This Test is a combination of DUTCH Cycle Mapping + CAR (Cortisol Awakening Response).
The DUTCH Cycle Mapping™ PLUS test maps the patterns of progesterone and estrogen in urine throughout the menstrual cycle and analyzes the salivary cortisol awakening response. This test bundle includes the insomnia cortisol sample.
This bundle cannot be ordered for patients under 12 years of age.
The DUTCH Cycle Mapping™ test maps the patterns of progesterone and estrogen throughout the menstrual cycle.
By requesting this test, the physician will get a complete picture of a woman’s cycle, which may be relevant for patients with month-long symptoms, infertility, and polycystic ovary syndrome.
Nine targeted estrogen and progesterone measurements are taken throughout the cycle to characterize the follicular, ovulatory, and luteal phases.
It is expected to find a pattern of hormones with relatively low estrogen levels early in the cycle, an increase around ovulation, and modest levels in the luteal phase.
Progesterone levels stay relatively low until after ovulation, but after ovulation levels ideally increase (10-fold) and then drop back down at the end of the cycle.
Critically, a disruption in this cycle can lead to infertility or hormonal imbalance.
The cortisol awakening response (CAR) by Precision Analytical offers a comprehensive assessment of cortisol levels at specific time points after waking, providing valuable insights into the body's stress response dynamics.
Cortisol, often termed the "stress hormone," plays a crucial role in regulating various physiological processes, including metabolism, immune function, and the body's response to stressors.
The CAR profile measures cortisol levels upon waking and at subsequent time points, allowing for the evaluation of the natural diurnal rhythm of cortisol secretion and the magnitude of the cortisol response to the morning awakening.
This information can aid in assessing individual stress resilience, identifying abnormalities in HPA (hypothalamic-pituitary-adrenal) axis functions and cortisol secretion patterns, and guiding personalized interventions to optimize stress management and overall well-being.
The DUTCH Cycle Mapping tests estrogen and progesterone metabolites nine times throughout one complete cycle by Gas Chromatography and Mass-Spectrometry in tandem (MS/MS).
This is the most accurate method for testing urinary reproductive hormones and their metabolites; research shows that urine hormones correlate well with serum hormones throughout a woman’s menstrual cycle, and can demonstrate ovulation with accuracy. [6., 8.]
In healthy individuals, cortisol is expected to rise in the morning by as much as 50%, peak approximately 30 minutes after waking, and fall back to morning waking levels within 60 minutes of waking. [5.] This is called the Cortisol Awakening Response, or CAR, and it provides valuable insight into the functioning of the HPA axis. [11.]
Five salivary measurements are taken during a 24 hour period in the Cortisol Awakening Response Profile. These measurements allow for the assessment of the cortisol awakening response, which is the natural increase in cortisol levels that occurs within the first hour after waking. By evaluating cortisol levels at these time points, the CAR profile provides insights into the body's stress response dynamics and diurnal cortisol rhythm.
Additionally, an individual’s salivary cortisone measurements are reported for each of the 5 time points. Knowing the cortisone levels in saliva is necessary for a complete understanding of adrenal function; for example, if the diurnal cortisol curve is low but the cortisone curve is elevated, this demonstrates increased activity of the enzyme 11b-HSD2 that deactivates cortisol to cortisone. When only the diurnal cortisol curve is available, the total amount of adrenal cortisol produced is not known. [7.]
The test assesses the following measurements throughout a 24 hour period:
Cortisol/cortisone levels immediately upon waking (0 minutes post-waking)
Cortisol/cortisone levels approximately 30 minutes after waking
Cortisol/cortisone levels approximately 60 minutes after waking
Cortisol/cortisone levels in the afternoon
Cortisol/cortisone levels at bedtime
It also provides a total cortisol level and a total cortisone level over the 24 hour collection period.
The graphs provided as part of an individual’s cycle mapping test results illustrate estrogen (E) and progesterone (Pg) production over the menstrual cycle, with reference ranges and patient results.
Cycles typically range from 21-35 days, and the 9 most relevant measurements have been selected from multiple samples. Single-day measurements are utilized for cycles <34 days, representing ovulatory and luteal peaks. In the case of longer cycles, samples are taken from 2-day averages to ensure that any peaks in estrogen or progesterone metabolites are not missed.
