Urine Steroid Hormones

Transcription

1 Unit A, Bearspaw Rd NW Calgary, AB T3L 2P5 Phone: Fax: Urine Steroid Hormones Accession Number: Date of Collection: 21-Oct-2011 Sample Received: 19-May-2012 Reported Date: 10-Sep-2012 Sample Type: Urine Provider: Patient: Gender : F Date of Birth : Age: 57 Status: No menses Cycle Day: N/A Hormone Therapies Premarin oral ( mg) Last Used 1 day, Biometrics Height (in) : 64 Weight (lb) : 199 Waist (in) : 44 Hip (in) : 52 N/A: not available All units µg/24hrs Cortisol/ Cortisol Metabolites Analyte Result 0% 20% 40% 60% 80% 100% Cum % Cortisol % Post Tetrahydrocortisol (THF) 1, ,000 89% Post allo-tetrahydrocortisol (athf) % Post Cortisone % Post Tetrahydrocortisone (THE) 3,100 1,400-2,900 87% Post 17 hydroxyprogesterone Metabolites Analyte Result 0% 20% 40% 60% 80% 100% Cum % Tetrahydrodeoxycortisol (THS) % Post Pregnanetriol (P3) % Post Total 17-hydroxysteroids = athf + P3 + THE + THF + THS Analyte Result 0% 20% 40% 60% 80% 100% Cum % Total 17-hydroxysteroids (Total 17HS) 5,600 2,200-4, Post 91% Page 1 of 11

2 Urine Steroid Hormones Accession Number: Mineralocorticoids Analyte Result 0% 20% 40% 60% 80% 100% Cum % Aldosterone % Post THA % Post allo-tetrahydrocorticosterone (athb) % Post Progesterone/ Progesterone Metabolites Analyte Result 0% 20% 40% 60% 80% 100% Cum % Progesterone (Pg) % Post Pregnanediol (P2) % Post Cortisol Metabolite Ratios Analyte Result 0% 20% 40% 60% 80% 100% Cum % athf / THF % Post (athf + THF) / THE % Post 17 ketosteroids Analyte Result 0% 20% 40% 60% 80% 100% Cum % Dehydroepiandrosterone (DHEA) % Post Androstenedione (ANDN) % Post Testosterone % Post Dihydrotestosterone (DHT) < % Post 3-alpha androstanediol % Post Etiocholanolone (ECHL) , % Post 11-ketoetiocholanolone (11KE) % Post 11-hydroxyetiocholanolone (11HE) % Post Androsterone (ANDS) ,100 45% Post 11-ketoandrosterone (11KA) % Post 11-hydroxyandrosterone (11HA) % Post Page 2 of 11

3 Urine Steroid Hormones Accession Number: Total 17-ketosteroids = DHEA + ECHL + ANDS + 11HA + 11HE + 11KA + 11KE Analyte Result 0% 20% 40% 60% 80% 100% Cum % Total 17-ketosteroids (Total 17KS) 2,400 1,300-4,300 46% Post Anabolic Catabolic Ratio Analyte Result 0% 20% 40% 60% 80% 100% Cum % Anabolic 17KS / Catabolic 17HS % Post Androgen Ratios Analyte Result 0% 20% 40% 60% 80% 100% Cum % DHT / Testosterone No Data % Post Androsterone / Etiocholanolone % Post Estrogens/ Estrogen Ratios Analyte Result 0% 20% 40% 60% 80% 100% Cum % Estrone (E1) % Luteal Estradiol (E2) < % Luteal Estriol (E3) % Luteal EQ = E3 / (E1 + E2) No Data % Luteal 2-hydroxyestrone (2OHE1) % Luteal 4-hydroxyestrone (4OHE1) % Luteal 16-hydroxyestrone % Luteal 2-methoxyestrone (2MeOE1) % Luteal 4-methoxyestrone (4MeOE1) % Luteal Sum of Estrogens % Luteal 2MeOE1 / 2OHE Luteal % Page 3 of 11

4 Steroid Hormone Pathways Page 4 of 11

5 WHAT KIND OF HORMONES DOES THIS TEST MEASURE? Steroid hormones are excreted in urine as a mixture of non protein-bound unconjugated hormone plus non protein-bound conjugates. Conjugates are steroids which have had sulphate and/or glucuronide functional groups attached to them to increase water solubility. They may originate in the liver, or may be formed in target tissues such as breast and uterus. Prior to analysis, the urine specimen undergoes a hydrolysis step, to cleave the conjugates. So for example, if the value for estrone E1 is 2.70 ug/24 hours realize that we are not measuring 2.70 micrograms of estrone; we are measuring mostly estrone conjugates which are being reported as 2.70 micrograms of estrone. This is an important but subtle distinction. Urinary estrone as measured here, is not directly comparable to serum or salivary estrone. Both those tests measure unconjugated estrone, which may be arising from a different source than conjugates. If the urine level of any particular hormone is markedly low or high, this usually represents markedly decreased or increased production of that hormone; however, if the patient has a congenital inability to form sulphate or glucuronide conjugates, due to a faulty gene SNP for the enzymes in question, or lacks requisite sulphate and/or glucuronide stores to allow conjugation, then hormone levels may be erroneously interpreted as low. This will depend on the relative proportions of non-conjugated and conjugated hormones that are excreted in any given case. Most of the time, steroids must be heavily conjugated to give them enough solubility to allow urinary excretion. 