HMCL223 Clinical Diagnostic Techniques

Transcription

1 HMCL223 Clinical Diagnostic Techniques Session 6: Hormone Testing: blood, spot, salivary, serum Endeavour College of Natural Health endeavour.edu.au 1

2 Session Objectives Hormone Testing: blood, spot, salivary, serum o Cortisol o Oestrogen, Progesterone, Testosterone, DHT, DHEA, Follicle Stimulating Hormone (FSH), Luteinizing Hormone (LH), Sex Hormone Binding Globulin (SHBG) o 24 Hour Urine Oestrogen Metabolites o Thyroid: Thyroid Stimulating Hormone, ft3, ft4, reverse T3 o Antidiuretic Hormone (ADH) o Parathyroid Hormone (PTH) Endeavour College of Natural Health endeavour.edu.au 2

3 Major Endocrine Glands Endeavour College of Natural Health endeavour.edu.au 3

4 Hormones (Lord & Bralley, 2012, p565). Endeavour College of Natural Health endeavour.edu.au 4

5 Cortisol Endeavour College of Natural Health endeavour.edu.au 5

6 Hormones: Cortisol (Sweis, BM 20012, HPA Axis Diagram, Viewed 14/07/2015 < s_2012%29.png/564px-hpa_axis_diagram_%28brian_m_sweis_2012%29.png>) Endeavour College of Natural Health endeavour.edu.au 6

7 Cortisol Diurnal Rhythm ( Date accessed 12/01/2010) Endeavour College of Natural Health endeavour.edu.au 7

8 Hormones: Cortisol Serum Reference Ranges (Adult) Diurnal Cortisol Levels Measures the level of cortisol (a glucocorticoid) in the serum, urine or saliva principally to assess adrenal function, or the hypothalamic-pituitary-adrenal axis function Serum 8am: nmol/l & 4pm: nmol/l Saliva 8am: ng/dL & 4pm - <401ng/dL Saliva Midnight - <100ng/dL Urine <100mcg/24hrs (<276 nmol/day) (Pagana & Pagana, 2014, p ; RCPA Manual, 2015) Endeavour College of Natural Health endeavour.edu.au 8

9 Hormones: Cortisol High Interfering/ risk factors raising Low Interfering/ risk factors lowering Cushing s Syndrome ACTH producing tumours Acute or prolonged stress Hyperthyroidism Obesity Pregnancy Physical & / or emotional stress (over stimulation of the HPA axis) Drugs: oestrogen, OCP, amphetamines, cortisone, spironolactone (Aldactone) Adrenal hyperplasia Addison Disease Hypopituitarism Hypothyroidism Drugs: androgens, aminoglutethimide betamethasone, exogenous steroid medications, danazol, lithium, levodopa, metyrapone, phenytoin (Dilantin) (Pagana & Pagana, 2014, p.181) Endeavour College of Natural Health endeavour.edu.au 9

10 Sex Hormones Endeavour College of Natural Health endeavour.edu.au 10

11 Endeavour College of Natural Health endeavour.edu.au 11 (Open Stax College, 2013, Figure jpg, vewed 18/07/2015 <

12 Oestrogen Endeavour College of Natural Health endeavour.edu.au 12

13 Oestrogen Three main oestrogen fractions: Oestrone (E1) o Major oestrogen after the menopause: small amounts ovaries but most from androstenedione conversion in peripheral tissues and fats. Oestradiol (E2) o In females, oestradiol (ovaries) is responsible for ovulation, conception & pregnancy. Promoting healthy bone structure & regulating cholesterol levels. o In men, the testes & adrenal glands are the principal source of oestradiol. (Pagana & Pagana, 2014, p. 227) Endeavour College of Natural Health endeavour.edu.au 13

14 Oestrogen Oestriol (E3) o Major oestrogen in pregnancy - large amounts produced in the placenta from precursors synthesized by the foetal liver and adrenal glands, therefore provides an important measure of placental and foetal well-being. o Oestriol levels start to rise in the eighth week of pregnancy and continue to rise until shortly before delivery. (Pagana & Pagana, 2014, p. 227) Endeavour College of Natural Health endeavour.edu.au 14

