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Dr. Sharon Stills, a licensed Naturopathic Medical Doctor with over two decades of dedicated service in transforming women’s health has been a guiding light for perimenopausal and menopausal women, empowering them to reinvent, explore, and rediscover their vitality and zest for life. Her pioneering RED Hot Sexy Meno(pause) Program encapsulates... Read More
Dr. Pushpa Larsen graduated from Bastyr University in Naturopathic Medicine, Naturopathic Midwifery, and Spirituality, Health and Medicine. She worked as a Research Clinician for the Bastyr University Research Institute and as Affiliate Clinical Faculty for Bastyr University, training students in her clinic. She practiced in West Seattle for 10 years... Read More
- Understand the differences between types of tests used to measure hormones – serum, saliva, urine, and their uses
- Learn about the importance of hormone metabolites in evaluating safety and effectiveness
- Discover why results from different labs sometimes don’t match up and what that might mean
Sharon Stills, ND
Hi, ladies. Welcome back to The Mastering Your Menopause Transition Summit. I am your host, Dr. Sharon Stills. And I just love being here with you all and having all these informative and educational conversations that I am bringing to you with experts from around the globe. Today, I have Dr. Pushpa Larsen with me. She is another naturopathic physician. She is also a midwife. And I know her from phone calls because she works at Meridian Valley Lab. She has been there for 11 years, and she is one of their consulting physicians. She works closely with Dr. Jonathan Wright, who is where I learned how to do hormone replacement. I call him the father of bioidentical hormone replacement in our country. I want to always give credit where credit is due. And because I learned from him, he is on the other side of his career, but because I learned from him, it always drives me crazy that in the hormone field, a lot of people do not even know who is Dr. Jonathan Wright? And I am like, How could you not know who he is? How could you not have studied with him? And in the hormone field that is happening now, there are a lot of people who push and do dried urine. And if you are a patient of mine or you have heard me speak, I am all about the 24-hour urine. And I wanted to bring Dr. Larson on so we can have this conversation. She works at the lab, and she is just full of knowledge. If I have a question, she is the one I call. I wanted to bring her here to all of you. Welcome.
Pushpa Larsen, ND
Thank you, Sharon. Nice to be here.
Sharon Stills, ND
It is nice to be here, as I always say. It is so nice to see your beautiful face because we have just talked on the phone before.
Pushpa Larsen, ND
It is right.
Sharon Stills, ND
You went to Bastyr. When did you graduate naturopathic medicine?
Pushpa Larsen, ND
I graduated in 1999.
Sharon Stills, ND
You are an old-timer like me, I graduated in 2001.
Pushpa Larsen, ND
Okay. Yeah.
Sharon Stills, ND
You have been.
Pushpa Larsen, ND
Yes. It was just about the time I was getting ready to open my clinic, I opened it in 2002.
Sharon Stills, ND
That is when I opened mine as well. How did you get involved working for Meridian Valley and helping run the lab and interpret test results?
Pushpa Larsen, ND
Well, I had my private practice for 10 years, and I liked it well enough. I mean, I actually love working with patients; I like being a doctor. I was such a great business person, that part was a struggle for me; it was a little bit exhausting. And then there were all kinds of things that happened, and the economy turned down. My mom passed away. A lot of things happened all at once, and I just said, I need to do something else, and I needed something that I had a regular income. This job just kind of popped up, and I thought, I can do that. And of course, I had heard about Dr. Wright, and I had seen him speak a few times. But in my training at Bastyr, we were not really trained in doing hormone replacement therapy of any kind, bioidentical or otherwise. And I know for years after I started working at the lab, I would talk to new doctors who had just graduated, and I would be explaining to them about how to use the tests and what different things meant. They would say, We never learned any of this in school. It is like, Yes, I know; we did not either. I kind of happened into the job, but I really loved it. And I am kind of one of those lifelong learners; I keep telling like, There is always more to learn. And I love working with Dr. Wright and with the doctors in the Tahoma Clinic. We have weekly meetings between the lab doctors and the clinic doctors, so we get to get feedback on the tests from the people who are using them and make correlations. There is a lot of information we have gleaned over the years by having that close relationship and being able to follow up on things. Anyway, that is how I came to be at the lab.
