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  1. 1. Saliva HOrmone Testing (SHT): Female hormone testing <ul><li>Jacqueline Rolletta </li></ul>
  2. 2. SHT <ul><li>This particular lab was developed in 1987 </li></ul><ul><li>Saliva hormone testing was developed as an alternative to the traditional female hormone blood panel. </li></ul>
  3. 3. Purpose <ul><li>(FHT) is a dynamic mapping of the free-fraction levels of estradiol (E2) and progesterone (P) throughout one cycle. The panel also includes a cycle average value for free testosterone and DHEA/DHEA-S. This panel uses 11 saliva samples collected during specified time slots throughout a menstrual cycle. The expanded panel version includes five additional FSH and LH measurements. (1) </li></ul>
  4. 4. Purpose <ul><li>SHT can map the hormones involved in a women’s menstrual cycle more frequently than the typical blood hormone panel. This is helpful to detect: </li></ul><ul><li>Hormonal Imbalance and PMS Many women suffer from hormonal imbalance in the estrogen to progesterone ratio. Our panels can define the hormonal state with exquisite accuracy which, in turn, provides specific insights for appropriate intervention to relieve hormonal imbalance and PMS-related symptoms </li></ul><ul><li>Luteal Phase Deficit There are at least three luteal phase-deficit patterns which are characterized by a progesterone/estrogen imbalance. This imbalance is usually associated with PMS, infertility, fibroids, and other female hormone-related problems and can be readily detected by our panels. </li></ul><ul><li>Helpful to use for: </li></ul><ul><li>Customized Hormone Therapy Presently, female hormone therapy is not individualized to the needs of each woman, because current diagnostic tests do not provide sufficient data. Consequently, most women are empirically treated without regard to their individualized physiology and specific needs. The FHP™, for the first time, will allow a clinician to customize therapy to each female patient.(1) </li></ul>
  5. 5. Patient explanation <ul><li>Saliva testing </li></ul><ul><li>The human ovary releases its hormones in a cyclical manner, which is referred to as the menstrual cycle. The average cycle is 26-30 days. The timing and pacing of hormone release is governed by GnRH, FSH and LH, hormones from the hypothalamus and pituitary glands in the brain. The two major classes of ovarian hormones released during the menstrual cycle are estrogens and progestogen, also known as the female steroid sex hormones. The major and most active estrogen released is estradiol, while the major progestogen is progesterone. </li></ul><ul><li>The Female Hormone Panel™ is a simple, non-invasive test. Eleven saliva samples are collected during specified time periods throughout the menstrual cycle.(1) </li></ul>
  6. 6. Mechanism <ul><li>Starts with the saliva: </li></ul><ul><ul><li>Saliva comes from the glands located under the tongue and along the sides of the mouth. </li></ul></ul><ul><ul><li>It’s a mixture of mucins, enzymes, antibodies, electrolytes, and hormones. (2) </li></ul></ul><ul><ul><li>Saliva manufacturing starts in the salivary ducts with electrolyte induced osmosis. The blood components we measure enter by active transport, ultrafiltration, or passive diffusion. </li></ul></ul><ul><ul><li>“ Steroids and other small neutral molecules not bound by blood proteins pass freely through the membranes of the salivary gland into saliva by passive diffusion” (4) </li></ul></ul>
  7. 7. Mechanism <ul><li>The movement of neutral steroids from the blood into the saliva is about 10 times faster than the flow rate of saliva (2). </li></ul><ul><li>Due to the swiftness of steroid transfer into saliva, serum hormone levels are not altered significantly when the flow of saliva is increased with stimulants. (4) </li></ul>
  8. 8. Marketing Methods <ul><li>female_hormone_patient_brochure.pdf </li></ul><ul><li>Salivary hormone testing is marketed to be easier, cheaper, and more accurate. </li></ul><ul><li>This accuracy is achieved through more frequent testing. </li></ul>
  9. 9. Advantages and disadvantages to SHT <ul><li>Advantages: </li></ul><ul><ul><ul><ul><li>* Stress-free </li></ul></ul></ul></ul><ul><ul><ul><ul><li>* Noninvasive (no needles) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>* Less expensive/more convenient for health care provider and patient </li></ul></ul></ul></ul><ul><ul><ul><ul><li>* Optimized for collection any time of day/month, any place </li></ul></ul></ul></ul><ul><ul><ul><ul><li>* No special processing (eg, centrifugation, ice-packs) prior to shipment </li></ul></ul></ul></ul><ul><ul><ul><ul><li>* Hormones stable in saliva for prolonged period of time </li></ul></ul></ul></ul><ul><ul><ul><ul><li>* Convenient shipment by regular US mail </li></ul></ul></ul></ul><ul><ul><ul><ul><li>* More representative than serum of total bioavailable steroid hormone levels </li></ul></ul></ul></ul>
  10. 10. Advantages and disadvantages to SHT <ul><li>Disadvantages: </li></ul><ul><ul><li>* Technically more challenging: need 10-20 x sensitivity </li></ul></ul><ul><ul><li>* Interfering substances-food, beverages </li></ul></ul><ul><ul><li>* Saliva easily contaminated with topical hormones on lips or hands </li></ul></ul><ul><ul><li>* Spurious results with peridontal disease (more problem with chewing gum) </li></ul></ul><ul><ul><li>* Lack of familiarity (serum is gold standard) </li></ul></ul><ul><ul><li>* Sublingual use of hormones often leads to inaccurate (high) results </li></ul></ul><ul><ul><li>* No proficiency testing (CAP, AAB) that reflects saliva hormone levels </li></ul></ul><ul><ul><li>* Topical application of hormones results in saliva levels higher than serum </li></ul></ul>
