The DUTCH Complete: A Complete Overview

Menstrual related symptoms are common among women. In fact, 90% of women report having some premenstrual symptoms. In addition, the menstrual cycle is considered the fifth vital sign for women, as it can give important insight into a woman's overall health and well-being.

The DUTCH Complete test can be incredibly helpful in assessing and finding the root cause of symptoms related to the menstrual cycle. This article will discuss the DUTCH Complete test, who it should be used for, and how to collect the test.

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What is The DUTCH Complete?

The DUTCH Complete is a test by Precision Analytical. The acronym "DUTCH'' stands for Dried Urine Test for Comprehensive Hormones. As its name implies, the DUTCH test uses dried urine samples to assess 35 different hormone metabolites, or breakdown products, in the urine. Additionally, it also tests for an oxidative stress marker, melatonin, and six organic acid markers. The test is broken down into three main parts: sex hormones, adrenal hormones, and additional markers including the organic acid test, melatonin, and oxidative stress markers.

The test begins with an overview page entitled "Hormone Testing Summary." This page is broken into three parts: the key, sex hormones, and adrenal hormones. In the key section, results are represented by a gauge. The gauge is color coded to show different reference ranges, with the premenopausal range in green and postmenopausal in purple. There are two stars on the gauge, one representing the bottom and one on the top of the reference range. A circle in the middle says "patient results'' as this is where the numerical value will be given. The hormone section shows the gauges for testosterone, estradiol, and progesterone with their numerical values given. The adrenal section gives a graph entitled "Daily Free Cortisol," with the y-axis showing the amount of cortisol and the x-axis showing the time of day the sample was taken (waking, morning, afternoon, night). Two black lines indicate the high and low reference ranges, and a red line indicates the patient's values. Lastly, there are gauges for total DHEA production, 24-hour free cortisol, and metabolized cortisol, which we'll discuss below.

At the beginning of the hormone and adrenal sections, there is a page with the numerical values of every metabolite tested. This may be overwhelming for the patient but can be useful to the practitioner for reference. The pages after that are visual representations of those numbers. We'll now discuss the sex hormone cascade.

Sex Hormones

This page begins at the top with the hormone pregnenolone. Pregnenolone is referred to as the "grandfather" of all hormones, as all hormones discussed on this page, estradiol, estrone, estriol, progesterone,  DHEA-S, and testosterone, begin as pregnenolone. Pregnenolone can convert into either progesterone in the ovary, or DHEA, in the adrenal gland.

Progesterone is a primary female hormone only made after ovulation. Progesterone can affect the function of the uterine lining, balancing out the growth effect of estrogen in the uterine tissues and elsewhere, such as breast tissue. Underneath the progesterone gauge are two arrows labeled "5a" and "5b" respectively. These labels represent the enzymes that cause the conversion of progesterone into their respective metabolites. When progesterone uses the 5a pathway and converts into a-pregnanediol this has the potential to elicit a calming, anti-anxiety, antidepressant effect in patients, as it stimulates the calming neurotransmitter GABA.  

Pregnenolone can also convert into DHEA, which will then convert to DHEA-S is the precursor to testosterone. However, it is also active on its own as it positively affects cognition and the stress response. DHEA can convert into androstenedione, a hormone that doesn't have much metabolic function, and will then convert into testosterone. Women make estrogen from testosterone, as indicated by the dotted arrows entering the estrogen section. It can affect sexual functioning, including libido, bone mineralization, energy levels, muscle mass, and more. Testosterone can be converted into dihydrotestosterone (DHT) which is 30x more potent than testosterone itself. This conversion happens via the 5 alpha reductase enzyme. Alternatively, testosterone can convert into another less androgenic metabolite by the 5-beta reductase enzyme. The DUTCH test provides a fan-like gauge entitled "5-alpha reductase activity", showing the person's preference for 5 alpha versus 5beta reductase. High testosterone and DHT are implicated in Polycystic Ovarian Syndrome (PCOS) and can cause problems with ovulation, acne, hirsutism (dark hairs in unwanted places), and more. Underneath this fan are the age-dependent ranges for these androgens.

