately after illness. You’ve been sick, you got the flu this season, you’re back at work but you’re super tired. You see patients but you need to sit down in between, you’re out of breath. We see that a lot of times the body as part of the healing, will convert into cortisone, sort of one of those, if we slow you down, try to get you to heal longer, or hopefully you’ll rest so that you can heal faster, versus people who get sick and it seems to linger around for a while. Those are the two big reasons that we’ll see cortisone be a lot higher on testing.
Dr. Weitz: Does this tie into the whole issue about adrenal fatigue and if we see somebody with a fairly flat cortisol level and we’ve traditionally thought that the adrenal gland is burned out and can’t produce cortisol? That really what’s happening is is a lot of it’s being deactivated?
Dr. Jones: It depends. If the metabolized cortisol is low and remember, unless it’s Addison’s disease, which is the autoimmune condition, the adrenal glands don’t burn out. They don’t run out of cells. It’s the brain where all the communication comes from. If the metabolized cortisol is low, then that means the brain is not telling the adrenal gland to make cortisol, therefore the free cortisol’s low. If your cortisone is high though, then you may have low, flat cortisol because everything’s getting deactivated to cortisone. In that case it’s not an adrenal issue at all. It’s not an HPA, meaning the brain is not telling the adrenal to make cortisol. It’s getting deactivated.
Dr. Weitz: Why would the brain tell the adrenals to make less cortisol?
Dr. Jones: Lots of reasons. Over time you get a lot of feedback up to the brain to make less cortisol. You’ve got receptor issues. You’ve got tissue issues. But a lot of times it’s like a child that’s trying to get its mom’s attention and so it says it over and over. Mom, mom, mom, mom, mom and so you get this down-regulation because the body initially puts out lots of cortisol and then it’s like, oh good gracious and it starts to down regulate the cortisol. And so it’s more of a brain down as opposed to the adrenal gland itself. Again, this is assuming it’s not Addison’s it’s just over time, people get this down-regulation. We also get assaults from all sort of environmental toxicants. We’re surrounded by viruses and mold and these and other infections. Again, initially it might bring your cortisol up but over time, it’ll start to drop it down. The brain starts to down-regulate the cortisol response.
Dr. Weitz: Now, myself and a number of other, a lot of Functional Medicine practitioners I’ve spoken to over the years, when we have patients who have this fatigue and you do one of these salivary cortisol tests and it shows that the cortisol levels are lower, flat lined, or something like that and then we use various sorts of supplements to help support the adrenal glands. Either we use adaptogens or we use glandulars or combinations and a lot of times those patients get better. If it’s not that the adrenal glands are not producing, what are we really doing? And why is it working?
Dr. Jones: Right? Well think about it. Everybody and I point this out all the time in lectures and people are like, oh yeah, of course. We give herbs that adrenal adaptogens. Ashwagandha, rhodiola, Eleutherococcus, but they are not just adrenal adaptogens. They don’t just hone in on the adrenal glands. They’re very immune supportive. They’re very thyroid supportive. They’re very digestive supportive depending where they are. They’re very neurologic supportive. And so when you give a quote unquote adrenal adaptogen, the title is misleading. Yes, absolutely it helps the HPA access but it’s a very broad spectrum helper type of herb. You’re getting the immune support, you’re getting the neuro support, you’re getting the GI, the thyroid support. You just forgot ’cause you called it an adrenal adaptogen or you told the patient, “Oh, it’s ashwagandha. It’s for your adrenals.” But ashwagandha is supportive to the thyroid absolutely and the immune system.
Dr. Weitz: Maybe with the glandulars we’re getting a good quality amino acid product?
Dr. Jones: Absolutely. Absolutely. And it depends what glandular that you use. A lot of companies will mix a few together. They’ll put adrenal and they’ll add in some other thymus or spleen or whatnot or brain. They’ll put in hypothalamus or thyroid. You’ve got this minute blend of some other really good glandulars that are helpful for other parts of the body and now things are working again ’cause you’ve got support from a systemic point of view, you just patient’s just didn’t realize it.
Dr. Weitz: Cool. Can you talk about the cortisol awakening response and how you measure it with your test and what incidence of this is?
Dr. Jones: It’s one of my favorite tests actually. The cortisol awakening response, the CAR, when you wake up in the morning, when your eyes open up then the signal goes from your brain to your adrenals to make cortisol right now. While you were sleeping, the signal is starting to get bigger and bigger and bigger but the adrenals aren’t listening because you haven’t yet opened your eyes. Once you open your eyes, all bets are off. Signal goes up, cortisol comes out. Your cortisol goes up exponentially in about 30 minutes. It goes up in about 30 minutes-ish and then after about 60 minutes, starts to fall back down and that initial up down in 30 to 60 minutes is what’s known as the cortisol awakening response. It’s super important. They call it the mini stress test of your day because it’s what gets your butt out of bed. It’s what helps you deal with the fact that you haven’t had breakfast yet. It’s blood sugar balancing, it helps with inflammation, your immune system. It helps reduce autoimmunity. And if you can’t get that right, if you overshoot, if you’re too high or if you undershoot, you’re too low, you’re flat lined, then you’re not going to get the rest of your day right either is what they say. If you can’t get that right, you’re going to miss a lot of other important parts of your adrenal response because you can’t get that part. You’re going to have inflammation issues. You’re going to have blood sugar issues. You might have autoimmune issues because you don’t get that initial CAR right. It’s a neat little test for those people who are really struggling with all sorts of symptoms.
