TESTING - SALIVA VS. BLOOD
By Stanford Field
August 2003
WHAT IS THE ISSUE?
Many medical doctors question the effectiveness of transdermal steroid hormones such as testosterone and progesterone. They say that these hormones are not appreciably absorbed into the bloodstream from the skin, and therefore, they do not have a significant physiological effect. This argument is based on the fact that when these hormones are used transdermally, they do not significantly raise the "blood" levels of the hormones. This is not only what doctors have been taught, but also what has been reinforced by the pharmaceutical industry which sells high-impact, unnatural (not bio-identical) steroid hormones.
From the doctors' perspective, that is the end of the argument. That is an understandable way to deal with the fact that neither doctors nor anyone else can keep up with the speed of biochemical and medical discoveries. It's really up to the patient to become knowledgeable about his problem and attempt to educate (or give some clues) to the doctor.
In contrast to conventional medicine, a small group of scientists and alternative medicine doctors have been successfully improving the health and slowing the aging of patients by using steroid hormones such as dehydroepiandrosterone, progesterone, testosterone, and the estrogens (estrone, estradiol and estratriol). The dosage of these hormones is adjusted by analyzing the results of saliva tests.
OBJECTIVES
This report has two primary objectives:
(1) to determine whether saliva testing or blood testing is more accurate for steroid hormones, and
(2) to determine whether transdermal application of steroid hormones does or does not raise blood concentrations of the hormones.
To achieve these objectives it is necessary to know some of the scientific details that support each position.
WHAT ARE STEROID HORMONES?
An endocrine steroid hormone is a chemical substance that is formed in a gland and is carried in the blood to target cells to exert specific physiological effects.
A steroid is any of numerous compounds that is derived from cholesterol. Cholesterol, itself, is derived from acetyl groups (a unit containing two carbon atoms) by a complex enzymatic process. The acetyl groups are formed in the biochemical processing of food into energy.
Although steroid hormones are present in the body in extremely low concentrations (parts per trillion in the blood and saliva), they exert potent physiological effects on sensitive tissues. The steroid hormones act on target cells to regulate gene expression and consequent protein biosynthesis. All steroid hormones are lipophilic (fat-soluble) and most are carried in the aqueous bloodstream bound to carrier proteins which are water-soluble. However, a small amount of steroid hormones are being carried in the aqueous part of the bloodstream not bound to anything. These "free." hormones are available to enter cells.
The "free" steroid hormones can diffuse through the target cell membrane which is made of fat and readily allows the passage to the interior of the cell. The hormone is attracted to high-affinity steroid receptor proteins. The hormone-receptor complex is then translocated into the nucleus of the cell which contains the genetic information. A particular genetic process is initiated in which specific proteins are synthesized. Those proteins go on to exert physiological effects that are then attributed to the steroid hormone.
BLOOD
Since this report is concerned with blood analysis, it is important to understand the general composition and characteristics of blood. Blood is a fluid consisting of red and white cells suspended in an aqueous plasma. The cells make up about 45 percent of the mixture (called the "hematocrit"), and the watery plasma is about 55 percent of the mixture. The majority of cells in the blood are red blood cells (erythrocytes). The most important constituent of the red blood cell is hemoglobin whose main function is to transport oxygen from the lungs to the somatic (body) cells.
The other cells in blood are white blood cells (leukocytes) that include platelets. The white blood cells are nearly twice the size of red blood cells and are concerned with immunity. For example, the white cells can engulf bacteria and foreign particles in a process called "phagocytosis."
The platelets function to control bleeding after an injury. The platelets liberate serotonin when the blood vessels are damaged. This causes small blood vessels (capillaries) to strongly contract, which reduces bleeding.
The blood also contains fibrinogen and other factors that cause blood to clot. The fibrinogen is a soluble protein precursor of fibrin which is an insoluble protein that forms the main part of a blood clot. Incidentally, a developing therapy uses enzymes to dissolve fibrin while the damaged area is being reconstructed.
Another interesting aspect of blood is how much glucose (sugar) it contains. A normal blood glucose reading of 90 mg/dl translates to about 5 grams in the whole bloodstream throughout the body. When a soft drink or morning cereal containing 30-40 grams of sugar comes down the hatch, it overwhelms the balance and stability of the glucose being supplied to all the cells of the body. The pancreas quickly secretes insulin to drive down the glucose, and a wild, unbalanced cycling occurs. This hyper-dose of sugar affects smaller bodies (young children) in ways that create Attention- Deficit-Hyperactivity-Disorder (ADHD). It is commonly treated, not by removing the source of sugar, but by drugging the child with amphetamines (Ritalin).
Now that we know something about the nature of steroid hormones and blood, what is it like for those hormones to travel in the bloodstream?
