I’ve committed myself to learning all about dried urine hormone testing (aka DUTCH) and here is what I’ve learned so far (the good, the bad….and my exact results).
The purpose of all hormone testing is to give you more information than you already have. If having more information is not going to change the diagnosis, or your doctor’s treatment plan, then lab testing is unnecessary. If you have clear and understandable clinical symptoms that can guide diagnosis and treatment you likely do not need hormone testing. If you want to know more about individual hormonal pathways or have symptoms of hormonal imbalance, then hormone testing may be for you! Keep in mind that the person is always more important than the numbers; naturopathic doctors always practice individualized medicine.
So what’s the DUTCH test and how is it completed?
DUTCH stands for dried urine test for comprehensive hormones. The test measures steroid hormones excreted in your urine (I will just be talking abut sex hormones in this blog).
In Canada, a naturopathic doctor can requisition this test for you from several different private lab companies. It’s a very simple test to perform. I used Rocky Mountain Analytical:
- “Collection day” is 6-7 days before your expected menses- e.g. if you have a 28 day cycle you will be collecting urine on days 21-22 of your cycle
- You’re given 4 sheets of laboratory paper for your samples
- You are instructed to pee on the paper at 4 different times: once around dinner time, once before bed, once when you wake up, and once 2 hours after waking (I brought my pee paper with me to work, it’s the only way if your collection days don’t land on a weekend!)
- You will be given specific instructions on how much water to drink as to not dilute the urine
- You will fill out demographic information and answer questions about your menstrual cycle and corresponding symptoms
- Then pack up all of the materials and send it to your lab and you’ll have the results within 3 weeks
How does the DUTCH test work?
Sex hormones exist in our bodies in many different forms. Inactive hormones are bound to proteins in the blood; active hormones are free in the blood. Hormone testing via blood measures both free and bound hormones. Urine testing measures free hormones. These free hormones are found in the urine as precursor hormones like estrone and estradiol, or in the form of free metabolites like 2-OH-E1. Estrogens for example, exist in their original forms: estradiol, estrone, and estriol, but they can also interconvert between their original forms or be converted by the liver into metabolites. I will discuss metabolite formation in detail, as it is one of the main “claims to fame” of the DUTCH test!
You may be wondering, well how do our hormones get into our urine?! And the answer is through liver processing!
In order for sex hormones to be excreted, they have to be processed by the liver. The liver is our main organ of detoxification, the goal of the liver is to take your hormones and make them more water-soluble so your body can excrete them in urine (and stool).
There are two phases to liver processing of hormones: aptly named phase 1 and phase 2:
Phase 1 takes your hormones and makes them more potent. It is during this phase that hormone metabolites are made through a process called hydroxylation. These metabolites can exert negative and positive effects in the body.
Phase 2 takes your hormones and tries really hard to get rid of them through a process called conjugation. Think of conjugation as tagging your hormones with a sticker that says “I don’t want this anymore”. Once hormones are conjugated they are ready to be excrete by your body. The hormones that are found in urine are conjugated with a sulfate or glucuronide group (now we’re getting fancy). After you’ve sent you urine samples to the lab, the lab has to break the conjugation bonds in order to measure your hormone levels.
Urine hormone testing measures free hormone levels only, because bound hormones are not metabolically active and thus are not broken down by the liver. Urine hormone testing allows you to get a picture of the active hormones in your body, not the bound and inactive hormones.
Oh but there’s more to hormone excretion- it’s called enterohepatic circulation!
After the liver detoxifies your hormones, the majority are excreted in the urine (and a small amount in the stool). However, pesky hormones can be reabsorbed by the gut before they make it to the urine through a process called enterohepatic recirculation. This is your body’s unfortunate way of storing hormones for later. If you don’t have a high fiber diet and lack healthy gut bacteria you are more prone to this recirculation. We don’t want this to happen, and supposedly measuring hormones in dried urine can help you measure this process. I’ll explain how as we go.
Now that we have a better understanding of how the DUTCH test works, I’ll explain the exciting part of INTERPRETING THE RESULTS!
Remember how I mentioned that the DUTCH test measures both “precursor” hormone levels and hormone metabolite levels? This is where interpretation gets interesting!
Here are the top 4 benefits of DUTCH testing:
The DUTCH can demonstrate whether your body is efficient at turning “mother” hormones into “daughter” hormones
For example, androstenedione is a mother hormone that makes testosterone but it also makes androsterone, eticholanolone, and estrone. Elevation in androstenedione can be found in PCOS and can cause symptoms of acne and male pattern hair growth.
This is a photo from my personal DUTCH test. You will see that of the three “daughters” of androstenedione, the smallest daughter is testosterone and the highest daughter is androsterone. This is okay news for me. It shows that my body is converting androstenedione into androsterone instead of testosterone, which is an extremely weak androgen. (I owe this ability to certain enzymes I will save for another blog). This explains why I don’t have symptoms of hyperandrogenism, even though my androstenedione metabolites are extremely high! Sure serum blood tests measure androstenedione and testosterone, but they typically don’t measure androsterone…which turned out to be crucial information for me.
