Lab Education
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November 4, 2024

Using The DUTCH Plus Test In Your Clinic

Medically Reviewed by
Updated On
November 7, 2024

In the evolving landscape of personalized medicine, understanding hormonal health is paramount for diagnosing and managing a myriad of conditions, from adrenal fatigue to reproductive disorders. 

The DUTCH Plus test by Precision Analytical (DUTCH) is a comprehensive test panel that provides detailed insights into a patient's hormonal milieu, providing answers to questions like: 

"Why am I tired all the time?"

"Why is my mood all over the place?"

"Why do I have menopausal symptoms?"

"Why am I having trouble losing weight?"

"How am I coping with stress?"

This guide aims to equip clinicians with the knowledge and confidence to effectively incorporate the DUTCH Plus test into their clinical practice, enhancing patient care through precise hormonal assessment.

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Understanding the DUTCH Plus Test

DUTCH is an acronym for "Dried Urine Test for Comprehensive Hormones." The DUTCH Plus test is one of many hormonal panels offered by Precision Analytical that uses dried urine samples to measure hormones and their metabolites. 

The DUTCH Plus combines the DUTCH Complete and Cortisol Awakening Response (CAR) tests to create a comprehensive hormonal overview of reproductive and adrenal function, nutritional status, intestinal dysbiosis, and oxidative stress.

DUTCH Plus Components

The DUTCH Plus includes measurements of the following biomarkers:

Sex Hormones

  • Estrogen Metabolites: estrone (E1), estradiol (E2), estriol (E3), 2-OH-E1, 4-OH-E1, 16-OH-E1, 2-Methoxy-E1, 2-OH-E2, 4-OH-E2, and total estrogen
  • Androgen Metabolites: testosterone, DHEA-S, androsterone, etiocholanolone, 5a-DHT, 5a-androstanediol, 5b-androstanediol, epitestosterone
  • Progesterone Metabolites: a-pregnanediol, b-pregnanediol 

Adrenal Hormones

  • Daily free cortisol pattern
  • Daily free cortisone pattern
  • Cortisol metabolites (a-THF, b-THF)
  • Cortisone metabolites (b-THE)
  • DHEA-S

Cortisol Awakening Response

  • Salivary CAR
  • Cortisol
  • Cortisone
  • Insomnia cortisol measurement (optional)

Organic Acids

Clinical Applications of the DUTCH Plus Test

The DUTCH Plus test provides clinically relevant information about hormone production and metabolism for patients who are experiencing a wide variety of health concerns, including:

Benefits of Using the DUTCH Plus Test in Your Clinic

Dried urine and salivary testing provide a comprehensive view of hormone metabolism and adrenal function. Scientific evidence supports the validity of urine and saliva testing for assessing sex hormones and cortisol. 

Urinary tests are particularly effective for measuring hormone metabolites, providing insights into how hormones are processed in the body. This level of detail is difficult to achieve with serum testing alone, which measures circulating hormone levels but offers limited information on how those hormones are metabolized. 

For instance, estrogen metabolites measured in urine can reveal the balance between potentially protective pathways and those associated with higher cancer risk, giving clinicians a deeper understanding of a patient's hormonal landscape.

Like sex hormones, research has validated urinary and salivary testing for accurately measuring cortisol and its inactive metabolite, cortisone. Salivary and urine cortisol tests offer several key advantages over traditional serum testing: 

  • Free cortisol is the fraction of hormone that is unbound to carrier proteins and is bioavailable to tissues and receptors in the body. It is generally a preferred measurement over total cortisol. Unlike blood tests, which measure total cortisol, urine and saliva tests are ideal for measuring free cortisol and its metabolites. 
  • The CAR, only measurable through salivary tests, is a sharp increase in cortisol levels within the first 30-60 minutes after waking. It is an important marker of adrenal health and stress adaptation.
  • Multi-sample collections throughout the day better capture the natural variations in cortisol secretion over 24 hours than a single-point blood test. 
  • Non-invasive and at-home sample collections make testing highly convenient for patients. 

Implementing the DUTCH Plus Test in Your Practice

Doctors should set their patients with accurate expectations for what at-home testing entails to ensure testing accuracy. 

Test Timing

Men and postmenopausal women can collect samples at any time.