11-beta HYDROXYETIOCHOLANOLONE AND 11-KETOETIOCHOLANOLONE These two steroids (also known as OHET AND OHAN) can be derived from cortisol as well as from etiocholanolone. If they are considered to be cortisol metabolites, they contribute to the "Catabolic" mass balance;if they are considered to be etiocholanolone metabolites, they contribute to the "Anabolic" mass balance, since etiocholanolone arises from androstenedione. Practice amongst various laboratories is divided in this regard. We have elected to include these steroids in the total for "Anabolic" hormones although they most likely arise from cortisol in the majority of cases. Steroids 2008;73: Hydroxylase/C17,20-lyase (CYP17) is not the enzyme responsible for side-chain cleavage of cortisol and its metabolites. Shackleton CH et al. RATIOS WHICH REFLECT 5-alpha/beta REDUCTASE BALANCE We report two ratios which are of the general form: 5-alpha reduced metabolite / 5-beta reduced metabolite. These are: allothf/thf and Androsterone/Etiocholanolone (or A/E), with allothf and THF being the 5-alpha and 5-beta cortisol metabolites, and Androsterone and Etiocholanolone being the 5-alpha and 5-beta Androstenedione metabolites. In our database, for postmenopausal women and for cycling women in the luteal phase, these two ratios correlate fairly well: they both tend to move in the same direction. A ratio near or above unity means that the equilbrium lies toward 5-alpha products. A ratio closer to zero means that 5-beta reduced products are favoured. Since the 5-alpha reduced metabolites are more androgenic, a ratio near or above unity is usually also accompanied by a clinical picture of androgenicity (excess facial hair growth, male pattern scalp hair loss, acne, irritability, oily skin). GENERAL COMMENTS ON THE RATIO: (athf + THF) / THE The ratio (athf + THF) / THE purports to look at the activity of the 11-betahydroxysteroid dehydrogenase (11bHSD) isoenzymes, which interconvert cortisol, cortisone and their metabolites. 11bHSD Type I : cortisone/cortisone metabolites ----> cortisol/cortisol metabolites 11bHSD Type II : cortisol/cortisol metabolites ----> cortisone/cortisone metabolites The ratio mentioned above has received attention recently, as manipulation of the balance of the enzymes in question is being studied as a target to achieve weight loss. The value of the ratio appears to be somewhat method-dependent, but nevertheless, relative changes in the ratio over time in the same patient are still valuable, even if the absolute value of the ratio varies from method to method. A ratio that is getting smaller would indicate a shift toward a greater proportion of cortisone/cortisone metabolites, Page 5 of 11

6 relative to cortisol/cortisol metabolites. This would be a desirable shift in a patient with clinical signs and symptoms of elevated cortisol. A ratio that is getting larger would indicate a shift toward a greater proportion of cortisol/cortisol metabolites relative to cortisone/cortisone metabolites. This would be desirable in a patient with clinical signs and symptoms of low cortisol. An example of a situation where the ratio should increase would be a patient supplementing with licorice to boost cortisol. BMI MAY BE HIGHER THAN OPTIMAL This patients Body Mass Index (BMI) is Patients with a BMI between 25 and 30 are defined as overweight and obesity is defined as BMI greater than 30. Elevated BMI is often associated with elevated estradiol, testosterone and DHEAS, and may also be associated with high urinary cortisol and aldosterone. Metabolic syndrome/insulin resistance are also associated with elevated BMI. Health risks associated with excess weight include increased risk of diabetes, high blood pressure, heart attack, stroke and cancer. Weight reduction and reduced consumption of refined carbohydrates may be worthwhile interventions for some patients with elevated BMI. Note that not all patients with high BMI have metabolic abnormalities. For example, a well-muscled individual may have a BMI in excess of 30, yet be metabolically normal. Note also that not all patients with high androgens have elevated BMI. RATIONALE FOR CHOICE OF REFERENCE RANGE The patient does not have any ovaries, therefore