Dr. Weitz: And so let’s say somebody has, doesn’t have that initial response, but then the rest of their adrenal pattern is normal.
Dr. Jones: But, remember, it’s going down. It’s easy to go down. It’s hard to go up. With the rest of the day normal, what you’ll see is maybe their afternoon and their dinner point in range but what you don’t know is if their response to things have been normal. You don’t know if those people are having normal responses to stress, normal responses to blood sugar issues, normal responses to pain.
Dr. Weitz: I got it.
Dr. Jones: All you see are the point in the afternoon and the point at night. And usually I’m sure you have your patients tell you, “No, I don’t feel normal.” Usually they say, “No, I have hyper, hypoglycemia. Yes I have pain. I feel more inflamed. My autoimmune is worse. I can’t sleep.” You’ll get these symptoms.
Dr. Weitz: Now I know one of the issues with the salivary cortisol testing is that it seems especially to women, say “I can’t fill up that little tube.” I know your testing uses a different method, right?
Dr. Jones: We do. The cortisol awakening response can only be done in saliva. While we are a dried urine company, when we do the cortisol awakening response, we do have a saliva component of it. Our saliva component are on these little sort of microfiber, basically like a cotton swab, like a wad of cotton. People just put it in their mouth and get it wet as they’re doing the testing. There’s no spitting, they just have to put cotton in their mouth and get it wet and then put it back in the tube. The reason we can do that is we don’t pull other hormone off of the cotton swabs. You can’t pull hormone, especially progesterone off of those cotton swabs. There’s a lot of interference and so saliva companies have tried in the past to do the cotton swabs but then they realized to get the rest of the hormones they need free flowing saliva but cortisol does not have that problem in the cotton swab so that’s why we can use ’cause we pull hormones off the dried urine and cortisol when we’re doing the cortisol awakening response off the cotton swab.
Dr. Weitz: Yeah, I’ve heard some discussion of one of the issues with doing this kind of test with the spitting into the little tubes is if the person’s stresses out about it then they’re going to create an adrenal cortisol response just trying to fulfill the test.
Dr. Jones: And the other, and I hear this response as well is you’ve got 30 minutes. When you’re doing the cortisol awakening response so you wake up, let’s say you wake up at 6:00 in the morning and you immediately have to fill up the tube with saliva, and then but you have to it again at 6:30 in the morning and then you have to it again at 7:00 in the morning and that can be really time consuming if you’re also trying to live your life or get ready for work or get your kids ups and going. And if it takes you 10, 15, 20 minutes to fill a tube but you have to do it every 30 minutes, I have definitely had that feedback that it is a challenge. Some companies what they’ve done to counter that is they’ve shortened their tubes. There are a few companies that have heard people’s complaints and now make smaller tubes for the cortisol awakening response. Not as much saliva’s needed.
Dr. Weitz: I see. The first test tube, the first tube, has to be done within five minutes, right?
Dr. Jones: Right. Which is the other problem because if you’re still trying to spit in a tube 20 minutes later, you’re sort of missing the point.
Dr. Weitz: And you can’t get up and get a glass of water and things like that.
Dr. Jones: No. You’ll dilute it. You can’t do it. You can’t eat. You can’t drink. You can’t wash your mouth out. You can’t do any of that because you will dilute the saliva. You can’t dilute the saliva.
Dr. Weitz: Now, but what about doing a urine test? What if you can’t urinate? Do you just drink as much water as you can? Or does that throw it off?
Dr. Jones: You can’t. No. The first morning, the first test is very easy ’cause usually most people have to wake up and go to the bathroom. With the Dutch test when we’re doing the hormone part, you do it on waking and then two hours later. In between those two hours, we suggest people drink no more than eight ounces of fluid. And the reason is we’re a urine test so don’t dilute it. Just like with saliva, you don’t want to drink water and then spit in the tube ’cause you’ll dilute it. If you drink copious amounts of water and hope to help yourself urinate, then you will dilute the results. We do suggest no more than eight ounces in between that two hour mark. Which can pose a problem for some people still but so far, most people, we don’t require much and so just a little bit to saturate the filter paper.
Dr. Weitz: Cool.
Dr. Jones: Yeah.
Dr. Weitz: Good, good. I think those are the questions that I had prepared for you for today and I think that was good amount of information.
Dr. Jones: Yeah, covered a lot.
Dr. Weitz: How can our listeners and viewers find out about the Dutch testing?
Dr. Jones: Easy enough, website, dutchtest.com, everything on there is free. You don’t have to be an actual practitioner. Right now all our videos and webinars and guide sheets and whatnot are all on there and they’re all available so people can go learn.
Dr. Weitz: And what about patients? Can patients order the test directly themselves?
Dr. Jones: They can order the test directly themselves. Unfortunately, when they do order it from themselves, we do have quite a markup on there and we don’t give any medical support. If somebody orders it themself, we do refer them. We have a Dutch provider referral network that we refer to every day all the time but we strongly encourage people to find a provider first and go through their provider to order the test because then of course they’ll get good quality care as opposed to floundering around by themselves.
Dr. Weitz: Right. Their best bet, find a Functional Medicine practitioner.
Dr. Jones: We can help with that people.
Dr. Weitz: Themself.
Dr. Jones: Yep, come see you. Call the lab. Let us know where you live. We can direct you to somebody who’s Dutch qualified and then they can help.
Dr. Weitz: Excellent. Thank you Carrie.
Dr. Jones: Yeah, thanks so much. I appreciate it.
