Hormonal imbalances are quite the norm these days. But accurate testing is not.

You’ve likely had your blood drawn to evaluate Estrogen or Progesterone. Or maybe a saliva test. But if you haven’t had urine testing, you are missing the whole picture entirely.

That’s right, urine. It is the “gold” standard, literally.

Serum (blood) testing is a quick and easy way to check Progesterone, Testosterone, and DHEA-S accurately. Saliva testing is generally used to check cortisol levels – but if you’re having to spit in a tube until it is full, it’s not accurate. But aside from that, hormone evaluation needs to be done with urine.

Let me explain.

I tell patients all the time – I can make a pretty good estimate of where your hormone levels are based off your symptoms. But what I cannot tell you, is how your body is metabolizing those hormones. And that is generally where issues come from!

Basically, it is not the level of your hormones causing problems. It is what your body is (or isn’t) doing with them, that creates a mess. And all of this applies to women AND men!

We make hormones. Use them. And then have to get rid of them. This is called hormone metabolism. The majority of this process takes place in the liver, and which pathways are involved and by how much, are determined by how you were made. But it is also why we must always address the liver and make sure it is functioning optimally!

Same with the gut. The third phase of Estrogen metabolism takes place in the gut. And if there is dysbiosis (imbalances), Estrogen will accumulate and contribute to Estrogen dominance. Which makes Estrogen levels in blood inaccurate for this reason!

So step one is to always make sure detox pathways are open and optimal. (Pooping once a week is NOT considered optimal, by the way.)

Let’s go into more detail with each hormone and its metabolites.

Pregnenolone is the precursor for all of our hormones, and comes directly from cholesterol. Which is why women MUST be eating healthy fats for hormone health! And also why women on statins can end up with significant hormonal issues.

Pregnenolone then turns into DHEA. DHEA must be sulfated (activated) for use. You can take all the DHEA in the world, but if your body isn’t activating it, it’s pointless. Sulfation is impaired because of genetics, inflammation, or gut dysbiosis.

Next we make Testosterone, with DHEA as its precursor. Testosterone works on a negative feedback loop (like most hormones) and if you are getting too much, it shuts down your body’s natural production. (Cough, cough—women with pellets, this one is for you!)

When Testosterone breaks down, there is a 5β and 5⍺ pathway. Depending on which one you favor, you will be more symptomatic from Testosterone, experiencing things like dark, coarse hair, acne, greasy hair, oily skin, and mood rages. And while we can’t change how God made you, we can shift that Testosterone over to the more favorable pathway with specific supplements.

It’s the same thing with Progesterone. It also has 5β and 5⍺ metabolites. Progesterone is supposed to be our calm, cool, everything is right in the world hormone. If you happen to favor one pathway over the other though, you will be the woman that suffers from irritability and maybe even PMDD before your cycle. It is also important to know which path, as it influences how well you will sleep in menopause and how to appropriately dose your bio-identical Progesterone.

And then there’s Estrogen. It metabolizes in three phases. 1 and 2 take place in the liver. And 3 takes place in the gut. (We have a great blog on this specifically, ​linked here​.) This is arguably the most important hormone to fully understand from a metabolism standpoint.

In phase 1, Estrogen (all three types) can metabolize down one of three pathways in the liver. Which pathway is preferred can be the reason you struggle with acne, fibroids, endometriosis, heavy periods, large clots, migraines, autoimmune disease, or even breast cancer.

Phase 2 is also in the liver and directly influenced by your MTHFR and COMT genes. Along with magnesium. If those are mutated, it can lead to Estrogen getting “stuck” and therefore Estrogen dominance and increased risk for lifetime accumulation of Estrogens, potentially causing major issues.

Cortisol and its metabolites give us insight into how the thyroid is functioning, if your body is storing most of your cortisol as cortisone for reserve, or if your lack of energy, motivation, brain fog, irritability, and weight gain is from a cortisol issue.

NONE of this can be evaluated with blood or saliva testing. See why urine is the ultimate way to test?

When I review a DUTCH (dried urine test for comprehensive hormones) test, patients are amazed. They had no idea hormones were so complex and intricate. And I will tell you, NONE of us are the same. Which is why your hormone treatment plan must be individualized for you. Not a standardized dose they give to everyone of just Estrogen, Progesterone, or Testosterone.

Now before you call us and insist we test your hormones, we MUST start with the gut! Your hormones will not stay balanced, if we do not fix your microbiome first. In fact, 68% of hormones improve by fixing the gut alone! And remember my analogy–your hormones are the thermostat in the house. If we keep adjusting the thermostat without addressing the roof that is pouring in rain, the walls caving in, and the cracked foundation–the thermostat will not stay where we set it!

At Nebraska Functional Medicine, we take a whole-person approach to your health. And this means doing things in the right order for the very best outcomes!