Sharon Stills, ND
I love that. And you have been there quite a long time.
Pushpa Larsen, ND
Yes. 13 years now.
Sharon Stills, ND
The right job appeared. Let us just dive in because I think that the question on the listeners, the audience, the lovely ladies who are here with us at the summit—the question on their mind is like, How do I get tested? There is so much conflicting
Pushpa Larsen, ND
Right.
Sharon Stills, ND
And I just kind of want to like, There is blood, there is saliva, there is urine, and there is dried urine, and there is 24-hour urine.
Pushpa Larsen, ND
Right.
Sharon Stills, ND
Just break it down. And what is the deal here?
Pushpa Larsen, ND
Okay. I think the first thing is, Why do you want to get tested? Why you want to get tested if you are using hormones that are bioidentical or otherwise? If you are using hormones, you want to see what is actually happening? It is like you may feel better, but you also want to know what is your body doing with those hormones. Are they processing them? Is it processing them in a safe way? That is one of the reasons why you want to want to test. It also helps us see where there are things that you might be able to adjust so that, where you might adjust dosages, that kind of thing.
There are a lot of reasons for testing. But the ways to test are, as you said, blood, which we also refer to as serum, saliva, and urine are the three primary ways to test. Serum is the most common, our blood, it is the most common. That is what is used mostly in the conventional world, and it has certain advantages. I mean, it has very well-established reference ranges, it has been around a lot, and people know what it means. But it is really good for certain types of hormones like luteinizing hormone, or follicle stimulating hormone, LH, and FSH. It is not as good for steroid hormones, which all of the sex hormones and the adrenal hormones are steroid hormones. One of the disadvantages of serum, our blood is, well, first of all, it is invasive. There are some people who really have a problems of having the needle put in their arm. I am not one of them, but there are some people for whom it is a real problem. But also, you are looking at a snapshot in time; you are looking at that one moment, and our hormones fluctuate throughout the day, and there are certain hormones that tend to be higher at certain times of day.
In men, for example, testosterone tends to be higher in the morning. But cortisol, the adrenal hormone, are produced throughout the day. When you are doing a single blood draw at a single moment in time, you are really just getting a snapshot of what is happening at that moment, not getting the whole picture. And some of our hormones are secreted at night when we are mostly asleep; serum is not very good for that, and it is not a very convenient time to get your blood drawn. The other thing is you do not see metabolites; you do not see how your hormones are being broken down in your serum, and that is pretty important. And it is also in serum; in your blood, you’re mostly looking at what we call bound hormones. Most hormones are bound to some sort of protein, a carrier protein, and they are usually bound pretty tightly. It is only a small percentage of the hormone that is actually bioavailable actually available to be used. And in serum, you are almost always looking only at the total, which means the bound plus any free, but the free is very little unless it specifically asks for it, like with testosterone, where you can get free and total in serum. But in most of the women’s hormones, you are only getting the total hormones; you are not seeing metabolites, and you are also not seeing how much is free or how much is actually available to be used. I do not know how; maybe I am not making this very clear.
Sharon Stills, ND
No, very clear.
Pushpa Larsen, ND
The point being is that in a serum test, it can look like, Yes, your hormones look fine; they are right in the middle of the reference range, but they are in the middle of the reference range but for bound hormones. And if what you want is free hormones, which you cannot get very easily for the female hormones, only for testosterone, you actually cannot find that in serum. If you want to see what you are actually getting and using, you need something else, like saliva or 24-hour urine.
Sharon Stills, ND
Is there anything, you said FSH and LH you like in the blood, is there anything else that you like in the serum like the free testosterone?
Pushpa Larsen, ND
Yes. Free and total testosterone is sometimes in serum; it is sometimes a nice backup, especially if, for some men, they have a tendency to hold on to their testosterone. It does not get into the urine very well, and you will see. And when you see low testosterone in the urine then doing a serum as a backup may give you a different perspective on it.
Sharon Stills, ND
That is what the ladies’ husbands. What about for women and testosterone?
