Written by dietetic intern Kylee Henschel and Orli Rabin of ThrivingBiome
Feb 2025
While some symptoms of hormone imbalances are quite obvious (like irregular periods or hot flashes), others are more subtle and can be easily overlooked. Some of the ways hormonal imbalances can manifest include:
As you can see, hormonal imbalances can contribute to a wide range of symptoms. These symptoms can often be misattributed to stress, aging, or lifestyle factors, but they may be linked to underlying hormonal imbalances. The Dried Urine Test for Comprehensive Hormones (DUTCH) test is a powerful tool for identifying the root causes of these imbalances, offering insights into your hormones, stress response, and overall endocrine health. This test digs deeper than symptoms alone, helping you understand what’s truly affecting your body and how to restore balance.
Upon receiving your DUCTH, your registered dietitian will interpret the results and help you modify your diet, lifestyle, and supplements. This will help support a healthy circadian rhythm, provide enough nutrients to manufacture hormones, support favorable hormone metabolism, and nourish the adrenals. It is important to note the limitations, however, because dietitians will NOT manipulate hormones themselves or act as a therapist if stress is an issue.
DUTCH is a diagnostic tool that measures hormone levels and their metabolites using a urine sample. It is commonly used to evaluate hormone imbalances linked to stress, adrenal function, reproductive health, and overall hormone metabolism.
DUTCH analyzes 35 different hormones to give you a well-rounded view of your hormonal health, helping to identify imbalances across various systems in the body, including the adrenal, thyroid, and reproductive systems. By looking at both hormone levels and their metabolites, it provides a comprehensive picture of how your body is managing stress, metabolism, and overall hormonal balance. Take a deeper dive into individual sections of the test below!
Free cortisol pattern: Cortisol, a critical stress hormone, follows a natural daily rhythm, peaking in the morning and gradually decreasing throughout the day. This pattern aligns with the body's circadian rhythm and helps manage the stress response, offering insights into adrenal function and chronic stress. Unlike standard blood tests that only capture hormone levels at a single point, DUTCH Complete uses urine samples to track cortisol fluctuations over 24 hours. This method provides a more comprehensive view of cortisol's dynamic changes, measuring both active cortisol and metabolized cortisol, offering deeper insights into adrenal health and stress responses that blood tests alone may miss.
Cortisol Metabolites: Cortisol metabolites are byproducts of cortisol that are processed by the body and primarily excreted in urine. Our bodies naturally convert cortisol to cortisone as a defense mechanism at high cortisol levels. DUTCH measures cortisone (the inactive form) to assess how efficiently cortisol is converted, offering insights into the body’s metabolic response. This can reveal hypermetabolic patterns like obesity, chronic stress, or hyperthyroidism. Urine samples collected over 24 hours capture the full picture of cortisol metabolism by tracking how cortisol is processed and converted into its inactive form which helps identify adrenal and stress-related imbalances. DUTCH Plus, which we discuss in another section below, takes saliva samples at key times (upon waking, in the afternoon, and before bed) to track free cortisol fluctuations and provide further details on your cortisol levels.
Melatonin: Melatonin plays a crucial role in your health as a powerful antioxidant, immune system regulator, and a promoter of growth hormone production. It’s also known for helping those who struggle with seasonal affective disorder (SAD). Low melatonin levels can lead to a range of issues, including trouble falling or staying asleep, a weakened immune system, mood swings, fatigue, and even reduced growth hormone production.
Estrogen Metabolites: DUTCH provides insights into how the body metabolizes estrogen by focusing on its three primary forms (estradiol, estriol, and estrone), and the three pathways that metabolize estrogen. These pathways include the 2-OHE pathway, the 4-OHE pathway, and the 16-OHE pathway. Ideally, we want to see around 60-80% of estrogen taking the 2-OHE pathway, represented by the green section in the pie chart below. This protective pathway leads to safe, beneficial estrogen metabolites that help prevent DNA damage and reduce risks like PMS, weight gain, mood swings, irregular cycles, and long-term health risks. The 4-OHE pathway produces more reactive, potentially harmful metabolites that can increase the risk of DNA damage. The 16-OHE pathway is mixed as it has benefits like supporting bone health, but we do not want too much of it. DUTCH results help identify imbalances in these pathways, offering a deeper understanding of estrogen metabolism and potential risks.