STEROID HORMONES IN THE BLOOD
Let us use testosterone as an example that is representative of all steroid hormones. Over 90% of the testosterone in the bloodstream is carried by water-soluble proteins (sex hormone binding globulin [SHBG] and albumin). The testosterone bound to those proteins is not readily bioavailable to target tissues because it is on its way to the liver for excretion in bile which enters the intestines when fat is eaten. Along the intestines, about 90% of the bile and testosterone is reabsorbed and recycled to the liver for new processing - thus conserving these valuable biochemicals.
Part of the testosterone-SHBG and testosterone- albumin complexes that went to the liver is converted into water-soluble chemicals that are excreted in the urine. Sometimes, a urine specimen is used to estimate the testosterone in the blood.
Less than 10% of total testosterone is bioavailable. More than 80% of this bioavailable (called "free") testosterone travels in the blood attracted to (adsorbed on) fatty red blood cell membranes. The other 20% of bioavailable testosterone (2% of total testosterone) is unbound traveling in the plasma, and is readily available to stimulate target tissues.
THE FALLACY OF BLOOD TESTS FOR STEROID HORMONES
When blood is drawn from a vein (low pressure going to the heart), it contains plasma and red and white blood cells. To analyze the blood, the plasma is separated from the blood cells by centrifugation. Since the plasma still contains clotting factors, an anticoagulant is added. This, then, is the plasma used for blood analysis. If the blood is allowed to coagulate, the cell-depleted fluid phase, devoid of fibrinogen, is called "serum." The serum may also be used for analysis. In either case, the blood being analyzed does not contain the red blood cells that held the free testosterone. What is being analyzed is testosterone that is attached to binding proteins and is not bioavailable.
When testosterone is applied transdermally, it is absorbed into the bloodstream as "free" testosterone. It has not been packaged with a binding protein by the liver because the liver did not have access to the testosterone. Most of the "free" testosterone is taken up by the red blood cell membranes which are not analyzed by a common blood test.
Conclusion: Common blood tests that use plasma or serum are not accurate for assessing bioavailable steroid hormone concentrations because neither the plasma nor the serum contain the red blood cells which hold the bioavailable hormones.
DIRECT COMPARISON OF PLASMA AND SALIVA LEVELS AFTER TOPICAL PROGESTERONE APPLICATION
A technical paper entitled "Absorption of Progesterone after Topical Application: Plasma and Saliva Levels" was presented by Dollbaum and Duwe in 1997 at the 7th Annual Meeting of the American Menopause Society. An abstract of the presentation follows:
Cream
(mg/d)
Progesterone
(pg/ml)
Progesterone
(pg/mI)Creams with varying concentrations of progesterone were applied to menopausal women, after which both plasma and saliva levels were measured, as shown in the table above.
In the menopausal women given the placebo, the plasma level of progesterone was 12 times greater than the saliva level. This indicated that most of the plasma progesterone was protein-bound and very little was bioavailable.
When only 0.34 mg/d of progesterone was applied, the plasma level rose 39%, whereas the saliva level rose 5-fold. This showed that most of the incremental progesterone that was applied transdermally was the bioavailable kind that was adsorbed by the red blood cells.
When a large dose of progesterone was applied transdermally, the plasma level rose by a factor of 3.6, while simultaneously, the saliva level rose by a factor of 57. This difference in the multiple increase between plasma and saliva can be explained by the complete saturation of target cells, the overflow progesterone being adsorbed by the red blood cells, and the subsequent reflection of that bioavailable progesterone in the saliva concentration.
This study clearly revealed that plasma progesterone levels are imprecise and misleading with respect to the bioavailable progesterone that is absorbed from topical application. The saliva level is far more accurate.
SALIVA REFLECTS THE BIOAVAILABLE CONCENTRATION OF HORMONES PRESENT IN THE BLOODSTREAM
Now for some background on saliva. There are three salivary glands in the mouth that produce about two pints of saliva per day. The saliva is about 99.5% water and 0.5% solute. Saliva is used for chewing, swallowing and the initiation of digestion by the enzyme amylase which begins the breakdown of carbohydrates. In addition, saliva is protective against pathogens. It is antibacterial, antifungal and antiviral. That's probably why rubbing saliva on an injury feels so good. Saliva also contains immunoglobulin A which protects the eyes, nose, throat, intestines and lungs from infectious diseases.
The secretion of saliva is entirely under the control of the nervous system. Sympathetic nervous system stimulation dominates during stress, resulting in dryness of the mouth. During dehydration, the salivary glands stop secreting to conserve water, and the resulting dryness in the mouth contributes to the sensation of thirst.
The salivary glands have an extremely high blood flow which is about ten times that of an equal mass of contracting skeletal muscle. Researchers have found that the "free" hormones from the red blood cells and plasma readily filter through the saliva glands into saliva where they can be measured accurately ( in parts per trillion).Conclusion: Saliva reflects the bioavailable level of hormones present in the bloodstream, and saliva testing is a far more accurate and relevant test than blood tests in measuring bioavailable steroid hormones.