the postmenopausal ranges have been applied to all the analytes, if no hormones are being used. If hormones are used, some reference ranges will be affected as outlined below. UNOPPOSED PREMARIN This patient is/was supplementing with unopposed Premarin. Unopposed estrogen has been the standard of practice for women who have had a hysterectomy; however, results from the Premarin-only arm of the Women's Health Initiative Study indicated that this form of therapy carries an increased risk of stroke and venous thromboembolism. Data from the ongoing Nurses Health Study also indicate that unopposed Premarin is associated with increased risk of breast cancer. The risk increases proportionally with the duration of use, and begins to be significant after 10 years of therapy. Most or all tissues which bear estrogen receptors also have progesterone receptors, and are accustomed to a balance of the two hormones (examples include thyroid, breasts, brain, blood vessels and pancreas), and this obviously remains true after hysterectomy! As a general rule, women on unopposed estrogen have more side effects including weight gain, migraines and breast tenderness. REFERENCE RANGES FOR METABOLITES AFFECTED BY SUPPLEMENTATION The patient's underlying status is postmenopausal, but she is on estrogen therapy. For this reason, the estrogen metabolites are referenced to mid-luteal ranges; all other metabolites are referenced to the usual postmenopausal ranges, according to the rationale mentioned in the preceding comment. ELEVATED TOTAL 17-HYDROXYSTEROIDS The result for total 17-hydroxysteroids is above the 84th percentile. Collectively, the steroids summed here make up more than half of the metabolites of cortisol; this total therefore gives a good measure of cortisol production and breakdown. Elevated 17-hydroxysteroids may be seen in a wide range of conditions of cortisol overproduction, including Cushing's Disease, adrenal hyperplasias, adrenal adenomas, acute stress, acute illness, depression, hyperthyroidism and obesity. In our database, there is a modest positive correlation between total 17-hydroxysteroids and waist circumference, which in turn is reflective of visceral obesity. Here the waist circumference is inches. In women, a waist circumference around or above 38 inches, or in men 40 inches, may be associated with visceral obesity. Body Mass Index or BMI is BMI equal to or above 27 is also more likely to be associated with increased visceral obesity, but not as strongly as increased waist circumference. Note that visceral obesity is usually associated with Metabolic Syndrome and/or hyperinsulinemia and insulin resistance. This patient should be assessed for the presence of these conditions, and treated accordingly. DISTURBED SLEEP PATTERN NOTED ON SYMPTOM INVENTORY The patient indicated some problems with sleep on the symptom inventory. Recognize that there is an optimum range for bedtime cortisol. If bedtime cortisol is too low, there is some evidence that normal sleep architecture is not established (insufficient REM sleep). Conversely, high bedtime cortisol is suppressive for melatonin, and Page 6 of 11

7 may result in difficulty initiating and sustaining sleep. Here the sum of metabolites thought to reflect 24 hour cortisol output is either low (less than the 16th percentile, or high (greater than the 84th percentile). It may be worth measuring the bedtime cortisol level in saliva, depending on the severity of the situation, to determine if cortisol is contributing to this patient's problems with sleep. ALDOSTERONE ELEVATED ABOVE 84th PERCENTILE Elevated aldosterone is an independent factor associated with Metabolic Syndrome. Aldosterone may also be elevated in normal individuals who are eating a salt-restricted diet. Diuretics and medications such as lithium and spironolactone may elevate aldosterone. Elevated aldosterone may be seen in individuals with hypertension and also in those engaging in strenuous exercise. Hypertension 2006;48: Plasma aldosterone is independently associated with the metabolic syndrome. Bochud M et al. Hypertension 2004;43: Epoxy-keto derivative of linoleic acid stimulates aldosterone secretion. Goodfriend TL et al. Scott Med J 2012;57: Effect of a multistage ultraendurance triathlon on aldosterone, vasopressin, extracellular water and urine