Androgen Metabolites: Androgens, such as testosterone and its metabolites, play a crucial role in both men's and women’s health. These hormones influence a variety of functions, including energy levels, mood, muscle mass, bone density, and sexual health. This test helps to identify testosterone imbalances, irregular DHT levels, or even PCOS.
Basic Hormones: This refers to the well-known central hormones typically looked at in other tests including estradiol, progesterone, testosterone, DHEA, etc. Instead of looking at how the hormones are metabolized, like the sections above, this section provides a snapshot of how much of these hormones are present at a given time. Basic hormones serve as a starting point for understanding your overall endocrine function.
See for yourself! Sample DUTCH Report
The DUTCH test requires you to collect 4-5 dried urine samples. The kit comes with instructions and all the materials needed for easy at-home collection, and there’s also this helpful video you can watch. Simply urinate directly onto the filter paper or dip the filter paper into a cup you urinate in. Allow the paper to dry for 24 hours. Here’s a tip: While your samples are drying, make sure to place them somewhere safe and out of the way—like on a high shelf or behind a closed door. Trust us, we’ve had clients lose their samples to water splashes from washing hands or even curious little ones grabbing them!
For optimal results, limit your total fluid intake to 40 oz. on the days of testing. Avoid alcohol and caffeine entirely, and refrain from drinking any fluids for at least two hours before collecting Samples #1 and #2. Between Samples #3 and #4, keep your fluid intake to no more than one cup. Additionally, avoid eating avocado, bananas, and fava beans for 48 hours before collecting your samples. This ensures the most accurate hormone level and metabolic results.
We know the collection process can feel a bit tedious, long, and even nerve-wracking—and that's totally normal! We’re here to support you every step of the way. Once your samples are dry, send them back to the lab for analysis. The lab will process your samples and generate a detailed report on your hormone levels and metabolites. Your healthcare provider will interpret the results and recommend personalized treatment options based on your specific needs.
CLICK HERE FOR DUTCH COMPLETE COLLECTION INSTRUCTIONS VIDEO
The DUTCH Plus encompasses everything found in the DUTCH Complete test, with the added benefit of assessing the Cortisol Awakening Response (CAR). This measures cortisol levels immediately after waking, providing valuable insights into how the body handles stress, particularly during the early morning hours. By offering a deeper look at adrenal function and the body’s stress response throughout the day, the DUTCH Plus is especially beneficial for those dealing with stress-related issues or potential HPA axis dysfunction. In addition, it includes organic acid testing, which helps identify nutritional deficiencies, oxidative stress, gut imbalances, melatonin levels, and neuroinflammation, offering a more comprehensive view of overall health.
The Cortisol Awakening Response (CAR) is a critical marker of your body's stress response. Naturally, cortisol production increases when you wake up, typically by about 50%. This spike is essential for getting your day started and handling stress. The peak level of cortisol at the 30-minute mark is often measured in other hormone testing, however, the real significance lies in how much cortisol levels change from the moment you wake up to about 30 minutes after. A large gap between these two measurements is linked to symptoms of high cortisol, like anxiety, depression, and stress. A low response can indicate low cortisol related to things like sleep apnea, psychological burnout, PTSD, chronic fatigue, and more. A continued increase in cortisol levels beyond the 30-minute mark could suggest an overactive HPA axis or indicate that the person woke up earlier than usual, which could also impact the response.
For DUTCH Plus, the waking saliva sample measures the cortisol released immediately upon waking, while the urine sample reflects the cortisol levels during the night. This combination allows DUTCH Plus to track your free cortisol levels at key points—when you're sleeping and when you wake up—offering a comprehensive view of your body’s stress response.
Interestingly, even if cortisol levels appear “normal” in both saliva and urine, a lack of change between the resting and waking cortisol levels can point to dysfunction in the HPA axis response, potentially contributing to fatigue and sleep disturbances. The additional insomnia cortisol sample from DUTCH Plus can help assess whether cortisol is playing a direct role in sleep issues, providing valuable insight into its impact on sleep patterns and overall health.
Here is an example of the CAR results:
The DUTCH Plus test follows a similar collection process as the standard DUTCH, but with additional markers to analyze more hormones and their metabolites. In addition to the dried urine samples, the DUTCH Plus includes saliva samples for testing progesterone and free cortisol (which provides a more detailed look at your stress response and hormonal fluctuations).
