I frequently see patients who have gotten saliva testing for various hormone levels from other practitioners they have seen in the past, so this is common practice in many integrative and complementary health clinics. However, the questions my patients usually will ask me knowing that I like to practice evidence-based medicine as much as possible is whether they can fully trust the saliva testing results.
During my integrative medicine fellowship, we had a module that addressed the validity of saliva testing for various hormone levels. As we reviewed the literature on salivary hormone testing, the general consensus was that saliva testing is appropriate for cortisol levels but not necessarily dependable for other hormone levels as compared to the gold standard for serum testing.
So, in general, I still repeat hormone levels via serum testing at appropriate times of the day and month, depending on which levels I am checking on. However, I will use saliva testing for cortisol checks so that we can look at the curve throughout any given day for patients who I am suspicious may have adrenal fatigue.
I have listed some references for studies that discuss hormone testing via saliva samples at the end of this post, but I want to be clear as to my stance on the issue of salivary testing. For most other hormone levels, there is a potential chance of some over- or under-estimation of levels using saliva testing, especially depending on the method of collection used for testing.
So, for those patients looking for a more accurate test level that is insurance-covered due to cost concerns, I would recommend serum testing. For those who have the option for saliva testing, cortisol salivary tests are more commonly covered by insurance compared to other hormone salivary tests, for the same reasons I discussed in this article; insurance companies have looked at the literature and recognized that because of the potential for outcome variability, they are not willing to cover for salivary hormone testing except for cortisol levels.
Let's use one of my patient examples to help you see what I mean by my concerns about saliva hormone testing -- except when it comes to cortisol, which I support using salivary testing whole-heartedly.
My patient is a 45-year-old man who was having issues with low sex drive and erectile dysfunction, and was told by his urologist that he had testosterone deficiency that was mild but that he could consider some testosterone therapy if he wanted it. This patient was concerned about using hormone therapy due to what he had read in the literature and wanted to avoid it. So he went to see an integrative practitioner who did testing for his hormone levels again but this time with saliva testing, which the patient had to pay for out of pocket. The results from that test showed that his testosterone level was very hearty and his adrenal cortisol level was low, so he decided to take deglycyrrhyzed licorice and ginseng for his adrenal functioning and refused to take testosterone therapy.
Despite therapy that did indeed help his adrenal functioning over the course of six months, he was still battling with low sex drive and erectile dysfunction. He asked to do repeat tests, and this time his testosterone level on saliva testing was very low but cortisol level had improved. He had to again pay out of pocket for this test, so he decided he wanted to re-evaluate his hormone levels so he came to see me.
When I saw him, I checked him for his thyroid functioning and his red blood cell counts to make sure he wasn't anemic. I also rechecked his testosterone level, both the total level and the free testosterone level using the serum test. I also checked him for PSA (prostate-specific antigen) level so that we could get a baseline level in case we needed to treat him for testosterone deficiency. I also checked his DHEA-s level to see if he needed replacement for this as well. Sometimes, if the DHEA-s is very low, simply replacing that can help with testosterone levels if the testosterone levels are only a little low.
When the results returned, it turned out the testosterone level was similar to what his urologist had initially gotten in the first serum level, and the free level was again low but the total level was fine. His DHEA-s was also low, so we replaced his DHEA and monitored the level closely as well as his PSA. After a few months of that, his free testosterone level improved, his libido improved and erectile dysfunction was less of an issue, according to the patient.
What's interesting about this patient case is that his serum level of testosterone remained about the same on repeated testing, yet his saliva test seemed to be up then down without a correlation to his serum level. So this was an example of how the saliva testing for hormones may not be as reliable sometimes for sex hormone testing, and so if in doubt, you should get a serum level checked. You have to just make sure that the physician is checking your free and total level for testosterone as well as DHEA-s and a baseline PSA for monitoring or therapy should you end up needing testosterone or DHEA therapy.
So, while I am not regularly in agreement with many insurance decision outcomes, for this one, I agree with them based on what literature we have. This is especially important for the readers who have limited funds for medical testing because you want to utilize your funds toward getting the results you can count on instead of wondering whether the test results from the saliva sample you gave are going to be over- or under-estimating your levels.
Consistency of lab testing outcome is important whether you are paying out of pocket or not because without accuracy, you could be treated with therapies that you don't actually need. So keeping this in mind, I would recommend using cortisol saliva testing if you need to figure out the severity of adrenal fatigue... But leave the other hormone testing to your serum tests where the studies support more consistency as to the results, so that you get more for the money you are paying for your health.
For more by Julie Chen, M.D., click here.
For more on personal health, click here.
For more on natural health, click here.
