DUTCH Sex Hormone Metabolites (Dried Urine)

The DUTCH Sex Hormone Metabolites (Dried Urine) test by Precision Analytical provides in-depth hormone testing and offers clinicians and patients additional insight into an individual’s hormone balance and hormone metabolism.  

DUTCH stands for "Dried Urine Test for Comprehensive Hormones," offering a comprehensive assessment of hormone levels and their metabolites. Unlike other hormone testing methods, the DUTCH Plus test utilizes dried urine samples collected over a 24 hour period, providing a more accurate and comprehensive snapshot of hormone production and metabolism throughout the day. 

The DUTCH Sex Hormone Metabolites (Dried Urine) test offers a holistic view of sex hormone function as well as their metabolites in a single test. This comprehensive assessment enables healthcare providers to identify hormonal imbalances, estrogen metabolism issues, and other factors that may underlie fatigue, mood swings, weight gain, and reproductive health issues. This is also an ideal test to initiate or monitor certain forms of hormone replacement therapy.  [12.]

This test is not suitable for patients under 12 years of age. 

What is Included in the DUTCH Sex Hormone Metabolites (Dried Urine) By Precision Analytical?

The following biomarkers are assessed in urine: 

Progesterone Metabolites

b-Pregnanediol

a-Pregnanediol

Estrogens and Metabolites

Estrone(E1)

Estradiol(E2)

Estriol(E3) 

2-OH-E1 

4-OH-E1 

16-OH-E1

2-Methoxy-E1 

2-OH-E2 

4-OH-E2

Total Estrogen 

Androgens and Metabolites

DHEA-S

Androsterone

Etiocholanolone

Testosterone

5a-DHT

5a-Androstanediol

5b-Androstanediol

Epi-Testosterone

Liquid Chromatography followed by Mass Spectrometry in tandem (LC-MS/MS) is the methodology used in this test. These highly sensitive methods show increased accuracy over immunoassays typically used in other hormone tests.

Why is Assessment of Sex Hormones and Their Metabolites Clinically Relevant?

‍

The DUTCH Sex Hormone Metabolites (Dried Urine) by Precision Analytical is a comprehensive assessment tool designed to measure estrogen, progesterone, and androgen hormones and their metabolites. It serves as an invaluable resource for establishing baseline hormone levels or monitoring hormone replacement therapy efficacy. However, it's important to note that this test is not suitable for patients under 12 years of age. With its detailed insights into hormone dynamics, the DUTCH test offers clinicians a valuable tool for optimizing hormonal balance and enhancing patient care.

Additional information regarding the specific biomarkers tested can be found below: 

Estrogens and Their Metabolites

The three main active estrogens in the human body are estrone or E1; estradiol or E2; and estriol, or E3.  The DUTCH Sex Hormone Metabolites (Dried Urine) test measures levels of these 3 primary estrogens in the urine, as well as some important metabolites.  

Estrogen is essential for maintaining reproductive function and overall hormonal balance.  Both estrogen excess and estrogen deficiency can both cause clinical symptoms and increase the risk of certain chronic illnesses.  

Excess estrogen can cause a clinical picture of estrogen dominance, with symptoms including fibrocystic, tender breasts and/or breast cysts; heavy menstrual bleeding, and menstrual cycle irregularity; headaches; mood swings; weight gain; and fibroids.  Long-term elevated estrogen levels increase a person’s risk of gallbladder and thyroid disease, estrogen receptor-positive cancers, endometriosis, blood clots and stroke. [3.]

In contrast, estrogen deficiency causes a clinical picture typically seen in menopause: hot flashes, night sweats, insomnia, heart palpitations, loss of libido, vaginal dryness, rapidly aging skin, mood swings and irritability, and others.  A woman with chronically low estrogen levels may be at increased risk for osteoporosis, cardiovascular disease, early cognitive decline, and sexual and urogenital concerns.  [13.]

Estradiol: Estradiol has the strongest action at estrogen receptors, making it the primary estrogen hormone responsible for regulating the menstrual cycle, reproductive health, and bone density in women. 

Estrone and Estriol: These hormone levels typically rise above normal levels in the body with hormone supplementation, with few exceptions: estrone levels may rise normally in menopause.  

Estriol levels rise normally in pregnancy.  

Phase 1 Estrogen Metabolites: these are 2-OH estrone, 16-alpha-OH estrone, and 4-OH estrone.  These are still active at estrogen receptors, so it is possible for parent estrogen levels and progesterone levels to be within range, but still have a functional estrogen dominance if these metabolites are elevated.  

2-OH estrone is primarily metabolized through the CYP1A1 pathway, potentially exerting protective effects. 4-OH estrone is metabolized via the CYP1B1 pathway, potentially associated with increased estrogenic activity, more DNA damage and oxidative stress. 16-alpha OH-estrone is metabolized through the CYP3A4 pathway, which is considered proliferative: good for supporting bone health, but dangerous in the setting of estrogen receptor-positive cancers.  [6.]