Pushpa Larsen, ND
Yes. For women and testosterone, you mostly do not get free tests. You could order free testosterone for women in serum, but mostly it does not come that way; it just comes as a total. Did I answer your question?
Sharon Stills, ND
Yes. But if you can get a free testosterone on a woman then in the serum you can trust that?
Pushpa Larsen, ND
Well, when you say, trust it.
Sharon Stills, ND
Is it accurate?
Pushpa Larsen, ND
Well, the likelihood is that whatever lab you are doing that does testosterone that they have their protocols, procedures, and their procedures and their methodology down so that the results are going to be accurate. Yes, you could ask for a free testosterone serum for women. Would I trust it? Yes, I would trust to say that is what is there, but I would still be looking at urine hormones because I want to see how they are breaking it down I want to see what they are actually doing with it.
Sharon Stills, ND
Right. Let us talk about the pros and cons. There is a lot of cons to the blood work. Are there any pros to the blood work?
Pushpa Larsen, ND
Mostly, it is widely available, it is easily understood, it is what everybody uses, and that is what they are used to looking at. But they are not necessarily getting the information out of it that they think they might be getting..
Sharon Stills, ND
Very misleading. I have seen a lot of patients who are only monitored in the blood, and they are told to reduce their doses or inappropriate.
Pushpa Larsen, ND
Right.
Sharon Stills, ND
Okay. Let us go do saliva. Because we are going to save the best for last. What are the pros and cons?
Pushpa Larsen, ND
Saliva collection is less invasive, although, I mean, you are not doing needles; you are spitting into a little tube, and that can be problematic for some people, especially as people get older. They do not produce as much saliva as they did when they were younger, and it can be a little bit problematic filling those up. Also, just the slightest bit of contamination, for example, if someone brushed their teeth and there is little microscopic traces of blood in the saliva that can affect, for example, any, well, hormones are carried in in the blood as well as in the saliva, you are getting an additional reading from any traces of blood that are in the saliva.
There are some problems with saliva in that regard. Again, it is a snapshot in time unless you are doing it for point saliva. When you are looking at cortisol and cortisone, you are just looking at a single point in time. And also, with saliva, you are not getting any metabolites. I would say the best thing is to use saliva for are four-point cortisol, cortisone, or cortisol awakening response. But I would not rely on it for monitoring hormones; I know people who do, but I would not. Another problem with saliva is that, as you will see that most saliva collection kits, they want people to be off of their hormones for a few days before they collect, which means that when you are collecting, you do not actually because most of these hormones have a very short half-life. If you are off of your hormones for two or three days, you are not seeing what are your levels like when you are actually on hormones; that is another problem with saliva.
Sharon Stills, ND
That makes no sense.
Pushpa Larsen, ND
Yes, it really does not.
Sharon Stills, ND
You can have false because of the blood; you are not getting metabolites, and you are not seeing what the hormones are actually doing in your system. I have been taught you never track hormones with saliva; it is just totally inaccurate.
Pushpa Larsen, ND
Yes, I would not.
Sharon Stills, ND
And I do agree with you. I do use saliva testing for my four-point cortisol. I think it can be very telling because it really shows what the curve is doing, and I can be more specific in how I help someone rebalance. Okay. Now let us get to the meat and the potatoes of this. 24-hour urine, which I love and have been doing since I opened up my practice in 2002, the same year as you. But there is a lot of talk, and a lot of people out there are just doing dried urine. And I would like for you to explain what is up with the dried urine and why it is more beneficial and important to do the 24-hour urine.
Pushpa Larsen, ND
Okay. Well, 24-hour urine has been around a lot longer than dried urine. I mean, it is been used 24-hour urine collection to look at steroid hormones has been being done in research for decades. I believe that we were the, I do not know if we were the first, but one of the first clinical laboratories to do 24-hour urine testing to look at steroid hormones. Do I have the ability to share my screen?
Sharon Stills, ND
I do not know, do you? You can try, let us see if it will let you.
Pushpa Larsen, ND
Okay. It looks like it will.
Sharon Stills, ND
Okay. Yeah, okay, there you go.
Pushpa Larsen, ND
Okay. Do you see this metabolism chart?
Sharon Stills, ND
Yes.
