The Complete Guide to Hormone Testing: How We Personalize Diagnosis, Detoxification, and Replacement
Hormones orchestrate nearly every system in the body. When estradiol, progesterone, testosterone, DHEA, and cortisol drift out of optimal range, patients feel it. Energy stalls, sleep falters, mood swings, stubborn weight creeps in, and libido fades. Treating symptoms without measuring root causes rarely delivers lasting relief. Precision hormone care requires high‑quality testing at the right time, in the right medium, with the right interpretation.
At our clinic, we use an integrated test stack—serum hormone testing, hormone saliva testing, HUMAP and/or DUTCH urine metabolite testing, and the Adrenal Stress Index (ASI)—to see the endocrine system from every angle. These tools help us identify whether production, transport, receptor sensitivity, circadian rhythm, or detoxification pathways are off target. The result is a tailored plan that can include lifestyle changes, nutraceutical support for detoxification, and hormone replacement via pellets, injections, creams/gels, or troches with precise monitoring.
Below, you’ll learn exactly what each test measures, when we use it, and how results translate into a safe, effective, and individualized protocol.
Why Test Hormones in More Than One Way?
No single test answers every clinical question. Serum provides gold‑standard quantification for many hormones. Saliva captures free, biologically active fractions and circadian dynamics without needles. Urine profiling (HUMAP or DUTCH) reveals metabolites and detoxification pathways across estrogens, androgens, and adrenal steroids. ASI maps the diurnal curve of cortisol and DHEA so we can link physiology to symptoms such as afternoon crashes, insomnia, or wired‑but‑tired states.
Using these tests together clarifies:
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Production vs. clearance: Are levels low because the body makes too little, or because detoxification and excretion run too fast?
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Binding vs. bioavailability: Do serum totals look “normal” while free fractions remain low?
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Timing: Do cortisol, progesterone, or testosterone peak or trough at maladaptive times of day or month?
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Safety: Are estrogen metabolites favoring protective pathways (2‑OH and appropriate methylation), or drifting toward 4‑OH/16‑OH patterns that demand attention?
Serum Hormone Testing: The Foundation
What it is: A blood draw that measures total and, when appropriate, free or bioavailable hormones.
Best for:
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Estradiol (E2), estrone (E1), estriol (E3) when establishing baselines or monitoring systemic HRT.
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Progesterone to confirm ovulation or monitor replacement in luteal phase support or menopausal therapy.
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Total and free testosterone (plus SHBG and albumin) to assess bioavailable androgen status.
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DHEA‑S as a stable adrenal androgen marker.
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LH, FSH, prolactin, TSH, free T4, free T3, and sex hormone binding globulin (SHBG) to provide context.
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Comprehensive metabolic and lipid panels to monitor cardiometabolic safety during HRT.
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PSA and hematocrit/hemoglobin in men on testosterone therapy.
When we use serum:
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Baseline assessment before any intervention.
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Ongoing monitoring for pellet therapy or injectables, where systemic exposure is most relevant.
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Confirmation of dose–response relationships and safety checks.
Strengths: Widely standardized; excellent for totals; ideal for safety and regulatory markers.
Limitations: Totals can look “normal” while free or tissue‑level effects remain suboptimal; serum captures moments, not daily rhythms.
Timing tips:
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Cycling women: mid‑luteal progesterone (about 5–7 days post‑ovulation); estradiol measured day 2–4 for baseline or mid‑cycle if assessing peaks.
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Men: morning total/free testosterone (7–10 a.m.) for most accurate peak.
Hormone Saliva Testing: Bioavailable Fractions and Daily Patterns
What it is: Noninvasive sampling that measures free (unbound) hormones diffused into saliva, often collected multiple times per day.
Best for:
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Cortisol diurnal curves (waking, mid‑day, afternoon, bedtime) to assess stress physiology.
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Free estradiol, progesterone, and testosterone when correlation to symptoms matters, particularly for topical therapies that raise tissue levels more than serum totals.
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Situations where needle stress could distort results or where multiple time‑points add value.
Strengths: Captures biologically active fractions and circadian nuance; excellent for follow‑up in topical HRT.
Limitations: Assay variability across labs; less ideal for absolute totals or for monitoring injectable or pellet dosing that drives systemic levels.
Clinical pearls:
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For women using creams/gels, saliva often reflects tissue availability more closely than serum.
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For patients with insomnia, anxiety, fatigue, or post‑viral dysautonomia, a four‑point saliva cortisol map reveals whether the curve peaks or flattens at the wrong times.