15 Oestrogen Serum Saliva Reference Ranges (Adult) Oestrogen Fractions Measurement of the various oestrogens which are used to assess sexual maturity, menstrual problems and fertility problems. Most commonly Oestradiol (E2) is measured, however Estrone (E1) and Oestriol (E3) can also be measured in both serum and urine. Salivary hormone profiles are also available Estradiol - serum Male 10-50pg/ml Female: Follicular pg/ml Midcycle pg/ml Luteal pg/ml Post-menopause 20pg/ml (Pagana & Pagana, 2014, p. 227) Endeavour College of Natural Health endeavour.edu.au 15

16 Oestrogen HIGH Feminization syndromes Precocious puberty Ovarian tumour Testicular tumour Adrenal tumour Pregnancy Liver disease Hyperthyroidism LOW Failing pregnancy Turner syndrome Hypopituitarism Hypogonadism Stein-leventhal syndrome Menopause Anorexia nervosa (Pagana & Pagana, 2014, p. 227) Endeavour College of Natural Health endeavour.edu.au 16

17 24 Hour Urine: Oestrogen 24 hour Spot Urine Metabolites o Oestradiol and Estrone liver metabolites are stimulatory (16α-hydroxyestrone, 4-hydroxyestrone & 4- hydroxyestradiol) or antagonistic to other oestrogen molecules (2-hydroxyestrone, 2-hydroxyestradiol, 2- methoxyestrone, 2-methoxyestradiol, 4-methoxyestrone & 4-methoxyestradiol). o Analysis of liver oestrogen metabolites can be indicative of health and disease risks such as breast cancer and lupus (Nutripath, 2015 viewed 17/18/ Endeavour College of Natural Health endeavour.edu.au 17

18 Progesterone Endeavour College of Natural Health endeavour.edu.au 18

19 Progesterone Serum Saliva Reference Range (Adult) Progesterone Progesterone : Often measured early (day 8) and mid-cycle (day 21) to determine a progesterone surge mid-cycle. Can evaluate difficulties in becoming pregnant or maintaining a pregnancy. Urinary pregnenediol (catabolic metabolite of progesterone) can also be measured. Serum Male 10-50ng\dL (rarely clinically significant) Female Follicular <50ng\dL Luteal ng\dL Post menopausal <40ng\dL Pregnancy1 st Tri ng\dL 2 nd Tri ng\dL 3 rd Tri ,900ng\dL (Pagana & Pagana, 2014, p.416-7; RCPA Manual, 2015) Endeavour College of Natural Health endeavour.edu.au 19

20 Progesterone: Interpreting the Results HIGH Ovulation Pregnancy Luteal ovarian cysts Hyperadrenocorticalism Ovarian choriocarcinoma Hydatidiform mole LOW Preeclampsia Toxaemia of pregnancy Threatened miscarriage Placental failure Foetal death Ovarian neoplasm Amenorrhea Ovarian hypofunction (Pagana & Pagana, 2014, p.418) Endeavour College of Natural Health endeavour.edu.au 20

21 Testosterone Endeavour College of Natural Health endeavour.edu.au 21

22 Testosterone Serum Saliva Reference Ranges (Adult) Testosterone Measurement of serum testosterone is used to evaluate sexual development, precocious puberty, virilizing syndromes (females), infertility and impotency (males). Total Testosterone - serum Male ng\dL Female <70ng/dL Free Testosterone - serum Male) % Female % (Pagana & Pagana, 2014, p. 476; RCPA Manual, 2015) Endeavour College of Natural Health endeavour.edu.au 22

23 Testosterone: Interfering/Risk Factors o Drugs that may cause increased testosterone levels include alcohol, anticonvulsants, barbiturates, estrogens, and oral contraceptives o Drugs that may cause decreased testosterone levels include androgens, dexamethasone, diethylstilbestrol, digoxin, alcohol, steroids, ketoconazole, phenothiazine, and spironolactone (Pagana & Pagana, 2014, p. 477) Endeavour College of Natural Health endeavour.edu.au 23