Pushpa Larsen, ND
You are familiar with this metabolism chart, are you not?
Sharon Stills, ND
I am sure am.
Pushpa Larsen, ND
When I talk about metabolites, this is what I what I mean here. You can see here DHEA. DHEA gets broken down to androstenedione, which goes to these two metabolites, androsternone and etiocholanalone, and also can become estrone, which then becomes estradiol. DHEA also becomes testosterone. DHEA is breaking down. Testosterone and estrone are actually metabolites of DHEA. But estrone has its own metabolites. Here we have 2-hydroxy and 2-methoxy. I do not want to go into all of them because I do not want to make it too technical. But some of these metabolites are carcinogenic, such as the 4-hydroxyestrone. That is the most carcinogenic of the estrogens, whereas the 2-hydroxyestrone and the 2-methoxyestrone are both very protective.
Looking at the metabolites allows us to see what is your body doing with your hormones. And here we are looking at cortisol and the breakdown into the cortisol metabolites and also mineralocorticoid; these are all different metabolites that we can look at that tell us various things about someone’s hormone balance and can allow us to tailor treatment, these treatment decisions. There are things, for example, that you can use so 2-hydroxyestrone is protective. 16-alpha is not as bad as 4-hydroxy, but it also has some problems. There have some things you why you want to have it, but there are also some reasons you do not want to have too much of it. And there are some botanicals that you can use and some supplements that you can use to push the metabolization of estrone more towards the 2-hydroxy, which is protective towards the 16-alpha. Knowing the metabolites and understanding this is really important for being able to make treatment decisions that really are looking at how effective the treatment is but also how safe it is to try to minimize risk.
Sharon Stills, ND
Do you get the dried urine versus the 24-hour urine?
Pushpa Larsen, ND
In a 24-hour urine, you are getting a full 24-hour perspective. And like I said, and despite what has sometimes been said about collection, collection for 24-hour urine is really much easier than a dried urine. In the drug, urine is promoted as you just tip these four cards, just four times that you do not have to carry this jug around with you. Well, first of all, most people are able to collect on a day when they can be home for the day, especially when you are talking about women who are in menopause and whether or not they are using bioidentical hormones. Because if they are using hormones, you are not waiting for a certain day of their cycle because they are not having cycles anymore.
For a younger woman, we want her to collect at a certain point in her cycle, and for someone like that, they might have a little bit more restriction about what day they can do it. But for most of the people you are talking about, this is a menopause summit; we are talking about mostly women who are not having menstrual cycles anymore; their collection time is not limited by that. If they are taking hormones, we would like for them to be on hormones for a while before they collect so you could see what their actual levels are, but they are not restricted in terms of what day of the week. People can do it at home, and usually, most people can do is not a problem to run out and go grocery shopping or something as long as you are somebody who can hold their pee as long as it takes to do that. Collection is easy; you need to pee, and you collect it, that is all, and pour it into the jug.
With the dried urine, you have to pay attention to the timing. And has it been the right amount of time since my last? When you have to be setting alarms, you have to be monitoring your intake of fluids to make sure that it is pretty even throughout between collections; otherwise, you are getting a lot of variation in the concentration of the urine because there is what you missed except for those poor collection points. And there is a lot of variability in terms of what patients can do. Some people can go for hours—four, five, or six hours—without needing to pee; other people may need to go to the bathroom every hour. You can see there is going to be a lot of difference in the collection points when you have that kind of variability in how often people are needing to produce urine and how much you are losing in between collections.
One of the biggest things is that you do not get a 24-hour perspective. You do get metabolites with dried urine because it is still a urine test. There are metabolites you cannot get in dried urine, though, or they are analytes. We do melatonin, growth hormone, and oxytocin in a 24-hour urine, all of which are really important hormones. Some people say, Well, I am not going to use growth hormone or be prescribed growth hormone, but it is still an important hormone to know about because it tells you something about the health of the person. And there are other things you can do to improve melatonin—I mean, sorry, growth hormone—besides actually giving it. I think it is something worth testing. There are things that you get in 24-hour urine that you do not get in dried urine, and like I said, you get the full-day perspective, and it is just easier to collect. But there are a lot more ways collection can go wrong with the dried urine, with people touching the card with maybe they still have some hormone cream on their fingers, or the card has to either be hung up to dry or it has to be laid flat to dry, but why are you doing that? If you are doing your collection at work, are you going to hang it up in the community bathroom or lay the cards on your desk to dry? I do not think so.
