Hormones Testing - Smith Rexall Drug

Transcription

Hormones Testing
Alison McAllister, ND
Disclosure
Alison McAllister, ND, is employed by ZRT Laboratory. Conflict of interest was resolved through peer review of slide content.
Professional Education Services Group staff have no financial interest or relationships to disclose.
© 2015
Disclosure
This continuing education activity is managed and accredited by Professional Education Services Group. Neither PESG nor any accrediting organization supports or endorses any product or service mentioned in this activity.
© 2015
Educational Grant Support
This continuing education activity is supported by an educational grant from PCCA.
© 2015
© 2015. All Rights Reserved
1
Learning Objectives
• At the conclusion of this activity, the participant will be able to:
– Explain current hormone testing methods.
– Discuss pros and cons of hormone testing methods.
– Discuss testing methods that more accurately measure topically delivered hormones.
© 2015
Why Do We Test Hormones?
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Current Testing Methods
• Blood Tests ‐ tests serum or whole blood values of hormones and their binding proteins –
Bloodspot and Serum testing
• Urine Tests ‐ tests urinary excretion of free hormones and their metabolites
• Saliva Tests ‐ tests salivary values of free hormones
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2
Know your technology
To get what you want
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© 2015
Saliva
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3
Saliva’s Main Components
• Water 98%
• Mucin
• Amylase – digestive function
• Electrolytes – esp. bicarbonate
• Surfactants
•
•
•
•
sIgA
Lactoferrin
Lactoperoxidase
VEGF – vascular endothelial growth factor
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1. Parotid
2. Sublingual
3. Labial (lips)
4. Submandibular
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* Davenport HW.The Digestive Tract, Year Book Medical Publishers, Chicago, 1971
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4
* D. Zava & ZRT 2006
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Saliva Testing PROS
Easy to do
Multiple samples easily ‐ circadian rhythm
Painless
Usually clinically relevant
Shows supplemental hormones especially progesterone and testosterone
• Relatively Inexpensive
•
•
•
•
•
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Saliva Testing CONS
• Research is ahead of clinical practice
• Only available through research hospitals or private companies
• Not 100% covered by insurance
• Sublingual hormones may contaminate the sample • Spit
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Saliva
• Easy‐ noninvasive
• Multiple collections
• Kids
• Monitor treatment
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Four tube salivary kit
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Specimen Collection and Handling
• Benefits of saliva vs serum/plasma collection:
– Convenient
– Ease of collection
– Non‐invasive and discomfort free
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6
Assay Challenge: Relative Lowest Expected Concentrations of Steroids in Saliva
1000-2000 pg/ml
Direct assays show poor accuracy at low concentrations
<0.5-1.5
pg/ml
<5-20 pg/ml
<100-500
pg/ml
<1-50 pg/ml
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DHEAS
NEAT SALIVA
Cortisol
Progesterone
Testosterone
Estradiol
MATRIX = BACKGROUND
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DHEAS
EXTRACTED SALIVA
Cortisol
Progesterone
Testosterone
Estradiol
MATRIX = BACKGROUND
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Comparing Estradiol Immunoassays
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EIA/LIA Direct Assay Problems for Estradiol
Cntrl #1 Cntrl #2
Cntrl #3
Cntrl #4
Cntrl #5
Cntrl #6
Cntrl #7
Cntrl #8
Cntrl # 9
Cntrl # 10
pg/mL
pg/mL
pg/mL
pg/mL
pg/mL
pg/mL
pg/mL
pg/mL
pg/mL
pg/mL
3.0
4.0
3.5
4.7
7.5
9.1
11.3
14.9
62
57
1.4
2.4
2.4
3.6
5.2
7.2
9.3
12.4
52
47
38
0.0
0.9
1.2
2.5
2.9
5.4
7.4
9.9
42
0.8
2.2
2.5
3.1
5.4
8.7
11.7
12.6
62
50
1.9
2.3
2.0
4.0
5.5
7.6
9.1
12.6
49
48
1.3
2.8
3.5
3.2
5.9
8.8
11.3
12.4
66
50
0.9
1.9
2.8
3.2
5.6
8.7
7.6
11.3
46
47
2.9
3.6
3.0
4.3
5.5
8.3
11.0
14.1
43
46
1.0
2.2
1.4
3.2
3.9
6.3
9.4
12.1
39
40
0.9
1.9
2.8
3.2
5.6
8.7
7.6
11.3
46
47
* Results from Manufacturer of FDA‐approved Direct Estradiol Kit
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8
Direct Assay Precision is Poor Below 2.5pg/ml for Estradiol
PHYSIOLOGICAL RANGE SALIVARY ESTRADIOL:
<0.5‐4 pg/ml
True Sensitivity: Detection Limit = 2.5pg/ml
Results from Manufacturer of FDA‐Approved Salivary Estradiol Kit
Manufacturer’s Reported Detection Limit = 0.3pg/ml
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Correlation of EIA Saliva Tests with LC‐MS/MS
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Correlate Salivary Test Results with Clinical Picture
• Do salivary estradiol levels show expected relationships with:
–
–
–
–
Menstrual Cycle
Premenopausal vs Postmenopausal
Symptoms of Estrogen Imbalance‐Deficiency and Excess
Estrogen Supplementation
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Serum Estradiol
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Salivary Estradiol © 2015
Salivary Estradiol: The Menopausal Transition
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10
Salivary Estradiol & Hot Flashes
OPTIMAL
REFERENCE RANGE
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© ZRT Laboratory.LLC
February 13, 2015
33
© 2015
Salivary Testosterone: Monitoring Supplementation
Physiological Range
N = 328
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A Guide to Testing Mediums With Supplementation
Route of Administration of Hormones
None
Saliva
Oral