24 Testosterone Normal Findings o Free testosterone: 0.3-2pg/ml & % Free Testosterone: 0.1%-0.3% o Slight variation in the secretion of testosterone. Peaks around 7am & is at its lowest at 8am Tanner Stage Male Total testosterone Female Total testosterone 7 mos-9 yrs (I) <30 ng/dl <30 ng/dl yrs (II) <300 ng/dl <40 ng/dl yrs (III) ng/dl <60 ng/dl yrs (IV, V) ng/dl <70 ng/dl 20 yrs and over ng/dl <70 ng/dl (Pagana & Pagana, 2014, p. 476) Endeavour College of Natural Health endeavour.edu.au 24

25 Male Female Testosterone: Interpreting the HIGH Sexual precocity Pinealoma Encephalitis Congenital adrenal hyperplasia Adrenocortical tumour Gonadal tumours Hyperthyroidism Testosterone resistance Ovarian tumour Adrenal tumour Congenital adrenocortical hyperplasia Trophoblastic tumours Polycystic ovaries Idiopathic hirsutism Results Klinefelter syndrome Cryptorchidism Hypogonadism Trisomy 21 Orchiectomy Liver disease LOW Not clinically significant (Pagana & Pagana, 2014, p. 478) Endeavour College of Natural Health endeavour.edu.au 25

26 Dehydroepiandrosterone (DHEA) Endeavour College of Natural Health endeavour.edu.au 26

27 Dehydroepiandrosterone (DHEA) Serum Reference Ranges (Adult) Tanner IV-V Values Dehydroepiandrosterone (DHEA) DHEA An androstenedione precursor to the formation of testosterone and estrone (E1). It is measured to evaluate virilizing syndromes, amenorrhoea and in the assessment of several types of cancer. In some cases dehydroepiandrosterone sulphate (DHEAs) may be measured. DHEA as 17-Ketosteroid can also be measured on urine. Male ng\ml Female ng\ml (Pagana & Pagana, 2014, p. 29) Endeavour College of Natural Health endeavour.edu.au 27

28 DHEA: Interpreting the Results HIGH Adrenal tumour Congenital adrenal hyperplasia Ectopic ACTH-producing tumours Cushings disease Stein-leventhal syndrome Ovarian sex-cord tumour LOW Adrenal insufficiency Ovarian failure Oophorectomy (Pagana & Pagana, 2014, p. 30) Endeavour College of Natural Health endeavour.edu.au 28

29 Follicle Stimulating Hormone (FSH) Endeavour College of Natural Health endeavour.edu.au 29

30 Follicle Stimulating Hormone Serum Reference Ranges (Adult) Follicle Stimulating Hormone (FSH) Measurement of FSH produced by the anterior pituitary which is used to evaluate menopause, gonadal failure and infertility. FSH is generally performed in combination with LH Male: units/l Female Follicular units/l Ovulatory units/l Luteal units/l Post Menopause units/l (Pagana & Pagana, 2014, p. 348; RCPA Manual, 2015) Endeavour College of Natural Health endeavour.edu.au 30

31 Luteinizing Hormone (LH) Endeavour College of Natural Health endeavour.edu.au 31

32 Luteinizing Hormone (LH) Serum Reference Ranges (Adult) Luteinizing Hormone (LH) Measurement of Luteinizing Hormone is used to determine menopause, gonadal failure and infertility. Both LH and FSH are commonly performed as a comparative assay. These are often performed mid-cycle (day 21) in females when determining fertility. Male: units/l Female: Follicular units/l Ovulatory units/l Luteal units/l Post menopausal units/l (Pagana & Pagana, 2014, p. 348; RCPA Manual, 2015) Endeavour College of Natural Health endeavour.edu.au 32

33 The Menstrual Cycle ( Viewed 12/01/2010) Endeavour College of Natural Health endeavour.edu.au 33

34 LH: Interpreting the Results HIGH Gonadal failure Menopause Infertility Turner syndrome Kleinfelter syndrome Precocious puberty Pituitary adenoma LOW Pituitary failure Hypothalamic failure Infertility Prolonged stress Anorexia nervosa Malnutrition (Pagana & Pagana, 2014, p. 350) Endeavour College of Natural Health endeavour.edu.au 34