Sharon Stills, ND
What about as far as results?
Pushpa Larsen, ND
Results? Well, I think the 24-hour urine is better.
Sharon Stills, ND
And can you tell why that is?
Pushpa Larsen, ND
Well, like I said, you are getting a full day’s perspective. And because, as with the four points and with having to, like I said, monitor fluid intake and all of these things, trying to keep everything so even the reason for that is because in a dried urine, the results are normalized against creatinine in a way to deal with the variability between different collections. In a 24-hour urine, you are still looking at creatinine, but the results are not normalized against creatinine in the same way. It is more precise; the 24-hour year is more precise than the dried urine. But that does not mean you cannot get usable results from dried urine, but it is definitely never the first thing I would recommend for someone.
Sharon Stills, ND
Yes. When I have patients who come in and all they have is a dried urine, I am like, We have to get a 24-hour urine, and it is always different; it is not reproducible; it does not cross over; and we want the most precise results, which is why we do 24-hour urine. And I do agree—I do not know if that is how it was sold—that it is easier; you only have to give four samples, but it is much easier to just carry. I always tell patients, Put the jug or a note on your toilet so you do not forget, and when you run through there, it is a reminder there because otherwise you have to start all over.
But when we are working with bioidentical hormones, which are such an important part of menopause, the transition, and perimenopause, you want the most accurate results. Why settle for something that is not as accurate? And I am really passionate about it, like I have been using your lab in 24-hour urine testing, like I said from the beginning, because when I decided I was going to do bioidentical hormone replacement because I too did not learn about it in medical school, I thought, Well, who do I want to go learn from? And I was like, Well, I want to go learn from the guy who wrote the first script for “Biased” in the country; I have to go listen to what he has to say, and this is his lab. When you are writing something, you want to create the best way to test it. And I would not let patients refill their hormones. If everything is status quo, we have to test at least once a year because I just want to make sure things are not changing and the metabolites are still in a healthy way. That is so super important. Is there anything else that you would like to share that I did not ask you about?
Pushpa Larsen, ND
With regard to 24-hour urine versus dried urine?
Sharon Stills, ND
Yes.
Pushpa Larsen, ND
I do not think so. I would say, you said that you see patients come into you with dried urine results, and when you do a 24-hour, they are always different. I think one thing I need to say is you never really can compare them because they are different methodologies; we are going to have different reference ranges. But also, you cannot compare one lab to another, I mean, just because everybody’s methodologies are slightly different. If you are not arriving at your results the same way, you cannot compare them; it is not like apples to apples.
Sharon Stills, ND
What I am saying, though, I just find because we know 24-hour urine is the most accurate. And I find discrepancies and that makes me learn that anyone who is relying on dried urine is not getting fed the right results that are the most accurate.
Pushpa Larsen, ND
Right.
Sharon Stills, ND
I want everyone who is listening, whoever is monitoring your hormones, that they learn how to do a 24-hour urine collection so you can get the best results. And yes, I love looking at the melatonin, the oxytocin, and the growth hormone; it is just such good, powerful information that just makes a difference in how I treat a patient, how we proceed, and so forth.
Just to recap, if you are having your hormones just monitored through blood, that is not a good idea because that is not the best way to monitor steroid hormones, and you are not going to see metabolites. If your doctor,
Pushpa Larsen, ND
And you are probably not getting what is actually bioavailable.
Sharon Stills, ND
Right, you are getting bound hormones, and you are just getting a snapshot. If you are testing for saliva and you are stopping your hormones before your test, that is absurd but okay. But you are also potentially getting some blood contamination; you are not getting metabolites; it is not a good way for monitoring or for testing. You just talked about the dried urine and why that is not as accurate as the full 24-hour snapshot. And I use blood. I will do thyroid hormones in blood, I will run DHT in blood, and I will run a sex hormone-binding globulin in blood. If you are if you are a patient of mine and you are listening, you are going, wait a second, she just made me got 30 tubes of blood drawn. I love blood work. But when you are a practitioner, you learn, especially if you have been doing this as long as we have been doing it, you just learn that you want to use the best method for whatever it is you are testing.