  11. 11. Ideal test report <ul><li>The ideal test report should contain the following information on the patient </li></ul><ul><ul><ul><ul><li>* gender/age </li></ul></ul></ul></ul><ul><ul><ul><ul><li>* menopausal status: pre vs peri vs post, menstrual cycle: follicular vs luteal, hysterectomy/oophorectomy, status use of hormones: </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>* types </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>* delivery (oral vs topical) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>* dose </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>* time since last used (hours vs days) symptoms </li></ul></ul></ul></ul></ul>
  12. 12. Efficacy <ul><li>Barrou Z, Guiban D, Maroufi A, Fournier C, Dugue MA, Luton JP, Thomopoulos P. Overnight dexamethasone suppression test: comparison of plasma and salivary cortisol measurement for the screening of Cushing’s syndrome. Eur J Endocrin 1996;134:93-96. </li></ul><ul><li>Salivary cortisol was compared to plasma cortisol for screening of Cushing’s Syndrome via overnight dexamethasone suppression test. Compared to plasma, salivary cortisol demonstrated superior performance with 100% specificity and 94% sensitivity (no overlap between controls and patients with Cushing’s Syndrome). In addition, salivary cortisol levels in women taking oral contraceptives were normal whereas the corresponding plasma levels were elevated (false positive) in some cases. </li></ul><ul><li>Belkien LD, Bordt J, Moller P, Hano R, Nieschlag E. Estradiol in saliva for monitoring follicular stimulation in an in vitro fertilization program. Fertil Steril 1985;44:322. </li></ul><ul><li>Serial serum and saliva measurements were compared in 23 patients undergoing ovulation induction in an in vitro fertilization program. Serum and saliva were well correlated (r=0.77) throughout, except for salivary estradiol levels less than 4 pg/ml. (Note that estradiol can easily be detected below this level with modern methods.) The authors conclude that, “assessment of ovarian function in clomiphene citrate (CC) or CC/hMG stimulated cycles can be performed precisely with the saliva estradiol assay.” </li></ul><ul><li>Bolaji II, Tallon DF, O'Dwyer E, Fottrell PF. Assessment of bioavailability of oral micronized progesterone using a salivary progesterone enzyme immunoassay. Gynecol Endocrinol 1993;7:101-110. </li></ul><ul><li>These authors looked at salivary progesterone levels in 40 postmenopausal women taking 100 mg oral micronized progesterone in cyclical fashion (23 days/month) for one year. These levels fell into the range observed in the luteal phases of a control group of 40 normally cycling women. Five patients had simultaneous serum and saliva levels of progesterone measured for 12 hours after ingestion of a 100 mg dose of progesterone. Levels in both cases followed the same time curve, with both peaking at 2 hours. This supports the notion that progesterone diffuses rapidly from serum to saliva. </li></ul>
  13. 13. efficacy <ul><li>Aardal E, Holm AC. Cortisol in saliva-reference ranges and relation to cortisol in serum. Eur J Clin Chem Clin Biochem 1995;33:927-932. </li></ul><ul><li>Parallel serum and saliva samples were acquired in 197 individuals, in the morning and evening. A slight decrease in morning cortisol was seen in the oldest individuals tested (61-70 years). As has been demonstrated in other work, once serum cortisol exceeded » 450 nmol/l, a marked increase in salivary cortisol was noted. This is attributed to a rapid increase in free plasma cortisol once the available sites on cortisol binding globulin are filled. The authors conclude by enumerating the advantages of saliva over serum (simplicity, decreased stress, convenience, sample mail-in, temperature stability). </li></ul><ul><li>Aardal-Eriksson E, Karlberg BE, Holm AC. Salivary cortisol- and alternative to serum cortisol determinations in dynamic function tests. Clin Chem Lab Med 1998;36:215-222. </li></ul><ul><li>Serum and salivary cortisol responses were compared in various dynamic tests of HPA axis function including insulin tolerance, CRH stimulation, and ACTH challenge. In 42 of 45 tests performed, consideration of salivary cortisol led to the same conclusion as serum cortisol. The authors conclude that due to a more pronounced cortisol response in saliva, and a closer correlation between salivary cortisol and serum ACTH, salivary cortisol may be used as an alternative parameter in dynamic endocrine tests. </li></ul><ul><li>saliva vs. serum </li></ul>
  14. 14. In text citation <ul><li> </li></ul><ul><li>Kumar V, Cotran R. Basic Pathology, 6th ed. </li></ul><ul><li>Vining, RF, McGinley, RA, The Measurement of Hormones in Saliva: Possibilities and Pitfalls, J Steroid Biochem 27: 8 1-94, 1987. </li></ul><ul><li>Zava D. Saliva Hormone Testing. 2011 </li></ul><ul><li>Lee, JR. Natural Progesterone; The Multiple Roles of a Remarkable Hormone. BLL Publishing, Sebastapol, CA, 1993. </li></ul>