Hormone Testing: What to Check and Why

Hormone Testing: What to Check and Why|Hormone Balance|Sara Gottfried MD

Questions about hormone testing are common among my patients and on social media. Women want to know which hormones they need to check and why. They also want to know what hormones and other biomarkers can be tested at home. In this video and accompanying article, I cover the biomarkers that I check for myself and my patients approximately once per quarter. Note that not all biomarkers I discuss below have been validated for blood spot testing versus the gold standard of a blood draw for serum testing, which is what I use for treatment decisions. Still, one can infer trends and screen for problems to investigate further. My highest recommendation is to perform serum testing for all treatment decisions, though that may be difficult during quarantine and lockdown. I created this video to show the blood spot test that I am performing in lockdown, even with the caveat that it is not considered the gold standard for all tests mentioned in this article.

What Hormones Do I Test?

During my current time in quarantine, I want to look at three different categories or functions:


I measure fasting insulin, glucose, growth hormone (IGF-1), and testosterone (consider thyroid function tests too). Testosterone is not just involved in libido; it is a multi-system hormone and therefore you will see it included in the second category. What I’ve found in women over age 35 is that insulin, growth hormone, and testosterone are the most likely to be out of whack when they struggle with weight loss. (Thyroid hormone can also be included in this category but you may notice that I didn’t discuss it in the video as I am not due for a check-up. When I need to run a thyroid function test, I measure in a blood draw the following: TSH, free T3, free T4, and reverse T3.)

Keep in mind that these are my basic screening tests, and I use the fasting insulin and glucose to calculate HOMA-IR as an indicator of insulin resistance. We may choose to order more advanced testing based on results.

Sex Hormones

Sex hormones that I commonly test include estrogen (estradiol), progesterone (tested on day 21 of your menstrual cycle), cortisol (the stress hormone), and testosterone. Occasionally, I will assess luteinizing hormone and follicle stimulating hormone levels in patients with irregular periods, difficulty conceiving, or egg quality.

For patients that are considering the risks, benefits, and alternatives to bioidentical hormone therapy, we may run additional testing for hormone metabolism and genetic polymorphisms related to the risk of exogenous estrogen therapy.

Cardiovascular Risk Factors

We need to be thinking and testing beyond the traditional five cardiovascular risk factors, which are hypertension, diabetes, dyslipidemia, obesity, and smoking. Overall, there are 400+ known cardiovascular risk factors and I’ll create a future video and article detailing the broader group. In my test today, I’ll look at hemoglobin A1C that shows the three month average of blood sugar as well as a lipid panel and C-reactive protein (hsCRP), which is a measure of inflammation. Occasionally I’ll measure sex hormone binding globulin (SHBG) because it’s an emerging biomarker of cardiometabolic risk. Additionally, I like to measure the ratio of testosterone to estradiol, a biomarker that I test as a baseline and then follow postmenopause as an indicator of cardiovascular risk based on the MESA (Multi-Ethnic Study of Atherosclerosis).

More advanced testing that I typically run on a Cleveland Heart Lab include myeloperoxidase and other advanced lipid testing. Additionally, I will sometimes assess cardiovascular genetic polymorphisms.

At What Age Should You Test Your Hormones?

I recommend a hormone test to measure your baseline labs around age 35-40. If you need help balancing your hormones but you never did a baseline hormone panel in your 40s, a knowledgeable doctor can make an educated guess. Some women find that their doctor is unwilling to order a full hormone panel for them. If this is the case for you, negotiate for a partial list. Alternatively, you can seek a functional medicine doctor here. I’d suggest reading my book THE HORMONE CURE and consider running your first test on your own, such as from one of the direct-to-consumer testing organizations mentioned in my book.

What Day Is Best for Testing?

It depends on your goals. For fertility, check estradiol (main estrogen before menopause) and FSH on day 3 of your menstrual cycle. This is a measure of egg quality and drives progesterone levels. For peak estradiol, check on day 12 of your cycle. I use that for bone mass. For progesterone and to check ovulation, I check day 21-22. If you don’t know what day, aim for estradiol and progesterone on day 21-22 as most lab data are standardized for those dates before menopause. If your cycles are very irregular, test day 21-22 after a period.

How to Test Your Hormones at Home?

My gold standard is a blood draw for serum testing, but it’s hard to get a blood draw during a pandemic! There are convenient, reliable alternatives for many biomarkers. In the video, I talk about the blood spot test from ZRT Labs. I also love the dried urine test (DUTCH) for hormone metabolism and to follow certain hormones in my patients on bioidentical hormone therapy. Occasionally I will run saliva tests but only for limited indications.

Can You Test While on Bioidentical Hormones?

For my patients on oral bioidentical progesterone, I use blood (serum) and dried urine. Serum tells me levels that are clinically relevant and supported by research. Dried urine tells me about the metabolism of progesterone and cortisol. I do not use saliva testing for my patients on bioidentical hormones as I believe the data suggests it leads to underdosing.

What If I Am Breastfeeding? Can I Still Test My Hormones?

It depends on the goal. When a baby is no longer breastfeeding exclusively (either solid food added or breastfeeding is augmented with formula) and menstruation resumes, testing is relatively accurate. I like to check estradiol in my patients who are breastfeeding more than 6-12 months to track estradiol and effects on bone mass. For a baseline, the most accurate would be 6-8 weeks after breastfeeding stops.

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