Pushpa Larsen, ND
Right
Sharon Stills, ND
I love to have that saliva for cortisol, great for that, and 24-hour urine for the sex hormones. And you want to test not guess and you want to have the right.
Pushpa Larsen, ND
I love that test not guess.
Sharon Stills, ND
This is my public service announcement to everyone listening: you want to be working with a physician who understands how to test so that you can be safely monitored and safely dosed. And that is why it was really important that we have this conversation today.
Pushpa Larsen, ND
Right.
Sharon Stills, ND
Because it is kind of like, I say it a lot with a chiropractor, someone goes to a chiropractor and they go, Yeah, chiropractic does not work; I still have a headache, and I am like, Well, it is not that chiropractic does not work it is just maybe you went to the wrong chiropractor or the wrong technique, and so forth.
It is the same with hormones. Can hormone replacement not work, be dangerous, not get rid of your symptoms, not support you in long-term challenges, not protect your brain, your bones, your cardiovascular system, and so forth? Sure, if they are not properly dosed, and they are not properly administered, and they are not properly monitored. And done correctly, they are such an important piece of the healthy aging journey plus menopausal.
Pushpa Larsen, ND
Yeah, definitely. I mean, there are definitely people after they first start on bioidentical hormones it is like their life has been turned around. And there are those people that it takes longer to kind of get the right dosing and the right balance of things. One of the things, you said, find a doctor who knows how to test, one of the things that we offer at the lab which about is free consults to practitioners. We do not offer consults to patients, we can not do that, it is actually illegal in Washington State for a lab doctor to consult with a patient. But we consult with our clients, the clinicians, doctors or osteopath or nurse practitioners, whomever orders our tests.
We will sit down so the metabolism flow chart I showed you earlier, we will go over all that and talk about which hormones are which metabolites are beneficial, which ones are protective, and which ones are important for maintaining bone density, we will go through and help people understand all of that. Because there is a lot of information in the report. I should have showed you a screenshot of the sample report, there is a lot of information in it. And this information as we both said we did not learn about this in school and neither did they, they only learned about blood testing.
Sharon Stills, ND
Right. Well, I am glad you brought that up. Because that is the other thing I will say, like, when you are looking for a doctor to help you with your hormones, like, How do you think I learned about this? I would get tests, and I still even sometimes call and get consults. It is good to stay sharp; it is good to stay up with the latest research, but this is how I learned a lot of things: I would get a test on a patient, and then I would call and I would go over it like you are saying, and then I would learn. You want to have a doctor, and if they are like, I do not do 24-hour urine, Okay, great. If you do not do it, well, maybe it is you could start doing it and get educated, and this is available. And I think that is a really important quality in a physician: that are willing to work with you and open-minded. If someone came to me and said, Well, now there is a new way; we are going to take your fingernails and check your hormones, I would be like, sounds weird, but okay, tell me who is doing it; let me look into it. I feel like it is our responsibility as physicians. You see me in the office, but there is a lot more that goes on behind the scenes that I am doing to make sure you are properly cared for. And making sure you have a doctor; do not let them cop out and say, I do not know how to do that. You can tell them; you can order the test for me; and then you can have a consult with them, and they will teach you how to explain it to me.
Thank you so much for coming and telling us the differences. I think it is just such an important topic. And I want you to be on hormones, and I want them to be monitored properly so that you are not like I said before. I can tell you how many patients have been improperly monitored and then have doses cut or doses increased, and they do not feel good. They were like, I felt really good, and then we had a test or the saliva test, and they made me change everything, and now I do not feel good. I do not want that for any of you. Hopefully, this really helped you just to understand. And you are a 24-hour urine kind of gal now. Go find someone who can do that for you and help you. We will be back with another conversation. But thank you, Dr. Larsen, for being here.
Pushpa Larsen, ND
Thank you so much, Sharon.
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