Clinical value of 24-hour urine hormone evaluations

Townsend Letter for Doctors and Patients,  Jan, 2004  by Alan Broughton

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Background

Hormone replacement therapy is the corner stone of anti-aging medicine. It represents a means by which physicians can make a great impact on the health and well being of their patients. Exciting developments in urinary hormone testing have allowed practitioners access to a very sophisticated way of assessing and tracking hormone replacement therapy.

There are numerous advantages to using the 24-hour urine hormone evaluations. These evaluations indicate the total daily hormone production and utilization. This overcomes a major dilemma of blood evaluations that only provide a snapshot and the assay limitations of saliva. The 24-hour urine provides a stable indicator of output and is not susceptible to minute-by-minute fluctuations seen in serum or salivary measurements. Equally important to knowing hormone levels is knowing how they are metabolized. Some researchers feel that hormone metabolites have as much if not more, biological action than the hormones they were derived from. Determining the levels of metabolites also enables the practitioner to trace a supplemented hormone through its metabolic pathway, which ensures the therapy is having the desired effect from an objective standpoint. No other method is as cost-efficient for the evaluation of hormones and hormone metabolites. To replicate the same number of analytes in serum would triple the cost and metabolites are not measured in saliva. A comprehensive, sophisticated urine hormone panel should consist of the following hormones and metabolites: Cortisol, 17-Hydroxycorticoids, Aldosterone, Dehydroepiandrosterone (DHEA), Testosterone, 17-Ketosteroids, Progesterone metabolites, Estrogens, Estrogen metabolites, Growth Hormone and key minerals.

Adrenal hormones and their metabolites

Cortisol is the major stress hormone and should be evaluated in cases of dysglycemia, fatigue, hyper- or hypotension, weight change and immune dysfunction. Additionally, cortisol must be evaluated in those patients who appear hypothyroid yet show no objective signs of thyroid deficiency. Deficiency signs and symptoms manifest as inflammations, hyperpigmentations and pain. Excess cortisol can create swelling as well as hair loss, agitation and weight gain. The urinary evaluation measures the free fraction of cortisol. While levels are commonly thought to rise with aging, it is not unusual to find suboptimal levels in aging populations. Still, clinicians often shy away from treatment due to fears related to pharmacological dosing of synthetic glucocorticoids and associated side effects. In patients deficient in cortisol, judicious use of physiological amounts of hydrocortisone may yield significant improvements. Cortisol has a major impact on many other hormones and it is vital to monitor it by utilizing a comprehensive urine hormone panel.

The 17-Hydroxycorticoids represent how well the body is dealing with stress. They are primarily metabolites of cortisol and detail cortisol utilization. If the amount of 17-Hydroxycorticoids excreted in the urine is high, then the level of stress on the body is high. Consequently, if cortisol is high and the 17-Hydroxycorticoids are low, then there is poor adaptation to stress. This can also occur with excess hydrocortisone dosing that exceeds the capacity for metabolism. Both alpha- and beta-reduced metabolites of cortisol are measured in the 24-hour urine hormone evaluation, indicating whether the site of metabolic (in)efficiency is peripheral or splanchnic. This can dictate treatment choices when seeking to improve cortisol metabolism.

Aldosterone, as the main mineralocorticoid, aims to excrete potassium and retain sodium. It is under control of the renin-angiotensin system though many other hormones such as adrenocorticotropic hormone (ACTH) can stimulate release. It is also dependent on water and salt (sodium) intake. Signs and symptoms of aldosterone deficiency include fatigue, dehydration, hypotension and polyuria. An excess of aldosterone may yield water retention and hypertension. Dr. Thierry Hertoghe, an internationally renowned physician experienced in hormone replacement therapy, feels that aldosterone deficiency is more common than previously thought and worthy of treatment. He believes the ideal way to assess aldosterone levels is with the 24-hour urine evaluation. This eliminates the variability seen with serum measurements. This serum variability is probably due to significant influence from many other factors that affect aldosterone release. The 24-hour urine evaluation provides a stable indicator of aldosterone production.

Dehydroepiandrosterone (DHEA) is the most abundant androgen and has a wide range of physiological effects. Previously thought to exert little or no biological action, DHEA is known to be important for immune function, psychological health, bone mineral density and cardiovascular health. Low levels in aging men have been shown to increase the risk of premature mortality. Common signs and symptoms of DHEA deficiency include loss of pubic and axillary hair, dry skin and mucous membranes, moderate fatigue and anxiety and low resistance to noise. Excess DHEA levels may cause oily skin and hair, acne and in women, androgenic alopecia, hirsutism and menstrual cycle disturbances. The 24-hour urine measurement of DHEA is an ideal way to determine daily production and the simultaneous measurement of 17-Ketosteroids can provide information on DHEA metabolism.