electrolytes. Knechtle B et al. allo-thb and athf BOTH RANK ABOVE 84th PERCENTILE Both allo-thb and athf are the product of a 5-alpha reductase enzyme. These analytes both rank above the 84th percentils. The ratio allo-thf/thf also reflects 5-alpha reductase activity and that ratio also ranks above the 84th percentile for this patient. Taken together, all these results point to increased activity of 5-alpha reductase, and this is often accompanied by complaints of excess facial hair growth and/or acne, in some patients, although this is not always the case. ELEVATED MINERALOCORTICOIDS (THA, allo-thb) Here, the other mineralocorticoids measured, tetrahydrocorticosterone (THA) and allo-tetrahydrodehydrocorticosterone (allo-thb), are also elevated, along with aldosterone. Together, these steroids regulate renal sodium reabsorption and water balance. Elevated mineralocorticoids may result in hypertension and edema, due to sodium retention, and muscle weakness, due to potassium loss. athf / THF ABOVE THAN MEDIAN VALUE FOR POSTMENOPAUSAL FEMALE The meaning of this ratio was explained in the preliminary discussion at the beginning of the report. In our laboratory, for postmenopausal females, the median ratio of allothf (5-alpha reductase cortisol metabolite) to THF (5-beta reductase cortisol metabolite) is 0.33 This patients ratio is 0.78, which is above the median value. This patient might also be expected to have symptoms of excessive conversion ot testosterone to dihydrotestosterone if the 5-alpha reductase system regulating testosterone metabolism is biased in the same way as the cortisol metaboltes are biased. CORTISOL METABOLITES RELATIVE TO CORTISONE METABOLITE ((athf + THF) / THE) The median ratio of cortisol metabolites relative to the cortisone metabolite tetrahydrocortisone is 0.45 for postmenopausal females. Here the ratio is Relative to the average postmenopausal female, this patient makes a greater proportion of cortisol metabolites relative to cortisone metabolites. This often occurs in situations where there is visceral obesity and increased waist circumference. In Caucasian women, a waist circumference greater than 38 inches is associated with increased visceral obesity. This patient's waist circumference is inches. DIHYDROTESTOSTERONE BELOW DETECTION LIMIT Dihydrotestosterone is the 5-alpha reduced metabolite of testosterone. In excess, it is often associated with increased facial hair growth, acne and oily skin as well as male pattern hair loss. Here the level is quite low. If hair loss is occurring, it is not related to DHT. The most common reason for low DHT is a low level of the parent hormone, testosterone. The marker which is displayed for this analyte represents the percentile corresponding to the detection limit (listed to the right of the bar graph, in grey). The true percentile (if it could be measured) may very well be much lower than this value. So in other words, the "true" location of the marker could be anywhere to the left of where it is shown. TESTOSTERONE BELOW 16th PERCENTILE : LOW TESTOSTERONE SYMPTOMS ARE PROMINENT Page 7 of 11

8 The level of testosterone conjugates measured in this specimen is below the 16th percentile and symptoms of low testosterone are prominent. These symptoms might include decreased sex drive, fatigue, depressed mood, decreased enjoyment of life and vaginal dryness, as well as bone loss. Before menopause, about half the testosterone in the body comes from the ovaries. The other half is made from DHEA of adrenal gland origin. After menopause, all the testosterone is made from DHEA. Hence low testosterone may be reflective of low DHEA, especially in post-menopause, but possibly at any age. ANABOLIC (17KS) / CATABOLIC (17HS) RATIO RESULT RANKS < 25th PERCENTILE The ratio of total 17-ketosteroids to 17-hydroxysteroids is generally taken to reflect the balance between anabolic and catabolic steroid hormones. A ratio greater than 1 reflects a tendency toward tissue growth and repair (anabolism) whereas a ratio below 1 reflects a tendency toward tissue breakdown and poor recovery from stress or illness (catabolism). Here, the ratio of total 17-ketosteroids to 17-hydroxysteroids is 0.42, well below the median value of 0.77 for postmenopausal women. RATIO DHT/TESTOSTERONE NOT SHOWN "No Data" is displayed in place of the result for the