HUMAP and DUTCH: Urinary Hormones and Detoxification Pathways
What they are: Comprehensive urine panels (spot or dried samples) that quantify parent hormones and metabolites across estrogens, androgens, progesterone, and adrenal steroids, as well as phase I and phase II detoxification markers.
Why this matters: Levels alone cannot tell the full story. We must see how hormones break down and which pathways the body prefers. For estrogens, phase I generates 2‑OH, 4‑OH, and 16‑OH metabolites; phase II methylates, glucuronidates, or sulfates those intermediates for safe excretion. Skewed patterns may raise concerns about symptom burdens or long‑term risk. For androgens, conversion across DHEA → androstenedione → testosterone → DHT → 3α/3β‑diols can explain acne, hair changes, or prostate symptoms. For adrenals, free cortisol and cortisone metabolites reveal total output vs. tissue activation.
What DUTCH/HUMAP illuminate:
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Estrogen balance and safety:
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Healthy emphasis on 2‑OH with efficient COMT‑mediated methylation safeguards tissues.
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Excess 4‑OH demands attention to antioxidant status and methylation support.
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Elevated 16‑OH helps explain breast tenderness, fibroids, or heavy cycles.
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Progesterone metabolites: Clues about luteal sufficiency and sedative neurosteroid effects.
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Androgen architecture: Whether symptoms arise from high DHT conversion, poor aromatization, or low substrate.
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Adrenal output vs. utilization: Free vs. metabolized cortisol clarifies whether the body produces too much, too little, or converts too quickly.
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Phase II capacity: Methylation, glucuronidation, and sulfation markers show whether detoxification needs support.
Strengths: Holistic view of production and clearance; critical for safety, symptom mapping, and personalization.
Limitations: Not a direct substitute for serum when managing pellet or injection dosing; best used alongside serum.
Detoxification‑support examples based on results:
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Heavy 4‑OH estrogens: Emphasize antioxidant support and methylation cofactors.
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Low 2‑OH and sluggish methylation: Support COMT and MTHFR‑related pathways.
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High androgen 5α‑reduction: Consider strategies that modulate that conversion, guided by symptoms and goals.
(We tailor nutraceuticals per patient. Examples often include cruciferous‑derived DIM and sulforaphane, calcium‑D‑glucarate, magnesium glycinate, N‑acetylcysteine, and methylation support blends with methyl‑B12, methyl‑folate, and betaine. Where helpful, we source from our in‑house formulary: Curcumin Complex, Omega 1300, CoQ10 Omega, and Methylation Complete.)
Adrenal Stress Index (ASI): The Cortisol–DHEA Circadian Map
What it is: A salivary profile of cortisol at several points throughout the day, often with DHEA included, designed to assess the hypothalamic–pituitary–adrenal (HPA) axis.
What we learn:
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Cortisol awakening response (CAR): A healthy rise within the first 30–45 minutes after waking signals resilient HPA regulation.
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Mid‑day and afternoon levels: Identify slumps that create “brain fog,” cravings, or reliance on caffeine.
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Bedtime cortisol: Elevated levels correlate with insomnia and nighttime rumination.
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DHEA trend: Balances catabolic cortisol effects and supports vitality and immune regulation.
Why it matters: Cortisol interacts with thyroid, sex steroids, and insulin. When cortisol stays high or flatlines, patients metabolize hormones differently and experience poor symptom control, even when serum or saliva sex steroids look fine.
Common patterns and next steps:
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High evening cortisol: Prioritize sleep hygiene, light exposure timing, breathwork, and targeted botanicals.
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Low CAR with fatigue: Focus on morning light, structured movement, protein‑forward breakfast, and restorative sleep.
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Low DHEA: Consider age‑appropriate DHEA support after confirming need and rule‑outs.
Putting It Together: How We Choose the Right Tests
A peri‑menopausal woman with night sweats and heavy cycles:
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Serum: E2, E1, progesterone, CBC, ferritin, thyroid, metabolic panel.
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DUTCH/HUMAP: Estrogen metabolites to assess 2‑OH/4‑OH/16‑OH balance and methylation sufficiency.
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Saliva or ASI: Cortisol rhythm if sleep is disrupted.
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Plan: If estrogen metabolism leans 4‑OH/16‑OH, start detoxification support first; consider transdermal estradiol plus oral micronized progesterone after improving the pathway profile.