A TRANSDERMAL PROGESTERONE EXPERIMENT
Australian researchers, Waddell and O'Leary, issued a report entitled "Distribution and Metabolism of Topically Applied Progesterone in a Rat Model" published in the "Journal of Steroid Biochemistry and Molecular Biology" in 2002 . A summary of the report follows:
They removed the ovaries and adrenal glands from female rats to shut down all significant sources of progesterone production from within the body. They then applied a single 150 mg dose of progesterone cream (Pro-Fern) providing 3.75 mg of progesterone to a shaved area of the abdomen. This dose was more than one hundred times greater per weight than the typical transdermal doses used for women with progesterone deficiency. The cream also contained a radioactive isotope of progesterone to allow tissue levels to be traced more accurately.
After three hours, the rats were sacrificed to measure tissue progesterone levels in the uterus, liver, lung, kidney and salivary glands. The researchers found tissue levels (free progesterone) many times greater than blood levels. The target cells were being saturated with progesterone.
The conclusion of the authors: "The present study establishes that topically applied progesterone is absorbed effectively immediately into the blood by a transdermal route. The subsequent pattern of tissue distribution and metabolism appears to be essentially the same as that for progesterone administered intravascularly (by injection). The accumulation of progesterone in several tissues, most notably the uterus, after topical application is consistent with transdermally absorbed progesterone being biologically active. Therefore, our results suggest that topical application of progesterone cream is a potentially viable option for progesterone therapy."
A PERSONAL EXPERIENCE SUPPLEMENTING WITH TESTOSTERONE AND PROGESTERONE CREAMS
I began using testosterone and progesterone creams in 1998 at age 69. I used approximately 1 mg/d of each for 3 days per week. I put them in the armpits where they could not readily be washed off. After a couple of years of trial and adjustment, I had reached a steady state with respect to saliva readings. My testosterone was about 300-400 pg/ml which was more than twice as high as a male in his 20's. I didn't even feel like I was in my 50's. The alternative doctor who was overseeing this situation said that I should not exceed the level of a male in his 20's. After a while, I began to realize that he feared the downside of too much testosterone, and therefore he was being very conservative.
So, I decided to take matters into my own hands. My background in chemical engineering provided the confidence for some experimentation. I increased the use of testosterone and progesterone to 4 times per week while keeping the dosage at 1 mg per application. I was more afraid of the potential pitfalls of higher dosage than I was of higher frequency of application. I steadied-out at 500-600 pg/ml for testosterone. I noted some improvement in sexual function, and I felt pretty good. Estradiol was kept at the lowest detectable level of 0.5 pg/ml.
On 10-01-01, I had surgery to totally replace my right hip. Thereafter, I began a more intensive campaign of supplemental nutrients and enzymes to rebuild everything. Part of that effort was to increase the frequency of application of the premier anabolic hormone to 7 times per week, still staying at 1 mg per day. Within two months of the operation, I was able to walk two miles, and after four months, I was back on the tennis courts playing old men's doubles three times per week. I felt great, and I guessed that my sexual function had improved to the 50-60 year old range. However, I was totally shocked to find that my saliva testosterone had gone up by a factor of six! Apparently, all the target cells became saturated with bioavailable testosterone and the excess was taken up by the red blood cells and eventually reflected in the saliva.
In any event, at that point, I stopped all supplementation of the testosterone and progesterone creams. Within three months (maybe sooner), the next saliva test showed that my testosterone was equivalent to that of an 80-90-year-old man. To make matters worse, the estradiol had gone up instead of down.
The data for the preceding events are summarized in the following table:
1 mg/d each
1 mg/d each
Zero
(pg/ml)
(pg/ml)
(pg/ml)
It was necessary to develop a protocol that would balance all of the various factors to give a healthy outcome. My first concern was to minimize the estrogens. They were high when testosterone was low, and they were rising when testosterone was high. That meant that there must be a minimum somewhere. I plotted all of the saliva data from 1999 to 2003, inclusive and found that estrogens were minimized when testosterone was in the 800-1200 pg/ml range, as shown below:
My protocol now is to use testosterone and progesterone creams every day at a very small dose. I am aiming for testosterone at 1000 pg/ml in the saliva. That should make me feel great and minimize the estrogens. The protocol uses aromatase and 5-alpha reductase inhibitors, a wide variety of antioxidants and anti-inflammatory enzymes and herbs to maintain the testosterone concentration, to prevent further prostate enlargement and to minimize the probability of prostate cancer.
TOO LATE SCHMART is written by Stanford Field (BS chemical engineering, 1951) who has been avidly studying biochemistry and physiology, since 1993, with an aim of staying healthy despite the ever-increasing odds of age-related decline. This publication is written to the best of his ability, and it is intended to document any findings that may be useful to interested readers. The publication has neither profit nor political motives.
August 2003
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