ratio DHT/Testosterone because either or both of DHT and Testosterone are below detection limit and the ratio therefore cannot be calculated explicitly. The marker is positioned at "100%" for display purposes only. 5-alpha REDUCTASE MORE ACTIVE THAN 5-beta REDUCTASE Both the ratios athf/thf and A/E rank above the 84th percentile, supporting the notion that 5-alpha reductase is generally more active than 5-beta reductase. This in turn is usually reflected by more prominent symptoms of elevated androgens such as increased facial hair growth, acne and scalp hair loss. This may be tempered by the extent of glucocorticoid opposition, as glucocorticoids compete directly with androgens at the nuclear androgen receptors. In other words, high glucocorticoid levels may blunt the impact or clinical manifestation of high androgens. PREMARIN SUPPLEMENTED BUT THE ESTRONE RESULT IS BELOW THE 16th PERCENTILE The patient indicates that she is taking some form of Premarin, yet the estrone result is below the 16th percentile. This is unusual because approximately 50% of a given dose is human estrone; this patient should be excreting ample amounts of estrone conjugates. One possible explanation for this finding is that the estrone is being converted rapidly to other downstream metabolites such as hydroxy- and methoxyestrones. ESTRADIOL BELOW DETECTION LIMIT Estradiol is below the detection limit of 0.5 mcg/24 hours. This is low. Approximately 33% of postmenopausal women who are not supplementing with estradiol will have an estradiol level at or below that level. Low estradiol in isolation from the other estrogens is less significant than low estradiol in the face of overall low estrogens. Remember that just because the amount of estradiol that is being excreted is low, this does not necessarily mean that an inadequate amount of estradiol was delivered to target tissues. These tissues such as brain, uterus, breasts and bone have varying capability to receive estradiol, process it and convert it to other downstream metabolites. Focusing on one hormone in isolation from its metabolites, may be misleading in some cases. Symptoms and signs of low tissue activity of estradiol include foggy thinking, problems with memory, depression, and vaginal dryness, as well as bone loss. The marker which is displayed for this analyte represents the percentile corresponding to the detection limit (33% in this case). The true percentile (if it could be measured) may very well be much lower than this value. So in other words, the "true" location of the result could be anywhere between 0 and 33%. ESTROGEN QUOTIENT (EQ) NOT SHOWN "No Data" is displayed in place of the estrogen quotient E3/(E1 + E2) because estradiol (E2) is below detection limit and the EQ result therefore cannot be calculated explicitly. An upper limit for the EQ is The actual result will be somewhat lower than this. The marker is positioned at "100%" for display purposes only. In non-caucasian populations with a low incidence of breast cancer, relative estriol excretion in urine tends to be higher, with an EQ above unity. Conversely, in North America, Caucasian women have an increased rsik of breast cancer, and they tend to excrete relatively less estriol in urine, with an EQ closer to 0.5. (J Natl Cancer Inst 1997;89: Re: ethnic differences in estrogen metabolism in healthy women. Lemon HM, Page 8 of 11

9 Rodriguez-Sierra JF.) Some authorities, notably Jonathan Wright MD, maintain that efforts should be made to increase the EQ above unity, to decrease the risk of breast cancer. Wright notes that supplementation with Lugol's iodine will generally accomplish this. (Townshend Letter, January 2010, ) 2-HYDROXYESTRONE BELOW 16th PERCENTILE: ESTROGEN SUPPLEMENTED 2-hydroxyestrone is generally found to be the most abundant estrogen conjugate in urine. Here the level is below the 16th percentile, even despite supplementation with estrogens. It is unclear whether there are any health risks attached to this situation. An estrogen dose increase might elevate the level of this metabolite into the normal range, but at the same time might elevate the levels of other undesirable metabolites such as 4-hydroxyestrone. One has to consider the overall picture. Measures to upregulate the main p450 enzyme systems which increase urinary excretion of this metabolite (CYP1A1, CYP1A2, CYP3A4) include increased intake of cruciferous vegetables, supplementation with I3C, DIM, Oil of Rosemary, and supplementation with T3 as well as progesterone. 