Premenopausal women with regular menstrual cycles should collect their samples 6-9 days before their cycle ends (between days 19 and 22 of a 28-day cycle). This handout will help patients determine what day during the month they should collect samples.

Test Preparation

72 Hours Before Sample Collection

  • Avoid taking oral estrogen, pregnenolone, or testosterone.
  • Consult your doctor if you take supplements containing tyrosine, L-Dopa, D,L-phenylalanine, mucuna, or quercetin, which can affect organic acid results.

48 Hours Before Sample Collection

  • Avoid eating avocados, bananas, and fava beans.
  • Avoid taking oral DHEA.

The Night Before Sample Collection

  • Avoid drinking alcohol and caffeine.
  • Limit total fluid intake to avoid diluting urine samples.
  • If you take oral progesterone, take it at bedtime.

Day of Sample Collection

  • Limit total fluid intake to no more than 64 ounces (spread evenly throughout the day).
  • Avoid drinking alcohol and caffeine.
  • Avoid exercising and flossing your teeth.
  • Do not eat or drink until after collecting sample #3.
  • Do not brush your teeth until after collecting sample #3 (in the morning) and sample #5 (in the evening).
  • Delay using hormone creams, gels, or suppositories until after collecting sample #4. 

Sample Collection

The DUTCH Plus requires patients to collect a total of 5-6 salivary samples and 4 urine samples over the course of a day:  

  • Sample #1: Collect saliva immediately upon waking and collect the first urine sample.
  • Sample #2: Collect saliva 30 minutes after waking.
  • Sample #3: Collect saliva 60 minutes after waking.
  • Sample #4: Collect urine 2-3 hours after waking.
  • Sample #5: Collect urine and saliva between 4 and 5 p.m. (before your evening meal). 
  • Sample #6: Collect urine and saliva at bedtime (no later than midnight). 
  • Sample #7 (Optional): Patients who struggle with staying asleep during the night should collect an extra saliva sample at the time of their sleep disturbance. Otherwise, collect this sample at noon. 

Saliva samples should be frozen within 12 hours of collection and should be kept frozen until ready to ship.

Urine collection devices should be fully saturated and left open to dry for at least 24 hours before being closed and placed in a resealable plastic bag.

Interpreting DUTCH Plus Test Results

DUTCH Plus results provide insights into clinical symptoms' hormonal and metabolic underpinnings. Results should always be interpreted within the context of the patient's health history and clinical concerns. 

Here is a brief summary of what general patterns in the DUTCH Plus panel can indicate:

Estrogens

High estrogen levels can lead to symptoms of estrogen dominance, including:

  • Heavy menstrual bleeding
  • Painful periods
  • Breast tenderness
  • Mood swings

Low estrogen levels, commonly seen in menopause, can result in: 

The DUTCH Plus test also assesses estrogen metabolism via the CYP450 enzyme pathways. 

  • Phase 1 Metabolism: 2-OH-E1 should be the favored estrogen metabolite. Elevated 4-OH or 16-OH metabolites are associated with DNA damage and cancer risk. (7) 
  • Phase 2 Metabolism: Methylation status is reflected in levels of 2-Methoxy-E1, which helps to deactivate estrogen metabolites. Impaired methylation could contribute to estrogen dominance and related risks. (7) 

Progesterone Metabolites

The DUTCH Plus test does not directly measure progesterone but evaluates its metabolites, alpha-pregnanediol and beta-pregnanediol, which correlate well with serum levels of progesterone. 

Low progesterone often accompanies estrogen dominance, leading to symptoms such as: 

  • Irregular periods
  • Headaches
  • Mood swings
  • Anxiety
  • Infertility

Androgens

High testosterone in women is associated with:

  • Acne
  • Weight gain
  • Mood swings
  • Increased body hair (hirsutism)
  • Menstrual irregularities
  • Fertility issues

Low testosterone in men and women may cause:

  • Fatigue
  • Low libido
  • Loss of muscle mass
  • Poor concentration
  • Depression

Cortisol and Adrenal Function

The DUTCH Plus test provides a detailed view of cortisol levels throughout the day, measuring both free cortisol and its metabolite, cortisone. 