1. American Association of Clinical Endocrinologists (AACE). Medical guidelines for clinical practice for management of menopause. Endocrine Pract. 1999;5:355-366. Available at: http://www.aace.com/clin/guides/menopause.pdf. Accessed February 15, 2002.
2. Hodgson SF, Watts NB, Bilezikian JP, et al. .American Association of Clinical Endocrinologists medical guidelines for clinical practice for the prevention and treatment of postmenopausal osteoporosis: 2001 edition, with selected updates for 2003. Endocr Pract. 2003;9(6):544-564..
3. AACE Thyroid Task Force. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the evaluation and treatment of hyperthyroidism and hypothyroidism. Endocr Pract. 2002;8(6):457-469..
4. Huppert FA, Van Niekerk JK. Dehydroepiandrosterone (DHEA) supplementation for cognitive function. Cochrane Database Syst Rev. 2006:(2):CD000304.
5. Grimley Evans J, Malouf R, Huppert F, van Niekerk JK. Dehydroepiandrosterone (DHEA) supplementation for cognitive function in healthy elderly people. Cochrane Database Syst Rev. 2006;(4):CD006221.
6. Contreras LN, Arregger AL, Persi GG, et al. A new less-invasive and more informative low-dose ACTH test: Salivary steroids in response to intramuscular corticotrophin. Clin Endocrinol (Oxf). 2004;61(6):675-682.
7. No authors listed. Chronic hypoadrenalism. GPNotebook. General Practitioner Notebook. Warwickshire, UK: Oxbridge Solutions, Ltd.; 2005. Available at: http://www.gpnotebook.co.uk/simplepage.cfm?ID=2127560704. Accessed September 16, 2005.
8. Odeke S, Nagelberg SB. Addison disease. eMedicine Endocrinology Topic 42. Omaha, NE: eMedicine.com; updated November 25, 2003. Available at: http://www.emedicine.com/med/topic42.htm. Accessed September 16, 2005.
9. Rubin GJ, Hotopf M, Papadopoulos A, Cleare A. Salivary cortisol as a predictor of postoperative fatigue. Psychosom Med. 2005;67(3):441-447.
10. American College of Obstetricians and Gynecologists (ACOG) Committee on Gynecologic Practice. ACOG Committee Opinion #322: Compounded bioidentical hormones. Obstet Gynecol. 2005;106(5 Pt 1):1139-1140.
11. National Institutes of Health (NIH). NIH State-of-the-Science Conference Statement on Management of Menopause-Related Symptoms. NIH Consensus and State-of-the-Science Statements. Bethesda, MD: NIH: March 21-23; 22(1).
12. Institute for Clinical Systems Improvement (ICSI). Menopause and hormone therapy (HT): Collaborative decision-making and management. Bloomington, MN: ICSI; October 2006.
13. The North American Menopause Society. The role of testosterone therapy in postmenopausal women: Position statement of The North American Menopause Society. Menopause. 2005;12(5):497-511.
14. Carroll T, Raff H, Findling JW. Late-night salivary cortisol measurement in the diagnosis of Cushing's syndrome. Nat Clin Pract Endocrinol Metab. 2008;4(6):344-350.
15. Elamin MB, Murad MH, Mullan R, et al. Accuracy of diagnostic tests for Cushing's syndrome: A systematic review and metaanalyses. J Clin Endocrinol Metab. 2008;93(5):1553-1562.
16. Doi M, Sekizawa N, Tani Y, et al. Late-night salivary cortisol as a screening test for the diagnosis of Cushing's syndrome in Japan. Endocr J. 2008;55(1):121-126.
17. Nieman LK, Biller BM, Findling JW, et al. The diagnosis of Cushing's syndrome: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2008;93(5):1526-1540.
18. Grￃﾶschl M. Current status of salivary hormone analysis. Clin Chem. 2008;54(11):1759-1769.
19. Carroll T, Raff H, Findling JW. Late-night salivary cortisol for the diagnosis of Cushing syndrome: A meta-analysis. Endocr Pract. 2009;15(4):335-342.
20. Raff H. Utility of salivary cortisol measurements in Cushing's syndrome and adrenal insufficiency. J Clin Endocrinol Metab. 2009;94(10):3647-3655.
21. Flyckt RL, Liu J, Frasure H, Wekselman K, et al. Comparison of salivary versus serum testosterone levels in postmenopausal women receiving transdermal testosterone supplementation versus placebo. Menopause. 2009;16(4):680-688.
22. Alexandraki KI, Grossman AB. Novel insights in the diagnosis of Cushing's syndrome. Neuroendocrinology. 2010;92 Suppl 1:35-43.
23. Sereg M, Toke J, Patￃﾳcs A, et al. Diagnostic performance of salivary cortisol and serum osteocalcin measurements in patients with overt and subclinical Cushing's syndrome. Steroids. 2011;76(1-2):38-42.