4-HYDROXYESTRONE RESULT RANKS ABOVE THE 84th PERCENTILE The result for 4-hydroxyestrone is which corresponds to a percentile of when the mid-luteal reference range is used. (The mid-luteal range is used when estrogen is being supplemented, regardless of what the patient's true menstrual status is.) The 4-hydroxyestrone metabolite is implicated in breast cancer, since it can form a depurinating (base-removing) covalent compound with oncogenic DNA, altering the growth properties of estrogen-sensitive tissues in the breast. In addition, redox cycling of this molecule between its quinone and semiquinone forms generates free radicals, which are also capable of damaging DNA. Unpublished database analysis done at Rocky Mountain Analytical indicates that there is an association between high endogenous urinary levels of 4-hydroxyestrone, and breast cancer. (The highest endogenous levels of this metabolite were seen only in breast cancer patients, not disease-free patients. Endogenous levels seen in breast cancer patients ranged upwards from 4 micrograms/24 hours.) The unresolved question is: What is the significance of a 4-hydroxyestrone level in the "breast cancer-associated" range, when that level is achieved by supplementation? Unfortunately, no formal studies have been done to delineate the risk of breast cancer associated with urinary 4-hydroxyestrone levels, with or without estrogen supplementation. Prudence might dictate that the 4-hydroxyestrone level be kept as low as possible, in any setting; a dose adjustment might therefore be warranted here. Measures to mitigate the potential effect of elevated 4-hydroxyestrone include strategies to promote methylation of estrogens, and strategies to increase glutathione. (Glutathionation of 4-hydroxyestrone prevents formation of DNA adducts and increased capacity for methylation may prevent adduct formation.) Fecal excretion of all conjugated estrogens may be increased by supplementation with calcium-d-glucarate. (Calcium-D-glucarate inhibits deconjugation of estrogens by colonic flora.) PROPORTION OF 4-HYDROXYESTRONE RELATIVE TO 2-HYDROXYESTRONE It is likely important to examine both the absolute amount of 4-hydroxyestrone being excreted and the amount of 4-hydroxyestrone relative to 2-hydroxyestrone. An individual might have a high level of 4-hydroxyestrone, but this might also be accompanied by high levels of other estrogens, making the finding of elevated 4-hydroxyestrone less unusual. In all three female reference range categories (Postmenopausal, Follicular and Luteal) the 75th percentile for the ratio 4-hydroxyestrone/2-hydroxyestrone is roughly In other words 4-hydroxyestrone was less than 15% of 2-hydroxyestrone in 3/4 of normal women. Here the ratio is In unpublished data amassed at Rocky Mountain Analytical, many patients carrying a diagnosis of breast cancer had ratios of 0.15 or higher, indicating that there was a tendency to form more 4-hydroxyestrone relative to a given amount of 2-hydroxyestrone, along with a higher absolute level of 4-hydroxyestrone. If the ratio is quite a bit higher than 0.15, and the absolute level of 4-hydroxyestrone is markedly elevated, this is probably due to supplementation with Estrogens. A dose alteration might be warranted in this situation. Note that Page 9 of 11

10 no prospective studies on the association of urinary 4-hydroxyestrone levels and breast cancer have been undertaken. ELEVATED 4-HYDROXYESTRONE: ESTROGEN SUPPLEMENTED Elevated 4-hydroxyestrone in the face of low estrone (E1) and 2-hydroxyestrone (2OHE1), despite supplementation with estrogen, may be consistent with preferential "flow" down the 4-hydroxylation pathway. 