High cortisol throughout the day is suggestive of maladaptive stress responses and circadian dysregulation, causing symptoms like: 

  • Sleep disturbances
  • Weight gain
  • High blood pressure
  • Menstrual irregularities

Conversely, low cortisol, especially in the morning, may indicate adrenal insufficiency or burnout:

  • Chronic fatigue
  • Weight loss
  • Low blood pressure and blood sugar
  • Muscle and joint pain

A blunted CAR may indicate chronic stress, PTSD, or depression, while an elevated CAR may be associated with anticipatory stress, glycemic dysregulation, or chronic pain (37). 

Organic Acids

The organic acids included in the DUTCH Plus provide information about the patient's metabolism but also have clinical relevance regarding hormone balance and function (37):

  • Imbalances in HVA and VMA can perpetuate estrogen imbalances. 
  • Deficiencies in B vitamins can negatively impact hormone metabolism.
  • Elevations in 8-OHdG, quinolinate, and indican are indicative of intestinal dysbiosis and inflammation, which can impair estrogen elimination and exacerbate symptoms of hormonal imbalance.

Integrating DUTCH Plus Test Results into Treatment Plans

For patients with high estrogen or imbalances in estrogen metabolites, a focus on supporting estrogen metabolism through lifestyle changes, diet, and supplements can be recommended: 

For low estrogen, progesterone, or testosterone, bioidentical hormone replacement therapy (HRT) or adaptogens may help restore balance. 

In cases of androgen excess (such as in PCOS), treatments may include: 

Addressing cortisol imbalances might involve stress management techniques like mind-body therapies, cognitive behavioral therapy, or supplemental adaptogens.

Challenges and Considerations

The DUTCH Plus test offers many benefits for hormone assessment, but there are several considerations that practitioners should keep in mind when using it in clinical practice. 

One of the primary challenges is the complexity of the test results' interpretation. The DUTCH Plus test provides a large volume of data, which can be overwhelming for clinicians unfamiliar with hormone pathways and metabolism. 

  • Providers new to DUTCH testing should be encouraged to use the clinical resources provided by DUTCH to help them learn how to interpret results and integrate them into comprehensive treatment plans.

While the DUTCH Plus test provides a comprehensive hormonal profile, it still reflects hormone levels at specific points in time. Hormonal fluctuations, which can occur due to various factors like diet, stress, or the menstrual cycle, may not always be fully captured, potentially leading to an incomplete picture of the patient's hormonal status.

  • Integrate and interpret DUTCH Plus results in the context of patient symptoms, medical history, and other clinical findings for a holistic approach to patient care. Follow up on abnormal results with additional tests as clinically indicated. 

The cost of the DUTCH Plus test may be prohibitive for some patients, as insurance coverage for such comprehensive hormone testing can be limited or unavailable.

  • Be transparent with patients about the out-of-pocket costs of the test. 
  • If insurance coverage is uncertain, provide patients with options to pay directly for the DUTCH Plus test. If insurance doesn't cover it, patients may be able to pay for it using their flexible spending account (FSA) or health savings account (HSA).

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Key Takeaways

  • The DUTCH Plus test by Precision Analytical represents a pivotal advancement in hormonal diagnostics, offering healthcare providers a nuanced and comprehensive tool for assessing adrenal and sex hormone health. 
  • By integrating this test into clinical practice, clinicians can achieve more precise diagnoses, tailor personalized treatment plans, and ultimately enhance patient outcomes. 
  • While challenges exist, informed implementation and continuous education can maximize the DUTCH Plus test's benefits, fostering a more holistic and effective approach to patient care.

Resources for Further Information

  • Ready to order the DUTCH Plus test by Precision Analytical (DUTCH) through Rupa Health? Click here!
The information provided is not intended to be a substitute for professional medical advice. Always consult with your doctor or other qualified healthcare provider before taking any dietary supplement or making any changes to your diet or exercise routine.

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Lab Tests in This Article

DUTCH Plus by Precision Analytical (DUTCH)
Saliva
Urine
The DUTCH Plus™ offers an extensive assessment of sex and adrenal hormones and their metabolites. It also assesses the Cortisol Awakening Response (CAR) and includes the insomnia cortisol sample. This test cannot be ordered for patients under 12 years of age.

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Jaime Cloyd
Author
Dr. Jaime Cloyd ND
Naturopathic Physician based in the greater Seattle area
Medically Reviewed by
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