A man with low energy, low libido, and rising visceral adiposity:
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Serum: Total/free testosterone, SHBG, estradiol (sensitive assay), LH/FSH, prolactin, lipids, A1c, hematocrit, PSA.
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Urine (DUTCH/HUMAP): Androgen metabolites and aromatization vs. 5α‑reduction.
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ASI: Cortisol pattern if sleep or stress issues persist.
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Plan: If replacement is indicated, choose injectable testosterone or pellets for convenience; monitor estradiol, hematocrit, lipids, and symptoms at defined intervals. Support detoxification if DHT runs hot or estradiol rises quickly.
A patient with chronic anxiety, poor sleep, and post‑meal crashes:
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ASI: To quantify cortisol dynamics.
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Saliva: Free hormone snapshots when topical therapies exist.
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Urine: Adrenal metabolites to distinguish production from clearance.
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Plan: Lifestyle timing, protein intake, glycemic control, sleep optimization, and adaptogenic support; layer sex‑steroid therapy only if indicated after pattern correction.
How Testing Guides Safe, Effective Hormone Replacement
Choosing the Delivery Method
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Pellets:
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Pros: Long acting; excellent adherence; steady levels.
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Considerations: Best monitored with serum; dose titration requires experience.
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Injectables (e.g., testosterone cypionate):
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Pros: Predictable pharmacokinetics; cost‑effective.
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Considerations: Peaks and troughs demand thoughtful scheduling; serum monitoring is essential.
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Creams/Gels (estradiol, progesterone, testosterone):
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Pros: Flexible, tissue‑friendly; useful for symptom targeting.
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Considerations: Saliva can reflect tissue exposure better than serum; absorption varies by site and skin health.
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Troches (buccal/sublingual):
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Pros: Rapid onset; convenient for some patients.
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Considerations: Oral mucosa absorption avoids first‑pass metabolism; monitoring should include serum and symptoms.
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Oral micronized progesterone:
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Pros: Improves sleep and vasomotor symptoms; favorable neurosteroid effects.
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Considerations: Sedation can occur; take at bedtime.
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Setting Targets and Intervals
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Before therapy: Complete serum panel with context labs; add DUTCH/HUMAP if metabolite risk or detox concerns exist. Consider ASI for sleep and stress mapping.
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Early follow‑up (6–8 weeks): Re‑check symptom scores and relevant labs tied to delivery method.
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Stability phase (every 3–6 months): Confirm levels, safety markers, and metabolite patterns remain in the desired lanes.
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Annual review: Reassess goals, risk, and the need for dose changes or delivery‑method shifts.
Safety Monitoring
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Women on systemic estrogen: Blood pressure, lipids, weight, symptom inventory; consider periodic imaging per age and risk guidelines.
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Men on testosterone: Hematocrit/hemoglobin, PSA, estradiol, lipids, blood pressure, body composition.
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All patients: Liver enzymes, fasting glucose/A1c, and inflammatory markers when indicated.
Detoxification: The Often‑Missing Link
Symptoms, side effects, and long‑term safety hinge on how hormones move through phase I and II pathways in the liver and gut. We use DUTCH/HUMAP to observe:
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Phase I (CYP) balance: Whether estrogens favor 2‑hydroxylation over 4‑ or 16‑hydroxylation.
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Phase II capacity: Methylation (COMT), glucuronidation, and sulfation competency.
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Gut–liver axis: Bile flow and β‑glucuronidase activity determine whether conjugated hormones re‑circulate.
Support strategies we personalize from results:
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Cruciferous concentrates (DIM, sulforaphane) to lean metabolism toward 2‑OH pathways.
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Methylation nutrients (methyl‑B12, methyl‑folate, betaine) when phase II methylation lags.
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Calcium‑D‑glucarate to reduce enterohepatic reactivation.
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Magnesium glycinate for smooth detox and sleep support.
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Curcumin, omega‑3s, and CoQ10 for inflammatory tone and mitochondrial resilience.
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Suggested options: Curcumin Complex, Omega 1300, CoQ10 Omega, Methylation Complete.
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Frequently Asked Questions
Which test is “best” for hormones?
None, in isolation. Serum quantifies totals and safety markers. Saliva reflects free fractions and diurnal patterns, especially for topical use. DUTCH/HUMAP shows metabolites and detoxification. ASI maps cortisol rhythm. The combination answers what, why, and how to fix it.
If my serum levels are normal, why do I feel poorly?
