The DUTCH Plus® takes hormone testing to a new level. In addition to sex hormones and their metabolites, the DUTCH Complete™ looks at the overall diurnal pattern of free cortisol, and the total and distribution of cortisol metabolites. The DUTCH Plus® adds the Cortisol Awakening Response (CAR) to bring another important piece of the HPA axis into focus.
What is the Cortisol Awakening Response and how do we test for it?
When we open our eyes upon waking, cortisol levels naturally begin to rise by an average of 50%. 30 minutes after waking, cortisol levels will still show this sharp increase. By 60 minutes after waking, cortisol levels have peaked and begin to decline. Measuring this rise and fall of cortisol levels at waking can be used as a “mini stress test”. Research shows that the size of this increase correlates with HPA Axis (hypothalamic-pituitary-adrenal) function, even if the sample measurements are all within range. A quick saturation of saliva swabs upon waking, and at 30 and 60 minutes after waking, provide what is required to assess a patient’s Cortisol Awakening Response.
A low or blunted Cortisol Awakening Response
This can be a result of an underactive HPA Axis, excessive psychological burnout, seasonal affective disorder
(SAD), sleep apnea or poor sleep in general, PTSD, chronic fatigue, and/or chronic pain. A decreased CAR has also been associated with systemic hypertension, functional GI diseases, postpartum depression, and autoimmune diseases.
An elevated Cortisol Awakening Response
This can be a result of an over-reactive HPA Axis, ongoing job-related stress (anticipatory stress for the day), glycemic dysregulation, pain (i.e. waking with painful joints or a migraine), and general depression (not SAD). A recent study showed that neither the waking nor post-waking cortisol results correlated to Major Depressive Disorder, but the CAR calculation (the change between the first two samples) did. This measurement of the response to waking has independent clinical value showing dysfunction that may be hidden by current testing options.
Even though a patient may have “normal” free cortisol levels throughout the day, that doesn’t always mean everything is functioning properly. The graph above shows two good examples. A blunted or exaggerated Cortisol Awakening Response (CAR) can appear, even when single samples return “normal” results. The HPA axis might not be appropriately responding when faced with a stressor, even when cortisol levels are fluctuating nicely throughout the day. The “stress” of waking allows us to test the HPA axis in a way that has been independently correlated to clinical outcomes and cannot be assessed by other cortisol tests on the market.
Why aren’t true Cortisol Awakening Response tests readily available?
A true CAR assessment requires salivary samples to be collected at the moment of waking, and twice more, at 30 minutes after waking and 60 minutes after waking. These specifically timed collections are difficult and impractical with urine and traditional salivary options. The DUTCH Plus® uses specialty, FDA-approved, and patented collection devices called Salivettes™. Salivettes™ are specifically made for testing cortisol when timing needs to be precise and are used in nearly all of the published CAR studies. The small synthetic cotton swab can be quickly saturated with saliva, providing a very fast and simple collection. Unfortunately for labs using saliva to test reproductive hormones, they are not a viable option as the swabs cannot be used when testing progesterone. The DUTCH Plus® offers the most accurate salivary cortisol sampling with Salivette™ collection and analysis using LC-MS/ MS. An unparalleled clinical tool is created when combining salivary cortisol with the extensive urine metabolites from DUTCH.
WHY USE DUTCH?
Analytical and Clinical Validation
Precision Analytical’s testing methods go through a rigorous validation process to verify accuracy, recovery, and linearity. We pride ourselves in relentlessly pursuing the most accurate and precise techniques available for testing. See the data on the next page to support the analytical and clinical validation of this powerful new testing model.
The Easiest Patient Collection
Patients collect just four or five dried urine samples over a 24-hour period. Dried samples are stable for several weeks making them convenient to ship worldwide.
HOW DOES DUTCH COMPARE TO OTHER HORMONE TESTS?
DUTCH vs. Saliva Testing
While the free cortisol pattern in saliva has clinical value, there is a significant missing piece to surveying a patient’s HPA-Axis function with saliva testing – measuring cortisol metabolites. To properly characterize a patient’s cortisol status, free and metabolized cortisol should be measured to avoid misleading results when cortisol clearance is abnormally high or low. Likewise with sex hormones, measuring estrogen and androgen metabolites gives a fuller picture for more precise clinical diagnosis of hormonal imbalances and HRT monitoring.
DUTCH vs. Serum Testing
While the most universally accepted testing method (due to the availability of FDA-cleared analyzers that are reliable and inexpensive), serum testing is lacking in some areas. Adrenal hormones cannot be effectively tested in serum because free cortisol cannot be tested throughout the day. There is also a lack of extensive metabolite testing (especially for cortisol and estrogens).
DUTCH vs. 24-Hour Urine Testing
There are two primary drawbacks to 24-hour urine testing of hormones. First, the collection is cumbersome, and as many as 40% of those who collect, do so in error (Tanaka, 2002). Secondly, dysfunction in the diurnal pattern of cortisol cannot be ascertained from a 24-hour collection. Some providers add saliva for daily free cortisol. DUTCH eliminates the need for two tests.
The kit includes:
• Easy-to-follow Directions and Requisition Form
• (4) Urine Collection Strips and (6) Salivette™ Saliva Collection Tubes
• Resealable Plastic Bag
• Sealable Return Envelope
The results include:
• Analysis of 35 different hormones: estrogen, progesterone, testosterone, DHEA-S, and cortisol along with their metabolites, plus the cortisol awakening response (CAR)
• Graphical representation of results and embedded video tutorials to assist in the hormone assessment to share with your medical provider
• DUTCH OATs: Melatonin (6OHMS), 8-Hydroxy-2-deoxyguanosine (8-OHdG), and six organic acid tests (OATs) including markers for vitamin B12 (methylmalonate), vitamin B6 (xanthurenate), kynurenate, glutathione (pyroglutamate), dopamine (homovanillate), norepinephrine/epinephrine (vanilmandelate).