Topical

Vaginal

Sublingual
contaminate
Pellet/IM

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Blood Spot
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Venous vs. Capillary Blood Matters
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Patient Convenience is Key
• Blood spot
 Minimally invasive testing
 Collection timing convenient  Convenient at home collection
 Quick and easy
 Less infectious pathogens with drying
 Dried sample stable for weeks at RT
 No refrigeration required for shipment
 Fewer shipment restrictions
 Labeling & Storage convenient © 2015
Patient Convenience is Key (cont’d)
• Venipuncture
 Invasive testing  Inconvenient collection timing
 Requires driving to clinic
 Time consuming
 Wet sample contains infectious pathogens
 Sample unstable‐overnight shipment
 Shipment requires refrigeration
 Restrictions for wet blood shipments
 Labeling and Storage difficult
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Bloodspot Pros and Cons
• PROS
– Easy collection
– Great for kids
• Can use toes or heel
– Perfect timing
– Shows topical delivery
– Fast collection
– Mailing is easy
• CONS
– Insurance reimbursement
– Patient collects themselves
– Careful about topical delivery on fingertips
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Correlation of Finger‐Stick Capillary Dried Blood (DBS) with Serum • Are DBS results quantitatively equivalent to venipuncture serum results? –
–
–
–
Menstrual Cycle
Premenopausal vs. Postmenopausal
Symptoms of Estrogen Imbalance‐Deficiency and Excess
Estrogen Supplementation
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Blood Spot and Plasma Levels of Estradiol, Progesterone, LH, and FSH Over a Normal Menstrual Cycle
* Validation of Blood Spot Sampling for Gonadotropins and Ovarian Hormone Levels in Reproductive Age Women. Fertility and Sterility, November 2007
* A. Edelman, R. Stouffer, D. Zava, J. Jensen
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14
Progesterone Blood Spot/Serum Correlation
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Blood Spot vs. Serum Correlations
Testosterone
LH
FSH
SHBG
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Serum = Blood spot
Endogenous production
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15
None
Oral
Serum


Bloodspot


Topical
Vaginal
Don’t show up


Sublingual
Pellet/IM




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What About Supplementation?
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* From: K. Nahoul, et al. Profiles of plasma estrogens, progesterone and their metabolites after oral or vaginal administration of estradiol or progesterone.
Maturitas ,16: 185‐202, 1993.
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16
Exogenous Hormones‐Oral Delivery
Levine et.al. Maturitas, 1998
LC‐
MS
EI
A
Nahoul et.al. Maturitas, 1993
Vaginal
Oral
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© ZRT Laboratory.LLC
February 13, 2015
51
© 2015
Topical Progesterone and Body Fluid Distribution of Progesterone
• Study: Progesterone cream and gel 80mgs and serial measurements for 24 hours
* Du, Joanna. Percutaneous Progesterone Delivery via cream or gel application in postmenopausal women. 2013, Menopause: Volume 20
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17
Endometrial Proliferation with Topical Supplementation
* Serum results from Carey British J. Ob & Gyn 2000 & O’Leary Clin. End. 2000
* Endometrial proliferation data from Leonetti F&S 2003
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Physiological Dosing (20‐30 mg) with Topical Progesterone Results in Physiological (Luteal) Levels (15‐25 ng/ml) of Progesterone in Capillary Blood
Optimal Luteal Range
Reported Serum Range for Topical Pg = 1‐3 pg/ml
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Ovarian Production = 25‐50 ug/day
Evamist Application = 1500‐4500 ug/day
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18
Distribution of Progesterone in Different Body Fluids Following 15 mg Topical Pg
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Serum Testosterone: Monitoring Supplementation
*
http://testim.com/pdf/Testim_PI_Medication_Guide.pdf
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Linear Increase in Capillary Blood Testosterone with Increasing Topical Testosterone Dosage
Physiological Range
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19
* Chang KJ. de Lignieres B. Fertile Sterility 63: 785‐791, 1995. Influences of Percutaneous Administration of Estradiol and Progesterone on Human Breast Epithelial Cell Cycle in vivo. Intraglandular Steroid Concentration
Placebo Pg
E2 E2+Pg
Treatment (n=8) (n=7) (n=9) (n=9)
Pg (ng/g) 0.6+/‐0.3 66+/‐120 2.1+/‐3.8 41.2+/‐75
E2 (ng/g) 0.5+/‐0.4 0.5+/‐0.7 91.0+/‐232 35.5+/‐69
© 2015
* Chang KJ. de Lignieres B. Fertile Sterility 63: 785‐791, 1995. Influences of Percutaneous Administration of Estradiol and Progesterone on Human Breast Epithelial Cell Cycle in vivo. • “The mean P plasma levels were consistently < 1 pg/ml in each treatment group”
• Summary: – Steroid hormones penetrate through skin and reach tissue sites (only breast?)
– Tissue progesterone levels increase without concomitant increase in plasma Pg
– Progesterone reduces breast cell uptake of estradiol
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ZRT Laboratory
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20
Tissue response of topically delivered steroids more closely reflects salivary and capillary blood levels than serum or urine levels
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Conclusion:
• All topical steroids result in a marked increase in salivary and DBS levels of hormone, but little increase in serum or urine hormone
• Tissue uptake of steroid indicate salivary and DBS hormone levels more accurately reflect tissue response
© 2015
None
Serum