Totals can sit in range while free fractions, receptor sensitivity, or metabolite balance remain suboptimal. Saliva, urine metabolites, and ASI reveal dynamics that serum alone cannot show.
Do pellets require different monitoring than creams or injections?
Yes. Serum is the primary tool for pellets and injectables. Saliva can guide topical regimens. DUTCH/HUMAP remains valuable across delivery methods for detox and safety.
How quickly will I feel better?
Some feel improvements within weeks, especially in sleep, hot flashes, and energy. Structural changes—bone density, body composition—take months. We set expectations and track progress with symptom inventories and labs.
Is hormone therapy safe?
Safety improves when dosing is individualized, detox pathways are supported, and monitoring is consistent. We use transdermal estradiol, oral micronized progesterone, and physiologic testosterone dosing where appropriate, with scheduled follow‑ups and lab checks.
A Sample Patient Journey
Patient: 51‑year‑old teacher with insomnia, hot flashes, brain fog, and weight gain around the middle.
Testing:
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Serum: E2 low‑normal; progesterone low; SHBG high; thyroid normal; lipids mildly elevated.
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DUTCH: Estrogen metabolites skewed toward 16‑OH with sluggish methylation.
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ASI: High bedtime cortisol, flat afternoon curve.
Plan:
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Detox support: DIM and sulforaphane concentrate, Methylation Complete, magnesium glycinate, evening Curcumin Complex.
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Lifestyle: Earlier light exposure, strength training 2–3 days weekly, protein‑forward lunches, digital sunset before bedtime.
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HRT: Low‑dose transdermal estradiol plus oral micronized progesterone at night for sleep and symptom relief.
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Follow‑up (8 weeks): Hot flashes down, sleep improved, afternoon energy steadier.
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Follow‑up (4 months): Serum confirms appropriate range; repeat DUTCH shows improved 2‑OH fraction and better methylation; ASI shows lower bedtime cortisol. The plan shifts to a long‑term maintenance dose.
Actionable Takeaways
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Test before treating. Start with serum for baselines and safety; add saliva and ASI for free fractions and circadian rhythm.
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See the whole map. Use DUTCH/HUMAP to evaluate phase I/II detoxification and guide targeted support.
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Match the method to the patient. Choose pellets, injections, creams/gels, or troches based on goals, lifestyle, absorption, and monitoring needs.
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Monitor with intention. Re‑evaluate symptoms and labs on a defined cadence; adjust dosing and support as the biology changes.
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Support detox. The right pathways keep therapy effective and comfortable long term.
Call to Action
Ready to stop guessing and start measuring? Schedule a comprehensive hormone evaluation with our team. We will pair serum, saliva, DUTCH/HUMAP, and ASI testing with a personalized plan that supports detoxification and optimizes hormone replacement through pellets, injections, creams/gels, or troches. Together, we will restore clarity, energy, sleep, and confidence—safely and sustainably.
References
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North American Menopause Society. The 2022 hormone therapy position statement. Menopause.
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Endocrine Society Clinical Practice Guidelines on Testosterone Therapy in Men. J Clin Endocrinol Metab.
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Stanczyk FZ, Clarke NJ. Measurement of estradiol—challenges ahead. J Clin Endocrinol Metab.
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Labrie F, et al. Intracrinology of sex steroids. Physiol Rev.
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Faiyaz‑Ul‑Haque M, et al. Urinary estrogen metabolites and risk assessment. Steroids.
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Peeters GM, et al. DHEA and aging: physiology and clinical relevance. Drugs Aging.
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Nimptsch K, et al. Dietary factors and estrogen metabolism. Am J Clin Nutr.
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Hackney AC. Endocrine responses to exercise. Compr Physiol.
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Rosner W, et al. Utility and limitations of free hormone assays. J Clin Endocrinol Metab.
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Vesper HW, et al. Standardization of steroid hormone measurements. Clin Chem.
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Hampson E. Estrogen effects on cognition and mood. Curr Opin Behav Sci.
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Zava DT, Zava LC. Assessment of hormone exposure via saliva. Clin Lab Med.
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Fiers T, et al. Sensitive estradiol assays in men and postmenopausal women. Eur J Endocrinol.
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Zimmermann T, et al. Cortisol awakening response and stress physiology. Psychoneuroendocrinology.
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Bergink V, et al. Progesterone and GABAergic modulation of sleep. Sleep Med Rev.
(References are provided for educational context. We tailor testing and treatment to the individual during clinical consultation.)