Phase 2 Estrogen Metabolites: this is demonstrated through 2-methoxy estrone, which is also an indicator of methylation activity.  Slowed methylation activity in the liver can cause phase 1 estrogen metabolites to build up, potentially leading to estrogen dominance and the proliferation of estrogenic cancer cells.  

Progesterone and Metabolites

Progesterone: Progesterone plays a crucial role in regulating the menstrual cycle, supporting pregnancy, and maintaining hormonal balance. It helps prepare the uterus for implantation of a fertilized egg and is essential for maintaining pregnancy.  

High progesterone levels are most often seen with progesterone supplementation.  Through complex negative feedback loops, progesterone excess symptoms often mimic an estrogen dominance presentation.  [1.]

Low progesterone levels are more common in the clinical setting and may be related to infertility and/or recurrent miscarriages and sleep problems.  In addition, symptoms of estrogen excess are common in the setting of progesterone deficiency.  [1.]  

Progesterone levels are also affected by HPA axis function; chronic stress can alter progesterone availability, highlighting the intricate relationship between healthy stress levels and healthy hormones.  [2.]

It is important to note that progesterone levels are not detected in urine hormone testing. Instead, progesterone’s two main metabolites are measured: alpha-pregnanediol and beta-pregnanediol.  Research shows that the sum of these two metabolites correlates well with serum progesterone (although not with orally or sublingually supplemented progesterone).  [4., 5.]

Alpha-pregnanediol has actions at the GABA receptor in the central nervous system, which correlates with positive effects on mood and sleep.  In contrast, beta-pregnanediol, the main progesterone metabolite, does not.  

Androgens and Metabolites

Testosterone: Testosterone contributes to libido, muscle mass, bone density, and overall sense of well-being. Low testosterone levels in women can lead to symptoms such as low libido, fatigue, and mood disturbances.  

In contrast, high testosterone levels are associated with androgenic hair loss, acne, depression, insulin resistance and PCOS, or polycystic ovarian syndrome, and infertility in women.  [9., 10., 11., 14.]

Testosterone Metabolites: The DUTCH Sex Hormone Metabolites (Dried Urine) tests for urinary testosterone, or bioavailable testosterone.  This can also be understood by looking at its metabolites: 5 alpha-dihydrotestosterone (5a-DHT), the most potent form of testosterone; 5 alpha-androstanediol, the metabolite of 5a-DHT, which may better reflect tissue activity of 5a-DHT; and 5 beta-androstanediol.  

5 beta-androstanediol is not as active as 5a-DHT or 5 alpha-androstanediol at the tissues, so it is not correlated with androgenic symptoms such as acne, hair loss, libido, and others.  

DHEA-S and Metabolites: DHEA is a prohormone made in the adrenal glands and sulfated to DHEA-S peripherally, which is often measured in the serum.  The best correlation to total DHEA production from the adrenal glands appears to be the sum of DHEA-S and its two metabolites, etiocholanolone, and androsterone.    [7.]  

Knowing a person’s DHEA level is an important indicator of adrenal function; additionally, because DHEA can be converted to testosterone and then to estrogen, DHEA has many known health benefits: bone health, sexual health and fertility, brain health, immune and cardiovascular health.  [7.]

Who Could Benefit from the DUTCH Sex Hormone Metabolites (Dried Urine) Test by Precision Analytical?

Women experiencing symptoms of hormonal imbalance: women with irregular menstrual cycles, mood swings, or infertility could benefit from the DUTCH Sex Hormone Metabolites Test to pinpoint underlying hormonal irregularities and guide treatment decisions. [8.]

Individuals considering or undergoing hormone replacement therapy (HRT): these individuals could benefit from the DUTCH test to initially assess and monitor hormone levels and ensure optimal hormone balance.  Urine testing is particularly suited for those using or considering oral progesterone, estradiol patches, gels or creams; or vaginal estradiol and/or testosterone.  [12.]

Men with symptoms of androgen imbalance: decreased libido, erectile dysfunction, or fatigue, could benefit from the DUTCH test to assess androgen metabolites and identify potential hormonal imbalances.

Individuals with polycystic ovary syndrome (PCOS): these individuals can benefit from the DUTCH test to evaluate androgen metabolites and assess hormonal imbalances associated with the condition.  [14.]

Pre-menopausal women with symptoms of estrogen dominance: symptoms including excess bloating, mood swings, heavy menstrual bleeding or breast tenderness, may find the DUTCH test helpful in identifying excess estrogen levels and guiding treatment strategies.  [3.] 

Collection and Shipping

Key Details

❌ You must avoid certain foods, beverages, and activities before and during the collection period.