35 LH & FSH: Test Ranges (Pagana & Pagana, 2014, p. 348) Endeavour College of Natural Health endeavour.edu.au 35

36 LH & FSH: Interfering/Risk Factors o Human chorionic gonadotropin (HCG) & thyroidstimulating hormone (TSH) may interfere due to the similarities of part of the hormone molecule. o HCG-producing tumours and clients with hypothyroid should be expected to have falsely high LH levels. o Drugs that may increase LH or FSH levels include cimetidine, digitalis, levodopa, anticonvulsants, clomiphene, naloxone, and spironolactone o Drugs that may decrease LH levels include estrogens, progesterones, testosterone, steroids, digoxin, oral contraceptives, and phenothiazines o (Pagana & Pagana, 2014, p. 349) Endeavour College of Natural Health endeavour.edu.au 36

37 Sex Hormone Binding Globulin Endeavour College of Natural Health endeavour.edu.au 37

38 Hormones: SHBG o Albumin and Sex hormone binding globulin (SHBG) are plasma proteins that binds to hormones to make them inactive to allow them to travel to target tissues. o Albumin easily disassociates from hormones but SHBG has a stronger association (especially with testosterone). o Elevated SHBG in men an elevated SHBG may be associated with decreased testosterone. When initial pathology tests testosterone & the levels are within range but the symptoms of testosterone deficiency present, SHBG levels will be checked. (Lab tests online, 2015) Endeavour College of Natural Health endeavour.edu.au 38

39 Hormones: SHBG o In women deficient SHBG may be associated with elevated testosterone levels. o An alteration in SHBG levels in both men and women may be associated with infertility, liver disease, hyper or hypothyroidism, PCOS and feminisation or masculinisation syndromes. o It may also be necessary to test albumin levels as albumin will also readily bind to testosterone. o A complete assay commonly referred to as a free androgen index (FAI) may be ordered. (Lab tests online, 2015) Endeavour College of Natural Health endeavour.edu.au 39

40 Thyroid Endeavour College of Natural Health endeavour.edu.au 40

41 Thyroid System (Häggström, M, 2009, Overview of the thyroid system viewed 22/07/2015 < /d1/thyroid_system.svg/414px-thyroid_system.svg.png>) Endeavour College of Natural Health endeavour.edu.au 41

42 Thyroid Stimulating Hormone Serum Reference Ranges Thyroid Stimulating Hormone (TSH) A measurement of the level of TSH produced by the anterior pituitary gland, used to differentiate primary (thyroid gland), secondary (pituitary gland), or tertiary (hypothalamus) hypo/hyper-thyroidism. Adult: mu\l There is a diurnal variation in TSH levels. Basal levels occur around 10 AM and highest levels (about 2-3 times basal levels) occur around 10 PM (Pagana & Pagana, 2014, p. 486; RCPA Manual, 2015) Endeavour College of Natural Health endeavour.edu.au 42

43 Thyroid Stimulating Hormone o Thyrotropin releasing hormone (TRH) from the hypothalamus stimulates the anterior pituitary to release TSH to stimulate the thyroid gland to produce thyroid hormones (T3 & T4) o Thyroxine (T4) is the precursor to the synthesis of Triiodothyronine (T3) through a process of monodeiodination in the liver, muscles and kidneys. o This test is used to differentiate primary hypothyroidism (Low T3/4) from secondary (low TSH) and tertiary (Low TRH) hypothyroidism (Pagana & Pagana, 2014, p. 487) Endeavour College of Natural Health endeavour.edu.au 43

44 Thyroid Stimulating Hormone HIGH Primary hypothyroidism Thyroiditis Thyroid agenesis Congential cretinism Iodine overdose Radioactive iodine treatment Surgical ablation of thyroid Pituitary TSH-secreting tumour LOW Secondary hypothyroidism Hyperthyroidism Suppressive doses of thyroid medication (Pagana & Pagana, 2014, p. 488) Endeavour College of Natural Health endeavour.edu.au 44

45 Thyroid o Recent radiacoisotope administration may affect test results o Decrease levels: Severe illness & drugs (aspirin, nonsteroidal anti-inflammatories, dopamine, heparin, steroids, and T 3 ) o Increase levels: Drugs (antithyroid medications, lithium, potassium iodide, and TSH injection) (Pagana & Pagana, 2014, p.487) Endeavour College of Natural Health endeavour.edu.au 45