Estrone (E1) and estradiol (E2) rise in the follicular phase, and estrogen stimulates luteinizing hormone (LH) surge before ovulation. This leads to Pg production in the second half of the cycle. Pg peaks 5-7 days post-ovulation, declining before menses. An absent or weak rise in Pg suggests anovulation or luteal phase defect, associated with infertility.
This test helps uncover ovulation and fertile days; many women do not ovulate on day 14, which can cause confusion regarding a woman’s fertile window and slow the process of conception. [2.] In fact, as few as 24% of cycling women may ovulate on day 14 or 15. [12.]
The addition of the CAR test to the DUTCH Cycle Mapping Test provides additional insight into the effects of chronic stress on a woman’s hormone cycle. Chronic stress alters HPA axis function, which can also alter HPO (hypothalamic-pituitary-ovarian) function and cause a range of downstream effects.
These may include:
Infertility [4.]
PMS symptoms [3.]
Irregular or absent periods [14.]
Heavy bleeding and/or spotting between periods [13.]
Painful periods [10.]
PCOS [1.]
This Panel is ideal for any woman struggling with menstrual or fertility issues who also reports current or past high stress.
Patient results, including creatinine for hydration correction, are presented in a table below the graphs, with low or high creatinine levels potentially affecting hormone measurement reliability.
Women struggling with infertility
Women with cycling hormones and no menses
Partial hysterectomy (ovaries intact but no uterus)
Ablations
Women with irregular cycles
PCOS
If the luteal phase shifts from month-to-month
Not sure when to test due to long or short cycles
Women whose hormonal symptoms tend to fluctuate throughout the cycle
Women struggling with PMS, mid-cycle spotting, migraines, etc.
Women who have not responded as expected to prior therapies for hormone imbalance
Women with complex presentations, especially in the setting of subjective or objective high stress levels
Presentations that include sleep problems
Individuals with a Suspected Hormonal Contribution to Chronic Conditions, including chronic fatigue syndrome, fibromyalgia, and certain autoimmune diseases, where hormone imbalances may play a role
Women who cannot or want to avoid repeated blood draws for serum hormone testing throughout the month
The test is not recommended in postmenopausal women, women on birth control, or women with cycles that follow the expected pattern. [9.]
This is a long and detailed test. Click here to access Collection and Shipping Instructions.
Video: Understanding Cycle Mapping and FAQs
Video: DUTCH Cycle Testing: Interpreting Common Results
Class: Understanding the Cortisol Awakening Response
Join us as Dr. Carrie Jones, ND, FABNE, MPH presents the Cortisol Awakening Response through the DUTCH Plus.
In our educational course Dr. Jones will discuss:
What is the Cortisol Awakening Response (CAR) in the DUTCH Plus.
How is CAR testing different from traditional 4-point cortisol testing.
Why the CAR is important to alertness, resiliency, autoimmunity and more.
Common causes of an elevated or flat-lined CAR.
Why timing is everything when it comes to treating the CAR.
How to work with brain signaling and the mitochondria to improve the CAR
[1.] Benjamin JJ, MaheshKumar K, Radha V, et al. Stress and polycystic ovarian syndrome-a case control study among Indian women. Clinical Epidemiology and Global Health. 2023;22:101326. doi:https://doi.org/10.1016/j.cegh.2023.101326
[2.] Bull JR, Rowland SP, Scherwitzl EB, Scherwitzl R, Danielsson KG, Harper J. Real-world menstrual cycle characteristics of more than 600,000 menstrual cycles. NPJ Digit Med. 2019 Aug 27;2:83. doi: 10.1038/s41746-019-0152-7. PMID: 31482137; PMCID: PMC6710244.
[3.] Gollenberg AL, Hediger ML, Mumford SL, Whitcomb BW, Hovey KM, Wactawski-Wende J, Schisterman EF. Perceived stress and severity of perimenstrual symptoms: the BioCycle Study. J Womens Health (Larchmt). 2010 May;19(5):959-67. doi: 10.1089/jwh.2009.1717. PMID: 20384452; PMCID: PMC2875955.