💊 If you are taking hormones or supplements, consult the information below and your healthcare provider to discuss collection timing.

🩸 If you are a cycling woman, you must collect the samples on specific days of your cycle.

🧊 Keep your saliva samples frozen until you ship them.

❗️Ensure the samples are fully dried before shipping them back.

📦 Samples should be shipped to the lab as soon as possible after sample collection.

📄 You MUST send the completed test requisition form back to the lab with your samples. If you are in MD, NY, or RI, you must also send a lab order document from your healthcare provider. Failure to send these forms with your samples may result in a recollection.

Preparation & Timing

DO NOT collect your sample if you are traveling for short periods of time.

Some supplements may affect your organic acid results. Please consult your healthcare provider regarding collection preparation and timing if you take any of the following supplements:

Tyrosine

L-Dopa

D,L-Phenylalanine (DLPA)

Mucuna

Quercetin

DO NOT skip doses of birth control unless instructed by your healthcare provider.

If you are taking

Patch, Pellet, or Injectable Hormones: Collect your sample midway between doses.

Sublingual Hormones: Please review the video instructions HERE.

Oral Hydrocortisone: Please review the video instructions HERE.

Glucocorticoids: Check with your healthcare provider regarding when you should collect your samples.

When to Collect Samples: 

Men and menopausal women can collect their samples at any time.

Cycling women should take the test according to the following schedule:

Irregular cycles: Watch THIS video to determine when to collect.

Regular cycles: Use the table below to determine when to collect your sample.

You should begin collecting your sample 6-9 days before your cycle ends.

72 hours before sample collection

Avoid taking the following oral hormones:

Estrogen

Pregnenolone

48 hours before sample collection

Avoid taking oral DHEA.

Night before sample collection 

Avoid the following beverages.

Alcohol

Caffeine

Limit your fluid intake.

If you take oral progesterone, take it at bedtime.

Sample Collection Day 1

Limit your fluid intake.

Keep fluids to no more than 40 oz total (spread evenly throughout the day).

Avoid the following beverages starting after lunch:

Alcohol

Caffeine

DO NOT drink any fluids for 2 hours before collecting each sample.

If you take hormones at night, wait to take them until after you collect the bedtime sample (sample 2).

 Sample Collection Day 2

Limit your fluid intake.

DO NOT drink any fluids before collecting sample 3.

You can drink a little water immediately after sample 3. DO NOT drink more than 8 oz.

If you take hormones in the morning, wait to take your hormones after you collect the second morning sample (sample 4).

Collection Instructions

Urine Collection

Write the following information on the collection device:

Your full name

Date of collection

Time of collection

Day of your cycle (if applicable)

Sample number (following the schedule above)

Collect your urine by either:

Urinating directly on the filter paper OR

Collecting your urine in a clean cup: dip the filter paper in the urine.

Ensure the filter paper is fully saturated.

Leave the collection device open to dry for at least 24 hours.

DO NOT touch the filter paper with your fingers.

Repeat steps 1-5 for each collection.

Once the filter paper is dry, close and fold each collection device.

Requisition & Payment

Your kit has been prepaid. You DO NOT need to pay anything extra.

Since you pre-paid for your tests, you do not need to fill in the payment information on this form.

You must complete your requisition form and send it back with your samples. Failure to complete and send the test requisition form may result in a sample recollection.

Click here for instructions on how to fill out your requisition form.

Failure to complete and send the test requisition form may result in a sample recollection.

Place all devices in the resealable plastic bag.

Place the completed requisition form and samples into the test kit box to ship back to the lab.

If you are in MD, NY, or RI, you must get one of the following documents from your healthcare provider and send it back with your samples: 

Written prescription

Lab order on a document with letterhead from the healthcare facility  

Shipping

Please ship your samples as soon as possible after collection.

If you have to wait to ship your samples, please keep all samples in the freezer until you are ready to ship.

To prepare your samples for shipping:

Once the urine collection devices are dry, close and fold each device.

Ensure all collection devices and tubes are clearly and properly labeled.

Place the urine sample collection devices into the resealable plastic bag.

Place the plastic bag into the test kit box.

If you are in MD, NY, or RI, place the lab order document from your healthcare provider into the provided UPS envelope. 

Seal the envelope.

Make a note of the tracking number so that you can track your sample back to the lab.

Results

Results should be released to your provider 7-10 business days after samples are received at the lab. Rupa Health cannot guarantee processing time.