46 T3 & T4 Serum Reference Ranges (Adult) Free T3 and Free T4 A measurement of the level of triiodothyronine (T3) and Thyroxine (T4) produced by the thyroid gland, used to differentiate primary (thyroid gland), secondary (pituitary gland), or tertiary (hypothalamus) hypo/hyperthyroidism. Free T3 <50 yrs ng/dL >50 yrs ng/dL Free T ng/dl (Pagana & Pagana, 2014, p. 497; RCPA Manual, 2015) Endeavour College of Natural Health endeavour.edu.au 46

47 T3 & T4: Interpreting the Results HIGH Primary hyperthyroidism Acute thyroiditis Familial dysalbuminaemic hyperthyrotoxinaemia Struma ovarii TBG increase LOW Hypothyroidism Pituitary insufficiency Hypothalamic failure Protein malnutrition Iodine deficiency Various non-thyroid illnesses (Pagana & Pagana, 2014, p.499) Endeavour College of Natural Health endeavour.edu.au 47

48 Thyroid: Interpreting the Results TSH FT4 FT3 Interpretation High Normal Normal High Low Low or normal Hypothyroidism Low Normal Normal Mild (subclinical) hypothyroidism Mild (subclinical) hyperthyroidism Low High or normal High or normal Hyperthyroidism Low Low or normal Low or normal Non-thyroidal illness; rare pituitary (secondary) hypothyroidism (Labtestsonline, viewed 2013) Endeavour College of Natural Health endeavour.edu.au 48

49 Reverse T3 (rt3) o The removal of an iodine from the outer ring of T4 generates Active T3 whereas a removal of an iodine form the inner ring generates Reverse T3. o Normally T4 converts to both T3 and a small amount of rt3 which is quickly eliminated. (Healthscope, 2011, p. 115) Healthscope, 2011, Reverse T3, viewed 17/08/2015 <file:///c:/users/elizabethmacgregor/downloads/rt3_overview.pdf>) Endeavour College of Natural Health endeavour.edu.au 49

50 Reverse T3 (rt3) o Stress, during fasting, starvation, fibromyalgia, CFS and in cases of liver disease, rt3 is produced more abundantly inhibiting synthesis of active T3 o rt3 levels are also increased in patients with Wilson s thyroid syndrome o Note: subclinical hypothyroidism may not be recognised by mainstream medicine (Healthscope, 2011, p. 115) Endeavour College of Natural Health endeavour.edu.au 50

51 Antidiuretic Hormone Endeavour College of Natural Health endeavour.edu.au 51

52 Antidiuretic Hormone Serum Reference Ranges (Adult) Antidiuretic Hormone (ADH) ADH: produced by the posterior pituitary, is measured in conjunction with other routine tests to evaluate problems associated with altered blood or urine osmolality, or diabetes insipidus Serum: 1-5 ng\l (Pagana & Pagana, 2014, p. 73; RCPA Manual, 2015) Endeavour College of Natural Health endeavour.edu.au 52

53 Antidiuretic Hormone (ADH) o Dehydration creates osmotic and volume changes within the blood which stimulates the release of ADH from the posterior pituitary. Acts on the distal nephron to conserve water and regulate the tonicity (osmolality) of body fluids. o ADH levels are tested in patients suspected of having diabetes insipidus or the syndrome of inappropriate ADH (SIADH). It is often performed in patients who complain of polyuria or polydipsia and are found to have marked variations in blood and urine osmolarity or sodium levels (Pagana & Pagana, 2014, p. 74) Endeavour College of Natural Health endeavour.edu.au 53

54 ADH: Interfering/Risk Factors o Drugs that increase ADH levels include acetaminophen, barbiturates, cholinergic agents, estrogen, nicotine, oral hypoglycemic agents, some diuretics (eg thiazides), cyclophosphamide, narcotics, and tricyclic antidepressants o Drugs that decrease ADH levels include alcohol, betaadrenergic agents, morphine antagonists, and phenytoin (Dilantin) (Pagana & Pagana, 2014, p. 74) Endeavour College of Natural Health endeavour.edu.au 54