As stated above, women make their estrogen from testosterone, which is represented by dotted arrows from testosterone into the estrogen section. Estradiol is the main estrogen in the premenopausal woman and can cause uterine lining and breast tissue growth. Estradiol can also play a role in bone integrity, cardiovascular, and cognitive health. High levels can lead to heavy and irregular periods, mood swings, weight gain, and more. Estrone is the primary estrogen in the postmenopausal woman. Although estrone is weaker than estradiol, it has a higher ratio of activating estrogen receptors that can lead to cancers. Estriol is the weakest estrogen and is usually only activated in pregnancy. This test is a favorite amongst practitioners as it shows how these estrogens are metabolized.

Phase I

Phase I is indicated by the green, red, and blue arrows that turn estrogen into metabolites.  Each of these arrows represents a different pathway that estradiol and estrone can go down in order to get out of the body. On the arrows are the enzymes that control those pathways. These enzymes are controlled by genes but can be modulated by various nutrients and compounds.

There is a pie chart on the right that shows the amount of utilization of each pathway broken down into percentages.

There is also an arrow going from estriol directly to the 16OH metabolite, as that is the only pathway estriol utilizes.

The green pathway is labeled "protective pathway," as its resulting metabolite is beneficial. The other two pathways, however, can be problematic and lead to an increased risk of certain cancers. If you follow the red arrow to the 4OH dial, you'll see 4OH has two choices. The green arrow choice neutralizes 4OH, while the red arrow shows damaged DNA.

Phase II

The second step of estrogen metabolism is represented by the lower left portion of the paper. This step takes the metabolites from step one and makes them water soluble so that they may enter the stool or urine. On top of the arrow in this step are the letters "COMT," and underneath is the word "Methylation." Methylation is the biochemical process responsible for this step, and this step specifically uses the methylation enzyme COMT. The fan to the left represents the speed of the COMT and thus can influence how estrogen is being metabolized.

There is a lot to be discovered within this section alone. Great care should be given to understanding estrogen metabolism and how to interpret and treat these results properly.

Adrenal Hormones

In the upper left-hand corner of the adrenal section, you'll see the outline of a head with a brain and three colored circles. This graphic describes the Hypothalamic Pituitary Adrenal (HPA) axis. "STRESS" written above the head signifies that stress activates this pathway. The hypothalamus, in a purple circle, senses the stress, and when it does, it releases a hormone (CRH) to the pituitary gland (blue circle). The pituitary gland will then release a hormone (ACTH) to the adrenal glands, stimulating the release of cortisol and DHEA. Cortisol is a hormone that plays a central role in the stress response and the circadian cycle. Cortisol imbalance can affect our hormones, causing fatigue, sleep issues, gastrointestinal symptoms, and more. Following the arrow to the right labeled "cortisol metabolism" to the "metabolized cortisol" gauge, this shows the total amount of cortisol found in the urine. Following the dotted arrow takes you to two graphs, "daily free cortisone" on the left and "daily free cortisol" on the right. The y-axis of these graphs has the amount of cortisone or cortisol, and the x-axis represents the time of day (waking, morning, afternoon, night).

Cortisone is the body's inactive form of cortisol. The body can convert cortisol to cortisone and vice versa, depending on what the body needs at that time. Like testosterone, this section includes a fan-like gauge showing the body's preference for cortisol or cortisone metabolites.   This can help assess the state of stress. Also, cortisol's metabolism depends on thyroid hormones, and thus this section can indicate thyroid health.

Following the DHEA arrow, the total amount of DHEA is given with age-appropriate reference ranges located above. Total DHEA level is needed to assess the full picture of how the adrenal glands are functioning. It can also be helpful to compare it to DHEA-S on the previous page to assess the state of stress and also may give answers to testosterone imbalance.

Melatonin levels are also assessed. Melatonin is known as the "nighttime" hormone as it aids in sleep. Melatonin works inversely with cortisol: when one is high, the other should be low. Assessing melatonin levels with cortisol gives a better understanding of the circadian rhythm and can help to resolve symptoms related to disturbed sleep and fatigue. Melatonin is also important for ovarian functioning and can thus affect sex hormones.