2-METHOXYESTRONE RANKS BELOW 16th PERCENTILE 2-methoxyestrone is low, either because the parent molecule, 2-hydroxyestrone is also low, or because there is diminished ability to methylate the parent molecule, due to lack of methylation cofactors (e.g. copper, methyl donors). WHY ISN'T THE RATIO 2-HYDROXYESTROGENS/16-HYDROXYESTRONE REPORTED HERE? The original research on this ratio was performed with an ELISA kit which was not able to distinguish between various 2-hydroxylated estrogens. Therefore the threshold ratio of approximately 2 pertaining to increased risk of breast cancer does not obtain when considering data generated by mass spectrometric techniques. Prospective studies would have to be undertaken, to determine what relationship, if any, exists between breast cancer and 2- and 16-oxidized estrones measured by GC-MS or LC-MS. Practitioners have also assumed that the same logic regarding the 2-16 ratio applies whether the patient is supplementing with estrogens, or making her own, the argument being "estrogen is estrogen". It would be very naive and probably dangerous to assume that a 2-16 ratio of 3 means the same thing when it is derived as 300/100 (supplemented case) compared to 12/4 (unsupplemented case). The absolute levels of the metabolites in question matter independently of their ratio. Markedly elevated levels of estrogens are probably harmful, regardless of any ratio we might concoct between them. Finally, a 2011 meta-analysis by Obi looked at all relevant published data, and concluded that although the ELISA 2-16 ratio might be very weakly related to breast cancer in premenopausal women, it is unrelated to risk of breast cancer in postmenopausal women. (Int J Womens Health 2011;3: Estrogen metabolite ratio: Is the 2-hydroxyestrone to 16?-hydroxyestrone ratio predictive for breast cancer? Obi N et al.) In summary, the 2-16 ratio has been misunderstood when transplanted across measurement platforms. It is misused, overinterpreted, and is not on solid ground from an epidemiologic standpoint. 4-HYDROXY PATHWAY IS A LARGE PERCENTAGE OF TOTAL ESTROGENS In regularly-cycling women in the luteal phase, 4-methoxyestrone and 4-hydroxyestrone rarely make up more than 5% of the total of all estrogens measured. For this patient, these two estrogens make up % of the total. Fewer than 25 out of 100 women will have a result like this. The implication is that the 4-hydroxy pathway is "overloaded". This is likely to occur when hormones which can be metabolized to estrogens are being supplemented or when estrogens are being directly supplemented, and in either case this may also be a function of dose. SUM OF ESTROGENS WHEN ONE OR MORE ESTROGENS ARE BELOW DETECTION LIMIT Here, one or more of the estrogen metabolites is below detection limit. The "Sum of Estrogens" reported here only includes the results that are above detection limit. This rarely, if ever, makes a difference to the interpretation of the findings. COMMENT ON RATIO 2-METHOXYESTRONE/2-HYDROXYESTRONE Some 2-hydroxyestrone is cleared by conversion to the methoxylated product, 2-methoxyestrone. Examination of the ratio of the methylation product to its parent may be helpful in some cases. Here, the ratio 2-methoxyestrone/2-hydroxyestrone is A lower ratio (closer to zero) may indicate a need for support of methylation pathways, since there is relatively less of the methylated product, relative to the precursor. A proportion of these patients may benefit from supplementation with any or all of betaine, methylated tetrahydrofolate, folate, B-12, SAMe, magnesium, B6 and MSM. A ratio close to or above unity indicates a relative excess of the methylated product, relative to the precursor. The ratio is also a function of the activity of the relevant methyltransferase enzyme, COMT. Polymorphisms which result in a loss of COMT function may therefore result in a lower ratio. Supplementation may or may not Page 10 of 11

11 be helpful in these cases. Catecholamines are also a substrate for COMT. Excessive catecholamines may compete with estrogens for COMT catalytic "space". Measures to normalize catecholamine output may free up COMT to form more methoxylated estrogen metabolites. Note that supplementation with estrogens may increase the demand for methylation cofactors, and in time, deplete them, leading to decreased "yield" of methoxyestrones relative to the parent hydroxyestrones. George Gillson, MD PhD Medical Director Note: The College of Physicians and Surgeons of Alberta considers some laboratory tests to be non-standard, or a form of complementary and alternative medicine.. These interpretation comments have not been evaluated or approved by any regulatory body. Commentary is provided to clinicians for educational purposes and should not be interpreted as diagnostic or treatment recommendations. Page 11 of 11