For the saliva collection, you’ll be asked to provide samples at specific times throughout the day to capture the changes in hormone levels over 24 hours. The collection times typically include a sample right after waking, 30 minutes after waking, 60 minutes after waking, before dinner, and before bed. It’s important to avoid alcohol and caffeine, exercise, and flossing the day of collection. Additionally, do not brush your teeth, eat, or drink anything until after collecting your third saliva sample. To collect the saliva, you will use the provided collection swabs, which you place in your mouth for a few minutes (no more than 5) until they absorb enough saliva. Once the swab is saturated, you will place it into the provided tube and screw the cap on tightly. The saliva sample should then be stored in the freezer until it’s time to send it back to the lab. These additional saliva samples, combined with the urine samples, provide a deeper understanding of your hormonal fluctuations and stress response throughout the day.
CLICK HERE FOR DUTCH PLUS COLLECTION INSTRUCTIONS VIDEO
Cycle Mapping shows your estrogen and progesterone metabolites and their pattern of production throughout the month, helping to identify imbalances that may contribute to symptoms like PMS, irregular cycles, or fertility challenges.
Both DUTCH and DUTCH Plus graph out the data of estrogen and progesterone metabolites from only your peak day. These tests are focused on a broader look at overall hormonal balance. The cycle map, however, shows your full monthly pattern and hormonal fluctuations during your menstrual cycle. This can highlight issues like luteal phase defects or estrogen dominance, which might not be detectable through single-point hormone testing.
The DUTCH Cycle Mapping test is recommended for:
CASE STUDY:
Sarah came to our practice seeking help with fertility after struggling to conceive for the past four months. She had a history of celiac disease and recurrent gut infections, including H. pylori and SIBO, which were currently managed. While she had no trouble conceiving her first child, she found that her attempts to expand her family with a second child had been unsuccessful despite months of trying. Sarah was eager to explore whether any hormonal imbalances had contributed to her fertility challenges and was interested in utilizing the DUTCH test for answers.
We ordered a DUTCH test, and while awaiting her results, we spoke with Sarah about optimizing her overall health. This included supporting her immune system, digestion, and hormonal balance through lifestyle recommendations, nutrition, and targeted supplements based on her results. After receiving Sarah’s DUTCH results, we gained a clearer picture of her hormonal health and identified areas for improvement that could have supported her fertility journey.
Sarah's DUTCH test results reveal a very elevated Cortisol Awakening Response (CAR), where cortisol starts off low but spikes dramatically in the morning and remains high throughout the afternoon. This suggests an overactive stress response or difficulty in managing daily stress. Additionally, there is a slight discrepancy between her total and metabolized cortisol, indicating her cortisol metabolism may be slightly downregulated, affecting her ability to process stress hormones effectively. Elevated DHEA levels point to a possible imbalance in her androgen production, and a marginal melatonin level suggests that her sleep-wake cycle may be suboptimal. Finally, her preference for cortisone, the inactive form of cortisol, is common in states of excess cortisol, indicating that her body may be converting cortisol to cortisone as a protective mechanism. Together, these results highlight potential issues with both stress response and overall hormone regulation that may be affecting Sarah’s fertility and overall health.
We asked Sarah a few key questions to better understand her daily habits and how they might have impacted her hormonal health, especially elevated CAR upon waking. These questions included:
In response to her results and answers, we created an action plan to help get Sarah’s hormones in balance. This plan includes adrenal nutrients for Sarah to help support her adrenal glands in managing her elevated cortisol levels and overall stress response. Additionally, adrenal support can help optimize hormone balance and support overall energy levels, which is important as Sarah works to maintain overall well-being and improve her fertility. The action plan also touches on achieving adequate sleep to regulate cortisol levels, with the understanding that this is not always possible for mothers.
KEY TAKEAWAYS: The DUTCH test provides a detailed view of your hormonal health, offering insights into imbalances that can affect everything from energy and mood to metabolism and sleep. By measuring both the levels and metabolites of key hormones, the DUTCH test helps pinpoint underlying issues like adrenal fatigue or estrogen dominance. In our experience, this comprehensive approach allows for a more accurate diagnosis, enabling us to create personalized treatment plans that address the root causes of hormonal imbalances and restore balance effectively.
REFERENCES: *all information came from the DUTCH website and resources
Precision analytical (Dutch test) - test kits, Providers & Patients. Precision Analytical (DUTCH TEST) - Test Kits, Providers & Patients. (n.d.). https://dutchtest.com/