Bloodspot

Saliva

Oral
Topical
Vaginal
Sublingual
Pellet/IM
Don’t show up









contaminate



© 2015
21
Urine Testing
© 2015
Dried vs. Wet Urine Collection
 4x collections allows for detecting abnormalities in circadian rhythms  Simple and convenient at home collection
 Flexibility in testing, storage, and shipment
 Discreet
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Dried vs. Wet Urine Collection
 24 hour collection‐not possible to evaluate circadian rhythms
 Inconvenient collection subject to errors
 Expensive and complicated return shipment
 Indiscreet
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22
Endogenous Steroid Hormones
• URINE (liquid and dry)
• LC‐ or GC‐MS: Yes
– Used mostly for total steroid metabolite testing
– Requires enzyme digestion of metabolites, extraction, and derivatization for most steroids‐very time consuming
– GC‐MS/MS more sensitive for some steroids‐estrogen metabolites
– Direct LC‐MS/MS assay of some steroids (e.g. urinary free cortisol & cortisone) possible without derivatization
– Diurnal testing possible with separate collections © 2015
Endogenous Steroid Hormones
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Urine Steroid Metabolite Testing
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23
Typical Cancer Patient: Cortisol and Melatonin Circadian Rhythm
Normal Healthy Adult: Cortisol and Melatonin Circadian Rhythm
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Urine Testing With Topical Progesterone
* Serum results from Carey British J. Ob & Gyn 2000 & O’Leary Clin. End. 2000
* E.P. data from Leonetti F&S 2003
© 2015
Urine Pregnanediol
3930
(1965‐7373)
N=131
Median (20‐80% Range)
152
(92‐346)
N=24
1324
(849‐1932)
N=37
209
(121‐2876)
N=7
81
(42‐171)
N=97
170
(85‐403)
N=262
400
(180‐588)
N=6
© 2015
24
6.70
(2.62‐12.43)
N=7
0.40
(0.26‐0.68)
N=173
0.84
(0.47‐1.40)
N=24
1.21
(0.78‐1.96)
N=75
0.11
(0.06‐0.23)
N=96
0.14
(0.12‐0.37)
N=7
0.63
(0.33‐1.42)
N=27
0.74
(0.37‐1.19)
0.33
N=173
(0.14‐0.84)
N=302
© 2015
GC/MS/MS Testing of Urinary Pregnanediol in Premenopausal Women at Different Phases of the Menstrual Cycle and on Hormonal Contraceptives, and in Postmenopausal Women Supplementing with Topical, Vaginal, and Oral Progesterone 3930
(1965‐7373)
N=131
152
(92‐346)
N=24
1324
(849‐1932)
N=37
209
(121‐2876)
N=7
81
(42‐171)
N=97
170
(85‐403)
N=262
400
(180‐588)
N=6
© 2015
GC/MS/MS Testing of Urinary Estradiol in Premenopausal Women at Different Phases of the Menstrual Cycle and on Hormonal Contraceptives, and in Postmenopausal Women Supplementing with Topical, Vaginal, and Oral Estrogens
6.70
(2.62‐12.43)
N=7
0.40
(0.26‐0.68)
N=173
0.84
(0.47‐1.40)
N=24
1.21
(0.78‐1.96)
N=75
0.11
(0.06‐0.23)
N=96
0.14
(0.12‐0.37)
N=7
0.63
(0.33‐1.42)
N=27
0.74
(0.37‐1.19)
0.33
N=173
(0.14‐0.84)
N=302
© 2015
25
Conclusions:
• All body fluids and assays work well for testing endogenous hormones
• Topically delivered hormones are NOT accurately tested with venipuncture or urine assays
• Topically delivered hormones are more accurately tested with saliva and DBS, but ranges need to be adjusted for saliva
© 2015
None
Oral
Topical
Vaginal
Sublingual
Pellet/IM
Serum


Don’t show up

Bloodspot






Saliva




contaminate

Urine




© 2015
Obtaining CE/CME Credit
If you would like to receive continuing education credit for this activity, please visit:
http://pcca.cds.pesgce.com
© 2015
26

Hormones Testing - Smith Rexall Drug

Transcription

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