55 ADH: Interpreting the Results HIGH Syndrome of inappropriate ADH (SIADH) CNS tumours and infections Pneumonia Pulmonary tuberculosis Ectopic ADH (Lung cancer) Myxoedema Addisons disease Primary renal disease Severe physical stress Dehydration Hypovolaemia Acute porphyria Post surgery LOW Neurogenic (CNS trauma) Surgically induced Hypervolaemia Nephrotic syndrome Diabetes insipidus (Pagana & Pagana, 2014, p. 74) Endeavour College of Natural Health endeavour.edu.au 55

56 Hormones: Parathyroid Hormone (PTH) Endeavour College of Natural Health endeavour.edu.au 56

57 Para Thyroid Hormone o Measured to aid the evaluation of hypercalcaemia or hypocalcaemia. o The test may establish a diagnosis of hyperparathyroidism. Also rules out hypercalcaemia due to non-parathyroid causes. (Pagana & Pagana, 2014, p. 381) (Häggström, M 2009, Overview of calcium regulation, viewed 16/07/2014 < Endeavour College of Natural Health endeavour.edu.au 57

58 Parathyroid Hormone (PTH) Serum taken at 8am Reference Ranges (Adult) Parathyroid Hormone (PTH) PTH is measured to assist in the evaluation of hyper or hypo-calcaemia, and is routinely monitored in patient with chronic renal failure. It is also used to differentiate between primary (parathyroids), secondary (kidney disease), and rarely tertiary, parathyroid disease. Commonly performed in combination with serum calcium levels. Whole PTH (active): ng\l N-Terminal (active): 8-24 ng\l C-Terminal (inactive): ng\l (Pagana & Pagana, 2014, p. 381) Endeavour College of Natural Health endeavour.edu.au 58

59 Calcium PTH relationship If both PTH and calcium levels are normal, then it is likely that the body s calcium regulation system is functioning properly Calcium PTH Interpretation Normal Normal Calcium regulation system functioning OK Low High PTH is responding correctly: may run other tests to check hypocalcaemia Low Normal/Low PTH not responding correctly: probably have hypoparathyroidism High High Parathyroid gland producing too much PTH: may do imaging studies to check for hyperparathyroidism High Low PTH is responding correctly: may run other tests to check for non-parathyroid-related reasons for elevated calcium (Lab tests online, 2015) Endeavour College of Natural Health endeavour.edu.au 59

60 PTH: Interpreting the Results HIGH Hyperparathyroidism Paraneoplastic syndrome Congenital renal defect Hypocalcaemia Chronic renal failure Malabsorption syndrome Vitamin D deficiency (Rickets) LOW Hypoparathyroidism Hypercalcaemia Metastatic bone tumour Malignancy Sarcoidosis Vitamin D toxicity Milk-alkali syndrome DiGeorge syndrome (Pagana & Pagana, 2014, p. 381) Endeavour College of Natural Health endeavour.edu.au 60

61 PTH Tests o PTH is metabolized to several different fragments, including an amino acid (N-terminal) & a carboxyl (Cterminal). o N-terminal antibody measures intact and amino terminal fragments ~75% sensitive for hyperparathyroidism. o Carboxy terminal antibody measures intact, carboxy terminal and mid-molecule fragments ~85% sensitive and 95% specific for primary hyperparathyroidism o Intact PTH assays are preferred because they detect PTH suppression in nonparathyroid hypercalcaemia (Pagana & Pagana, 2014, p. 381) Endeavour College of Natural Health endeavour.edu.au 61

62 References o o o o o Labtestsonline, 2015, Viewed 17/08/ Lord, RS & Bralley, JA (eds) Laboratory evaluations for integrative and functional medicine. 2 nd edn, Metametrix institute, Duluth, Georgia Pagana KD & Pagana, TJ (eds) 2014, Mosby s manual of Diagnostic and Laboratory tests, 5 th Edition, Elsevier, Missouri, USA Royal College of Pathologists of Australasia, 2015, RCPA Manual viewed 13/07/ Manual/Home) Weatherby, D & Ferguson, S 2002, Blood chemistry and CBC analysis, Bear Mountain Publishing, Jacksonville, USA. Endeavour College of Natural Health endeavour.edu.au 62

63 Recommended Readings o Video: How to know when you are ovulating. o Video: The menstrual cycle and your body s natural sign of fertility cervical mucus o Video: Early facial signs of thyroid dysfunction self help Endeavour College of Natural Health endeavour.edu.au 63

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