Carrie Jones, ND, MPH Medical Director– Precision Analytical, Inc.

©2016

Dried Urine Testing for Comprehensive Hormones: Case Examples and Clinical Pearls

Objectives

• What is DUTCH and how is this test different?

• What is the research validating DUTCH testing?

• When do I use Dutch testing?

• Clinical Pearls and case study examples

What is the job of a lab test?

->To characterize the patient with respect to a particular

biomarker

Your patient needs lab testing… • 4-Spot Dried Urine (DUTCH) • Assess diurnal pattern in 4 easy at-home collections

throughout the day • Free cortisol/metabolized cortisol • DHEA and metabolites, melatonin • Sex hormones (testosterone, progesterone

metabolites, estrogen including estrogen metabolism) • Billable to insurance, HSA/FSA • Can indicate Addison’s/Cushing’s

• 24-Hour Urine • Collect urine in a jug over 24 hours – no diurnal pattern,

just one total number • Reports cortisol (some labs “free,” some “total”) and

metabolized cortisol • DHEA and metabolites, sex hormones and melatonin can

be added to some tests • Estrogen metabolism can be done • Often covered by insurance • Can indicate Addison’s/Cushing’s

• Serum • Single blood draw done during hours of lab or clinic

• No diurnal pattern unless multiple draws

• Total cortisol and DHEA-s or DHEA done at that single moment (no free or metabolized cortisol)

• Hormones progesterone, estrogen, total and free Test. –no estrogen metabolism

• Often covered by insurance

• Test for Addison’s or Cushing’s

• Saliva • Assess diurnal pattern by 4 saliva samples at home

throughout the day

• Free cortisol and DHEA-s or DHEA

• Hormones (free) progesterone, estrogen, testosterone

• Metabolized cortisol, estrogen metabolism not reported

• Not often covered by insurance but HSA/FSA okay

• Can indicate Addison’s/Cushing’s

The reason saliva became popular (Missing in 24hr urine testing and serum testing)

Saliva

Serum

24-Hr Urine

4-Spot Urine

Urine Caveats Not OK if there are significant kidney issues Do not overhydrate

With DUTCH you get it all with easy collection

Metabolized Cortisol

Free cortisol graphed

throughout the day

Estrogen Metabolism

Validation Data • Urine free cortisol correlates very well to

salivary free cortisol

Do Urine & Saliva Free Cortisol Agree? – Internal Data (Precision

Analytical)

Jerjes, (2005, 2006)

Urinary Free Cortisol Salivary Free Cortisol

Do Urine & Saliva Free Cortisol Agree? – Externally Published Data

Validation Data • Urine free cortisol correlates very well to

salivary free cortisol

• DUTCH Values correlate to 24-hour values

• Reproductive hormones correlate very well to serum values

• Dried samples correlate to liquid urine values

Unpublished data, Precision Analytical

So when do I use Dutch testing? • All sex hormone issues

– PMS

– PCOS

– Irregular cycles

– Fertility

– Men’s health

– Peri-menopause and menopause

• Patients on hormones

• Thyroid issues

• Adrenal issues – Fatigue, ‘Adrenal Fatigue’

– Insomnia

– stress

• Obesity/weight loss – Anabolic/catabolic

Pregnenolone

Progesterone

Estrogens

Phase 1 metabolites

Part of phase 2 detox

Androgen metabolites and 5a- reductase

Pregnenolone

Cholesterol

Progesterone

Cortisol

Pregnenolone

Cholesterol

Progesterone

Cortisol

WHICH MODEL IS CORRECT?

Circulating Hormone

Adrenal gland makes cortisol from circulating pregnenolone or progesterone (ie. supplementing)

Cholesterol is converted to pregnenolone, then progesterone, and finally cortisol all within the mitochondria of the adrenal gland

In Mitochondria of Adrenal Gland

Reading the DUTCH Test

• Start at the top with pregnenolone (serum)

• Pregnenolone DHEA and Progesterone

• Progesterone alpha and beta metabolites • DHEA DHEA-s/etiocholanolone/androsterone

• Testosterone alpha and beta metabolites

• 5-alpha reductase/5a-DHT activity = androgenic?

• Testosterone Estrogens

• Estrogens phase 1 detox (2, 4, 16 OHE1) phase 2 detox = methylation

Metabolized cortisol

Free Cortisol Free Cortisone

Preference systemically

Adrenal Hormone Recap

Adrenal Cortex (outer layer)

• Zona Glomerulosa = Aldosterone • Sodium/potassium/H2O balance

• Zona Fasciculata = corticosterone and cortisol

• Zona Reticularis = DHEA, DHEA-s, Androstenedione (metabolites etiocholanolone and androsterone; precursor to testosterone)

Adrenal Medulla (inner layer)

• Norepinephrine (20%-25%)

• Epinephrine (75%-80%)

• Release triggered by Achmuch quicker than HPA cortisol response due to preformed concentrations

• **At high levels, cortisol goes from Cortex to Medulla and converts norepi epi

Let’s talk examples

What is so important about metabolized cortisol?

Metabolized cortisol represents 80% of total

cortisol production Free cortisol = 1%

(Stewart and Krozowski, 1999).

Typical Salivary “Adrenal Fatigue” result

Low free cortisol

levels all day

Which one is “Adrenal Fatigue” or insufficiency?