[4.] Lewinski A.,Brzozowska M., Female infertility as a result of stress-related hormonal changes, GREM Gynecological and Reproductive Endocrinology & Metabolism (2023); 02-03/2022:094-098 doi: 10.53260/grem.22302035
[5.] Lim WT, Torpy DJ. Chronic Fatigue Syndrome. [Updated 2023 Aug 30]. In: Feingold KR, Anawalt B, Blackman MR, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279099/
[6.] Newman M, Pratt SM, Curran DA, Stanczyk FZ. Evaluating urinary estrogen and progesterone metabolites using dried filter paper samples and gas chromatography with tandem mass spectrometry (GC-MS/MS). BMC Chem. 2019 Feb 4;13(1):20. doi: 10.1186/s13065-019-0539-1. PMID: 31384769; PMCID: PMC6661742.
[7.] Nomura S, Fujitaka M, Jinno K, Sakura N, Ueda K. Clinical significance of cortisone and cortisone/cortisol ratio in evaluating children with adrenal diseases. Clin Chim Acta. 1996 Dec 9;256(1):1-11. doi: 10.1016/s0009-8981(96)06392-9. PMID: 8960783.
[8.] Pattnaik, S., Das, D. & Venkatesan, V.A. Validation of urinary reproductive hormone measurements using a novel smartphone connected reader. Sci Rep 13, 9227 (2023). https://doi.org/10.1038/s41598-023-36539-w
[9.] Prior JC, Naess M, Langhammer A, Forsmo S. Ovulation Prevalence in Women with Spontaneous Normal-Length Menstrual Cycles - A Population-Based Cohort from HUNT3, Norway. PLoS One. 2015 Aug 20;10(8):e0134473. doi: 10.1371/journal.pone.0134473. PMID: 26291617; PMCID: PMC4546331.
[10.] Rafique N, Al-Sheikh MH. Prevalence of menstrual problems and their association with psychological stress in young female students studying health sciences. Saudi Med J. 2018 Jan;39(1):67-73. doi: 10.15537/smj.2018.1.21438. PMID: 29332111; PMCID: PMC5885123.
[11.] Stalder T, Kirschbaum C, Kudielka BM, Adam EK, Pruessner JC, Wüst S, Dockray S, Smyth N, Evans P, Hellhammer DH, Miller R, Wetherell MA, Lupien SJ, Clow A. Assessment of the cortisol awakening response: Expert consensus guidelines. Psychoneuroendocrinology. 2016 Jan;63:414-32. doi: 10.1016/j.psyneuen.2015.10.010. Epub 2015 Oct 20. PMID: 26563991.
[12.] Symul L, Wac K, Hillard P, Salathé M. Assessment of menstrual health status and evolution through mobile apps for fertility awareness. NPJ Digit Med. 2019 Jul 16;2:64. doi: 10.1038/s41746-019-0139-4. PMID: 31341953; PMCID: PMC6635432.
[13.] Tufail A, Mustafa R, Munaver SA, Nawaz B. Frequency of psychological stress among women with new onset menstrual disorders amid corona pandemic lockdown. Pak J Med Sci. 2022 May-Jun;38(5):1159-1164. doi: 10.12669/pjms.38.5.4606. PMID: 35799741; PMCID: PMC9247749.
[14.] Vigil P, Meléndez J, Soto H, Petkovic G, Bernal YA, Molina S. Chronic Stress and Ovulatory Dysfunction: Implications in Times of COVID-19. Front Glob Womens Health. 2022 May 23;3:866104. doi: 10.3389/fgwh.2022.866104. PMID: 35677754; PMCID: PMC9168655.
The DUTCH Cycle Mapping™ PLUS provides a comprehensive analysis of a woman's monthly cycle, including hormone metabolites and the Cortisol Awakening Response (CAR). This helps to identify issues with infertility, PCOS, and other month-long symptoms. This test includes the insomnia cortisol sample. This test cannot be ordered for patients under 12 years of age.
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On December 11th, join Dr. Terry Wahls in a 
