24-Hour Urinary Testing: The Difference Between Sick and Well

By: Catherine Chua, DO, FAAFP, FMNM, CPE (Certified Physician Executive)
Chief Medical Officer
Davis Health System
Elkins, WV

While attending courses during my Fellowship training, I distinctly remember an esteemed colleague asking the audience, “How many of you think that women develop a Prozac deficiency when they turn 35?”  We were all somewhat stunned at the question, but we also realized she was absolutely correct.  Fast forward, and I have now been a practitioner of both Family Medicine and Functional and Nutritional medicine for many years.  I have often found that I am the last stop for many frazzled, exhausted, depressed, inflamed, overweight women and men.  These patients have been to multiple doctors – primary care, rheumatology, endocrinology – only to be told that there is “nothing” wrong and that they are just stressed out.  They are often sent out with nothing more than a prescription for an NSAID and an SSRI or SNRI and a pat on the head.  I often hear in my office, “I don’t feel I’m depressed, but I know SOMETHING is wrong.”

Over the years, there has been much debate over salivary vs. urinary hormone testing, and now dried urine spot testing is in the debate as well.  I have pored over the literature during my time as a practicing functional medicine physician, and I still exclusively rely on 24-hour urine testing for my patients for a number of reasons.  I appreciate that with 24-hour testing, the clinician is able to look at all three estrogens as well as their downstream metabolites, and that 24-hour testing removes the problem of variable daily fluctuations in a patient’s hormone levels.  When sitting down with my patients, I explain how when we are younger, we have a lot more circulating estriol and less estrone and that as we age, those ratios shift increasing our risk of breast cancer and causing significant symptoms.   I am able to use testing results to help educate my patients on lifestyle changes, medications, vitamins, and supplements that can help to relieve symptoms as well as improve their overall health risks.  With 24-hour urine testing, I am also able to assess progesterone levels and differentiate between the two types.  That allows me to more effectively treat anxiety, dysmenorrhea, PCOS, peri-menopause, and PMS.  It also allows me to properly treat post menopausal women with a full array of hormones.

I also appreciate that I am able to get a 4-6 point cortisol and cortisone level.  Most patients who come to see me for functional medicine are completely worn out by the time that they make it through my door.  Using a 24-hour urine test allows me to show the patients the difference between being “sick” and being “well”.  These patients have had bloodwork showing that their cortisol is “normal” and have been told that, therefore, there is no adrenal dysfunction (i.e., they are not sick).  When they see the 24-hour urine results, however, their feelings that they are not “well” are validated.  With the wellness norms established for 24-hour urine testing, I have been able to successfully identify and treat patients with adrenal dysfunction and get them back to their normal lives.

Over the years I have treated many patients with many different issues, including a young woman who had multiple miscarriages and failed fertility treatments.  She came to me because she was tired of having her hormones manipulated, and she wanted to get her “hormones back to normal”.  After 24-hour urine testing, as well as some bloodwork, I found her to have very low progesterone and subclinical hypothyroidism.  When she returned for her follow up four months later, she asked me if the hormones should be causing her to not have a period.  I explained that, no, she should be having more regular menses and asked if she’d taken a pregnancy test.  She became a little perturbed and told me that the whole reason she was there was that she could not get pregnant; that is why she was trying to go back to normal hormone levels.  Her pregnancy test was positive, and that little girl is a feisty 10 year-old today. 

Another case that has occurred more recently was that of a 47 year-old female who presented to a free clinic offered by my facility.  She is a full-time employee in a minimum wage job, and therefore can not afford insurance.  She stated that she was about to have to quit her job, because with her brain fog and fatigue, she could no longer make it through the day at work.  She had put on weight, her periods were long and heavy, her hair was thinning, and overall, she felt like she was dying.  She had not gone through any testing, because she thought she couldn’t afford it.  When I talked to her about the 24-hour urine testing, and the cost of it compared to running a battery of bloodwork, she jumped at the chance to try to find out what was wrong.  When we got the test back, she had very high estrone levels, a low 2:16 ratio, a flat cortisol curve that was below normal levels, and very low progesterone.  I started her on progesterone (at night during the second half of her cycle), DIM and Ashwagandha.  I also discussed lifestyle modifications that would support lowering her estrogen levels and changing her cortisol curve and levels.  She was also started on Armour thyroid at that meeting.  Over the last year, this patient has lost 34 lbs and her blood pressure has come down from 145/80 to 126/80.  She kept her job, and her boss even reached out to thank me for “changing her life”.  She stated that she feels better than she has in years and is excited to start getting out of the house and exercising when the weather gets better. 

Success stories such as these are par for the course for functional medicine.  The information I gain from looking at women’s (and men’s) hormones is yet another very important tool in my doctor bag.  I’m very fortunate, as a provider, that I am able to practice functional medicine even in one of the most impoverished and unhealthy areas in our country.  I am also very fortunate to be able to partner with a state of the art laboratory while actively pursuing optimal wellness for my patients.