Which one is “Adrenal Fatigue” or insufficiency?

What does this mean? It means patient #2 has a lot of cortisol in total!

They are not in ‘adrenal fatigue’ They do have low levels of FREE cortisol so they likely feel fatigued! Must address both WHY the metabolized cortisol is high and help

that lower free cortisol.

Q: Why is the metabolized cortisol elevated?

(The ‘Why’ portion of your patient)

What causes elevated metabolized (total) cortisol or

an up-regulation in cortisol clearance? • Long term stress

• Inflammation

• Obesity • Increased inflammatory cytokines • Increased 11bHSD1

• Insulin dysregulation/resistance

• Hyper thyroid (or meds too high)

• THIS IS NOT ‘ADRENAL FATIGUE!’ • But they are stressed and tired • Or stressed and wired • They are ‘fighting a fight’

Let’s talk about the obesity example

Obesity and 11bHSD1 (11-beta-hydroxysteroid dehydrogenase-1)

• 11b-HSD1 found in every cell in the body • Highest in fat, liver and brain • More at risk for adipose gain, diabetes/fatty liver, and memory

issues

• Converts inactive cortisone back into active cortisol (11bHSD2 converts it back to cortisone)

• More cortisol = more fat storage esp. when 11bHSD1 is coming from right within the fat cell

• Even with low controlled “systemic” cortisol, if 11bHSD1 is upregulated in the fat cell, it ‘sees’ higher cortisol = cortisol gets amplified = fat gain

Male, mid-forties, central obesity

If you just ran a free cortisol, and it was low, does that make sense?

Male, mid-forties, Central obesity: The full picture

Very high metabolized

cortisol

Suboptimal free cortisol

11bHSD1 upregulated

Relative Catabolic/Anabolic on DUTCH

Anabolic

Catabolic

This person is very catabolic!

So what’s happening?

• Inflammatory cytokines, insulin issues and stress are telling the brain to tell the Adrenals to make more cortisol

• 11bHSD1 is upregulated in fat tissue which causes more cortisonecortisol conversion creating more FAT GAIN

• With all this cortisol they are CATABOLIC (=↑glucose ↓muscle mass)

• To compensate, the liver upregulates cortisol clearance out of the body

• So free cortisol declines due to the clearance

• Result = higher metabolized cortisol, higher 11bHSD1, lower free cortisol and excess fat around the middle!

When cortisol clearance is abnormal, “free” cortisol

measurements can be misleading without

concurrent metabolite measurements

(without knowing the entire HPA picture, your diagnosis and treatment of your patients might be leading you down the wrong path )

Let’s talk Sex Hormones

Progesterone

DHEA metabolites

Estrogen Phase 1

Estrogen Phase 2

5a or 5b dominant?

Let’s talk estrogen! (Baseline test first, then re-test 3-6

months after treatment)

Common Estrogen Issues

• PMS

• Heavy periods

• Endometriosis

• Tender/fibrocystic breasts

• Weight gain

• Mood swings

• Fertility challenges

• Peri-menopause/menopause

• Estrogen cancer risks: breast, uterine, cervical

Men:

• Weight gain

• Breast development

• Fatigue

• Mood swings

• Erectile dysfunction

• Low libido

• Prostate cancer risk

Urine/Saliva/Serum shows Estrogen Dominance (male or female)

Whoa!

Sluggish clearance

Estrogen Dominant (male or female) DUTCH testing gives you the WHY

Whoa!

Sluggish clearance

Phase I detox

Before and After DIM (Phase 1)

Much better!

Let’s talk DIM… • E1 and E2 2, 4 or 16OH E1

• DIM: pushes E1 and E2 2OH E1

• 4OH E1 = more potent carcinogen because of the higher level of depurinating adducts (as opposed to stable adducts)

• When a quinone metabolites is formed reacts with DNA to form mostly depurinating adducts that break off from the DNA at N-3 and/or N-7 of Adenine or N-7 of Guanine leaving a DNA with a apurinic site (stable adducts stay attached to the DNA FYI)

• Poor repair of these sites mutations cancer

• NAC/glutathione – prevent damage to DNA by inhibiting formation of catechol quinones and/or reacting with them to stop problems via GST gene

• Resveratrol – non-competitive inhibitor of CYP1B1 to prevent E1/E24OH E1.

http://www.gestaltreality.com/wp-content/uploads/2012/07/Estrogen-estradiol-metabolism-CYP3A4-quinone-oxidative-CYP1B1.jpg

http://www.gestaltreality.com/wp-content/uploads/2012/07/Estrogen-estradiol-metabolism-CYP3A4-quinone-oxidative-CYP1B1.jpg

Estrogen: Phase 2 problems (Genetics)

General phase 2 methylation/COMT support

• Magnesium

• Trimethyl glycine (TMG)

• Choline

• SAMe

• Methionine

• Folate/methyl B12

Do you give DIM for Phase 2 issues?

Do you give DIM for Phase 2 issues?

Is the problem at the 2 and 4OH?

You may not always need DIM!

Worse Case Scenario: Estrogen Bad

Bad Bad

Knowing estrogen metabolism in men and women

allows you to evaluate phase 1 vs. phase 2 treatment

(They are different)

With DUTCH testing you get the complete picture

in order to understand what the issues are

and can address them properly

Thank you.

Carrie Jones, ND, MPH drjones@dutchtest.com

©2016