[HD: This is the third post in my series about the use of HRT in menopause. It can be read as a stand-alone piece, but it’s not a bad idea to check out the first two for context, as I do assume you are familiar with the substance of those posts: Why You Shouldn’t Care About Estrogen Dominance and Are Bioidentical Hormones Safe?]
You know what really burns my muffin?
Y’all are getting a little cheeky, aren’t you? Listen, I’m not a total malcontent, but I do get riled up when I see people wasting their money on worthless, expensive testing that is not covered by insurance. I’m no fan of insurance companies – believe me – but why do you think they typically won’t cover salivary testing for bioidentical hormone replacement therapy?
Because they are in cahoots with Big Pharma, trying to drive women toward FDA-approved forms of HRT that will give them cancer and heart attacks!
Annnnnnnd…there it is. Wow, it didn’t take long today for the conspiracy-theorist trolls to rev their engines. No, salivary testing for hormones like estrogens, progestogens, testosterone, and DHEA is not covered because the results have little to no value for guiding peri/post-menopausal HRT.
No Correlation Between Symptoms and Levels
There are so many problems with these salivary hormone assays that I almost don’t know where to start. I think the best way to begin is with the bottom line, which was eloquently stated by Boothby et al in a review paper about bioidentical hormones, published in Menopause (2004).
Although attractive on the surface, individualized NHT [natural hormone therapy] is an ill-conceived attempt to apply pharmacokinetic principles to drugs that do not meet the criteria for individualized dosing.
Dr. Boothby’s (PharmD) quote beautifully illustrates a point I have repeatedly driven home on this site. When Medicine has excellent, accurate testing for a condition, Alt Med tells people to ignore the results and focus on symptoms, allowing them to diagnose anybody with anything. On the other hand, when Medicine recommends empiric treatment for a condition that isn’t amenable to objective quantification with lab tests, Alt Med recommends a battery of non-validated testing.
Salivary hormone testing that lacks clinical applicability serves the financial interests of Alt Med, but not the interests of the patient. This type of testing obfuscates and unnecessarily complicates the treatment plan, leading the patient to believe she is receiving highly specialized, individualized care that is superior to the care offered by her mainstream physician. Makes sense, right? Her regular doctor only offered a couple of pills – or maybe a patch – while her Altie did a deep dive into her unique physiology and had a special hormone cocktail custom-compounded for her. Sadly, the only thing generated by this salivary/urine/blood testing is a large bill from the testing facility, along with pages of numbers that aren’t worth the paper on which they are printed.
Getting back to Dr. Boothby’s point, Alt Med wants to test your “levels” so that you can replace exactly what’s deficient. As I described in Why You Shouldn’t Care About Estrogen Dominance:
If you are cycling regularly, you know that your hormone levels will depend entirely on when within the cycle they are drawn. The only thing those numbers can tell you is that you are cycling (not talking about fertility/ovulation issues today), which you kind of already knew! If you are perimenopausal and starting to have some irregular cycles plus other symptoms, you know there’s a good chance that your estradiol levels will be swinging widely, which should not affect your choice of treatment. If you are postmenopausal, then it’s ludicrous to test anything, because estrogen and progesterone levels will be low, by definition.
This is all to say that menopausal hormone replacement therapy is a misnomer. We’re not trying to restore normal physiology by replacing your hormones to a “normal” level. Why? Well, how would you define normal? Is it the estradiol level of an early-follicular phase 20-year-old? A late-follicular phase 30-year-old? A mid-luteal phase 40-year-old? [See menstrual cycle diagram below.]
If you are menopausal, “normal” levels of estrogen and progesterone are low, by definition! We’re not replacing hormones that you should be making; we’re performing a pharmacologic intervention to relieve your hot flushes and other menopausal symptoms. And we accomplish this with the lowest dose of hormone therapy that ameliorates those symptoms. Period.
The “No’s” of Salivary Hormone Testing
When it comes to using salivary hormone testing to guide bioidentical HRT, the word “no” seems to come up a lot:
- no standardization of different assays offered by different labs
- no independent quality control programs
- no universally accepted reference ranges
- no evidence for correlating levels with symptoms
- no evidence for how to use testing to adjust medication dosages for either efficacy or safety
Compounded Hormones Have Unpredictable Pharmacokinetics
As demonstrated by the above list of problems with salivary testing, it’s hard to know what to do with your test “results,” other than toss them in the shredder. Tabling that for a second, do you think your Alt Med provider understands the pharmacokinetics of the cocktail she has prescribed? Does it result in a rapid rise in estradiol levels with a quick crash? Maybe a delayed crash? A slow initial rise with sustained levels? Do the salivary levels of the hormones vary dramatically depending on when your sample is taken in relation to a dose?
I guarantee you she doesn’t know the answers to these questions, because none of this has been well-studied. One of the few studies out there comparing the pharmacokinetics of FDA-approved therapy to cBHT found that 24-hour area under the curve of E2 (estradiol) was 80% lower with the compounded product (Sood et al, Maturitas, 2013). Take that for whatever it’s worth.
If you want to approach this whole HRT thing from a data-driven perspective, what I can tell you is that Steingold et al published a paper in JCEM in 1985, which demonstrated that circulating blood E2 levels of 60-80 pg/mL were sufficient to control symptoms in most women. This E2 range is similar to early-midfollicular levels in normally cycling women. But Steingold’s findings have not been reevaluated since then, so again – take that for what it’s worth.
Everyone is Special
Look, I get that it’s appealing to be treated as an individual. What you need to understand is that your mainstream healthcare provider (HCP) is treating you as an individual when she offers you FDA-approved formulations of estradiol and progesterone. She is doing exactly what Alt Med loves to promote for other types of hormone therapy (e.g. thyroid): she’s treating your menopausal symptoms. Your HCP will adjust the dose of your estradiol/progesterone until your hot flushes and other symptoms are under the best control possible.
What your HCP will not do is offer you a battery of worthless salivary/urine/blood tests that do not aid in clinical decision-making. I realize that many of you believe that more testing = more thorough = superior care. I also understand that, when your Alt Med provider spends an hour with you, a provider-patient bond has more time to develop, leading to greater trust in their recommendations. If your mainstream HCP could get reimbursed adequately for 1 hour visits, she would do the same thing. Our medical system is broken, so she just can’t.
Here are my asks: stop spinning your wheels with Alt Med, stop paying for expensive and unnecessary lab tests, and stop paying for pricey compounded products when safe and effective FDA-approved alternatives are available. It’s ok to expect to be treated as an individual, but demand that your provider treats you based on the best available medical evidence which – in the case of menopausal HRT – does not require pages upon pages of worthless labs.
Still have questions after reading the menopausal HRT series? Want to share your story? Comment below!
By reading this site and interacting with me in the Comments, you agree to abide by my Disclaimer.