Additional Resources for Clinicians

Class: Mastering the Menstrual Cycle: a Truly Comprehensive Lab Assessment of Female Reproductive Hormones

An accurate understanding of the menstrual cycle is a critical foundation for helping your female clients.  Whether your patient is dealing with irregularity, abnormal bleeding, PCOS, infertility, or other hormonal disorders, a clear view of hormonal patterns through the menstrual cycle is the first step in developing a successful treatment plan.  In this presentation, Dr. Smeaton, a top women’s health and fertility expert, will review how she uses conventional and functional lab testing to evaluate female reproductive hormones throughout the cycle.  Attendees will:

Review the “normal” hormonal cycle and understand how various hormones will shift throughout the cycle

Obtain an understanding of how and when to measure the various female reproductive hormones

Understand the pros and cons of serum, urine, and salivary assessment of hormones

Leave with a clear clinical approach to evaluate menstrual hormones in cycling and postmenopausal females

Learn what tests Dr. Smeaton prefers to use in her own practice and how she interprets them to extract the most clinical value for her patients

References:

[1.] Cable JK, Grider MH. Physiology, Progesterone. [Updated 2023 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK558960/

[2.] Chrousos GP, Torpy DJ, Gold PW. Interactions between the hypothalamic-pituitary-adrenal axis and the female reproductive system: clinical implications. Ann Intern Med. 1998 Aug 1;129(3):229-40. doi: 10.7326/0003-4819-129-3-199808010-00012. PMID: 9696732.

[3.] Delgado BJ, Lopez-Ojeda W. Estrogen. [Updated 2023 Jun 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538260/

[4.] Newman MS, Curran DA, Mayfield BP, Saltiel D, Stanczyk FZ. Assessment of

estrogen exposure from transdermal estradiol gel therapy with a dried urine

assay. Steroids. 2022 Aug; 184:109038. doi: 10.1016/j.steroids.2022.109038.

Epub 2022 Apr 26. PMID: 35483542.

[5.] Newman M, Pratt SM, Curran DA, Stanczyk FZ. Evaluating urinary estrogen and progesterone metabolites using dried filter paper samples and gas chromatography with tandem mass spectrometry (GC-MS/MS). BMC Chem. 2019 Feb 4;13(1):20. doi: 10.1186/s13065-019-0539-1. PMID: 31384769; PMCID: PMC6661742.

[6.] Parl FF, Egan KM, Li C, Crooke PS. Estrogen exposure, metabolism, and enzyme variants in a model for breast cancer risk prediction. Cancer Inform. 2009 May 5;7:109-21. doi: 10.4137/cin.s2262. PMID: 19718449; PMCID: PMC2730178.

[7.] Samaras N, Samaras D, Frangos E, Forster A, Philippe J. A review of age-related dehydroepiandrosterone decline and its association with well-known geriatric syndromes: is treatment beneficial? Rejuvenation Res. 2013 Aug;16(4):285-94. doi: 10.1089/rej.2013.1425. PMID: 23647054; PMCID: PMC3746247.

[8.] Santoro N. Perimenopause: From Research to Practice. J Womens Health (Larchmt). 2016 Apr;25(4):332-9. doi: 10.1089/jwh.2015.5556. Epub 2015 Dec 10. PMID: 26653408; PMCID: PMC4834516.

[9.] Schiffer L, Arlt W, O'Reilly MW. Understanding the Role of Androgen Action in Female Adipose Tissue. Front Horm Res. 2019;53:33-49. doi: 10.1159/000494901. Epub 2019 Sep 9. PMID: 31499495.

10.] Sharma A, Welt CK. Practical Approach to Hyperandrogenism in Women. Med Clin North Am. 2021 Nov;105(6):1099-1116. doi: 10.1016/j.mcna.2021.06.008. Epub 2021 Sep 8. PMID: 34688417; PMCID: PMC8548673.

[11.] Stanikova, D., Zsido, R.G., Luck, T. et al. Testosterone imbalance may link depression and increased body weight in premenopausal women. Transl Psychiatry 9, 160 (2019). https://doi.org/10.1038/s41398-019-0487-5

[12.] Testing Matrix. DUTCH Test. Accessed February 15, 2024. https://dutchtest.com/resource/testing-matrix/?utm_source=interpretive-guide&utm_medium=provider-resources&utm_campaign=bhrt-matrix

[13.] Thaung Zaw JJ, Howe PRC, Wong RHX. Postmenopausal health interventions: Time to move on from the Women's Health Initiative? Ageing Res Rev. 2018 Dec;48:79-86. doi: 10.1016/j.arr.2018.10.005. Epub 2018 Oct 21. PMID: 30355506.

[14.] Zeng LH, Rana S, Hussain L, Asif M, Mehmood MH, Imran I, Younas A, Mahdy A, Al-Joufi FA, Abed SN. Polycystic Ovary Syndrome: A Disorder of Reproductive Age, Its Pathogenesis, and a Discussion on the Emerging Role of Herbal Remedies. Front Pharmacol. 2022 Jul 18;13:874914. doi: 10.3389/fphar.2022.874914. PMID: 35924049; PMCID: PMC9340349.