Organic Acids Test and Additional Markers

Cobalamin, known as vitamin b12, is essential for many functions in the body. Methylmalonic acid (MMA) is a byproduct of energy production and requires B12 to fully metabolize it. Therefore, if MMA is high, B12 is low. In relation to hormones, B12 is a necessary nutrient for estrogen metabolism.

Vitamin B6 is needed for over 100 reactions in the body. The DUTCH test measures two enzymes that require B6 in order to be broken down, xanthurenate and kynurenate, and thus high levels of one or both can indicate B6 deficiency. Both high estrogen and cortisol levels can lead to a greater need for B6.

The DUTCH test measures levels of b-Hydroxyisovalerate, an enzyme made when biotin levels are deficient. Biotin is important for mitochondrial functioning, where many of the processes on this test take place.

High pyroglutamate is a marker for glutathione deficiency. Glutathione is the strongest antioxidant that the body makes and plays an important role in estrogen metabolism.

Indican is a byproduct of microbes in the microbiome and can signify a dysbiosis, or imbalance. This is important as the third step in estrogen metabolism occurs in the microbiome, and an imbalance may cause estrogen to be recycled in the body, leading to higher levels.

Homovanillate (HVA) is a metabolite of the neurotransmitter dopamine. Dopamine imbalance can cause sleep issues, anxiety, addictive behaviors, changes in mood and more.

Vanilmandelate (VMA) is a metabolite of the fight or flight hormones norepinephrine and epinephrine. Enzymes involved in estrogen metabolism are also involved in the breakdown of these neurotransmitters, affecting VMA levels. Additionally, these hormones are made from the adrenal glands and can parallel cortisol output or be inversely related to cortisol levels, depending on the state of stress. Low blood pressure, high blood pressure, irritability cravings and more are symptoms of imbalances in norepinephrine and epinephrine levels.

Quinolinate is a neurotoxic byproduct that is high in neurodegenerative disorders, major depressive disorder, and vitami B3 deficiency. Phthalates, a component of plastics, can affect hormone levels and also cause high quinolinate.

8-Hydroxy-2-deoxyguanosine is a marker of oxidative stress in the body. High levels have been found in breast and prostate cancer.

Which Patients is the DUTCH Complete Best Used For?

The DUTCH Complete can be a great choice to evaluate heavy and painful periods, hormonal acne, hair loss, hormonal mood swings including PMS, and more. Menopausal symptoms including hot flashes, night sweats, mood swings can also be addressed with a DUTCH Complete Test. Lastly, it can also be used to monitor certain bioidentical hormones.

Women having irregular periods or those who have had ablations or their uterus removed but still have ovaries would be better served by the DUTCH Cycle Mapping Test.

What Type of Sample is Needed to Complete the DUTCH Complete?

The DUTCH Complete needs to be done during the luteal phase, or the second half of the cycle. This is because the hormone progesterone is only made during this time. Since a healthy menstrual cycle can be anywhere from 21-35 days long, ideal collection windows will vary, as seen in the chart below.

The test requires four dried urine samples collected at different times during the day.

1. Sample 1, dinnertime (5pm)
2. Sample 2, bedtime (10pm-12am)
3. Sample 3, waking
4. Sample 4, 2 hours after waking

An additional sample can be collected if overnight waking occurs. Samples need to be left to dry for 24 hours before shipping. Certain medications, supplements, and foods should be avoided or limited prior to taking the test.

How to Naturally Balance Reproductive Hormones Based on DUTCH Complete Testing

Since the DUTCH Complete provides a surplus of information, and as hormones are all interrelated and affect each other, treatments will vary based on individual results. Nutrition, lifestyle changes, botanicals and nutraceuticals, medications, and other modalities can be used to formulate a treatment plan to aid in balancing hormones. For more individualized treatment options, we suggest checking out our Women’s Health Category section.

Summary

The DUTCH Complete is a comprehensive test to assess hormone levels in women. Showing levels and metabolites of reproductive and adrenal hormones, as well as organic acid markers, this test can help resolve an array of symptoms and provide the patient with details unique to their own biochemistry. With all this information, a personalized treatment plan can be formed, focusing on the root cause of the patient's symptoms.