The DUTCH measures estrogen metabolites, and certain metabolites are more harmful than others.
As I mentioned earlier, estrogen has many potential metabolites. The DUTCH test measures three estrogen metabolites: 16-OH-E1, 4-OH-E1, and 2-OH-E1.
2-OH-E1 is considered the healthiest and most protective form of estrogen. 16-OH-E1 and 4-OH-E1 are more potent and harmful and have been indicated in cancer risk. Here is the breakdown of my estrogen metabolites:
My production of 16-OH-E1 is low, which is good, however I’m not making much of the protective 2-OH-E1 estrogen either. Having this information is extremely valuable, because naturopathic medicine has the potential to alter the metabolism of estrogen in a more favourable way and preferentially metabolize estrogen into the protective and healthy 2-OH-E1. Both 2-OH-E1 and 4-OH-E1 can be methylated by an enzyme called COMT, and naturopathic medicine can support the function of specific enzymes! Pretty awesome!
Speaking of methylation, the DUTCH measures the function of the COMT enzyme
It measures the amount of methylated 2-OH-E1 in your urine. You want this enzyme in tip top shape to prevent DNA damage. Here’s my result: given the small amount of 2-OH-E1 I make, my body is doing a pretty good job with methylation.
Can the DUTCH measure whether or not my body is adequately excreting hormones, and not just reabsorbing them in the gut?
Remember that the DUTCH test is based on the urinary excretion of hormones, so you may be wondering “what if my body isn’t excreting the hormones properly, does that mean my hormone levels will look deceptively low?!?!” I’ve wondered the same thing!
The three estrogen metabolites all come from a form of estrogen called estrone, except for 16-OH-E1, which is produced from a number of reactions! Below you will find my estrone level. Next to the photo of estrone, are my metabolites. Now look at where all of the green arrows are pointing. My estrone level is midrange, however my metabolites are all low range. The makers of the DUTCH would like to see the arrows of the metabolites all pointing in the same direction as their precursors- meaning they are all in the same range. This is not to say that the metabolites should directly equal their precursors, hormone production is much more complicated than that! Given this information, my results indicate that I have high circulating levels of metabolites and I am not excreting efficiently. Do I buy this information? I’m not sure that I do! Estrogen metabolism is so interconnected that each form cannot be expected to be in the same range as another form at any given moment in time. If you have thoughts on this please comment!!!
Holy smokes?!?! I know that’s a lot of information to take in! I would like to leave you with a pros and cons summary of the DUTCH test so you can make the most informed decision possible when it comes to hormone testing.
It can easily be performed at home. The interpretation gives us information on metabolic pathways and enzyme function. It also gives as a greater picture of active hormones levels, compared to bound and inactive hormones in serum. It may potentially provide us with insight on hormone elimination and recirculation.
It is extremely new and still being validated. The creators have a lot more research ahead of them and gathering enough data to solidify reference ranges of urinary hormones. As more awareness is given to DUTCH testing, the references ranges for the hormone levels will change and there will be a greater pool of patient data to use. Many hormones, like progesterone, are not found in the urine so we rely on the metabolites of progesterone to measure overall levels. Furthermore, I mentioned that we cannot assume that metabolites are within the same range as their precursor hormones.
The CONS of ALL hormones testing:
The worst part of every hormonal test is that it’s not financially or physically feasible to test your hormone levels every day, twice a day. Given this barrier, there’s always a chance you miss something important if you do not test on the right day, or just have a weird cycle the moment you decided to test! Hormones are extremely dynamic, so testing in any medium has it’s flaws. If you’ve every used hormone testing you will see that the reference ranges for “normal” hormones are so massive that it’s almost impossible to catch abnormal hormonal levels. This is a direct reflection of the fact that hormones are extremely dynamic and don’t like to be pinned down! Here’s a little more on hormonal blood work if you’re interested.
Want to order the DUTCH? Book an appointment with Dr. Sumner
If you want to learn about more specific labs offering DUTCH, check out the links below:
Rocky Mountain Analytical: http://rmalab.com/sites/default/files/tests/spec_sheets/20160317_pt_dutch.pdf
Tsuchiya, Y., Nakajima, M., & Yokoi, T. (2005). Cytochrome P450-mediated metabolism of estrogens and its regulation in human. Cancer letters, 227(2), 115-124.
- Whirl-Carrillo, E.M. McDonagh, J. M. Hebert, L. Gong, K. Sangkuhl, C.F. Thorn, R.B. Altman and T.E. Klein. “Pharmacogenomics Knowledge for Personalized Medicine” Clinical Pharmacology & Therapeutics (2012) 92(4): 414-417.
Im A, Vogel VG, Ahrendt G, et al. Urinary estrogen metabolites in women at high risk for breast cancer. Carcinogenesis. 2009;30(9):1532-1535. doi:10.1093/carcin/bgp139.
Sanderson, J. T. (2006). The steroid hormone biosynthesis pathway as a target for endocrine-disrupting chemicals. Toxicological sciences, 94(1), 3-21.