I get a ton of questions from women who are confused about their hormones. When you’re trying to figure out why you feel so crappy every month, it can be frustrating trying to get access to the appropriate tests. It can be even more frustrating to suffer terrible symptoms and yet have no diagnosis because your bloodwork comes back “normal.” Part of the problem is that you simply don’t know when is the best time to test hormone levels.
In this article, I’m outlining some of the more common testing recommendations I make for women in my medical practice.
For a more in-depth exploration, check out my best-selling book Beyond the Pill. It will help you narrow down your specific hormone imbalance and has a ton of great resources regarding testing.
When evaluating hormone health, it is important to also understand gut and liver function since they play a huge role in breaking down hormones to maintain proper levels. For the purpose of this article, we will focus on hormone testing.
Understanding The Hormonal Cycle for Testing
If we want to talk about when to test hormones, we first have to understand how the menstrual cycle works and how doctors talk about it in terms of timing.
Overview of Menstrual Cycle for Hormone Testing
- Day 1 — this is the first day you see bright red blood.
- Day 14 — this is when women are typically told they ovulate, but that’s not true for everyone or every cycle. But we use this as a baseline when discussing lab tests and timing. You should monitor your cycle and symptoms to find out when you *actually* ovulate for sure.
- Day 28(ish) — not everyone has a 28-day cycle. However, you’ll often hear the menstrual cycle talked about in terms of 28 days. This is where your hormones drop if you don't get pregnant. If you’re tracking your period and you know that you have a shorter or longer cycle.
- Back to Day 1 – this is when you’ll once again see blood.
>> It’s important to note: While on hormonal birth control you should not ovulate and you don’t have a period. Instead, you have a medication-induced withdrawal bleed that isn’t actually a period. Some women will continue to ovulate with an IUD.
When Is the Best Time to Test Hormone Levels?
If you’re struggling with a hormone imbalance, testing your sex hormones can help you understand where the issue is rooted. Evaluating estrogen, progesterone and testosterone can be helpful in understanding which hormones are driving your symptoms.
Hormone levels aren’t static throughout the month…and this is why so many women get “within range” blood test results.
What Day Should Estrogen Levels Be Checked?
When evaluating female estrogen levels, day 3 is when estradiol, along with follicle stimulating hormone (FSH) and luteinizing hormone (LH) blood tests will be performed.
Testing at the beginning of the cycle, along with FSH can help us understand brain-ovarian communication. Measuring FSH and LH is important to assess how the brain is talking to the ovaries.
When Should FSH Levels Be Checked?
For fertility or evaluating ovarian reserve, FSH is tested on day 3 of your cycle. If you cannot have lab testing done, most providers are fine testing between days 2-4. Remember, day 1 is the first day of your period.
Testing on or around day three of your cycle can be helpful in evaluating PCOS diagnosis as well. Note, this test alone will not diagnose PCOS. FSH and LH can help us understand how the brain is talking to the ovaries and the hormones can help us know how the ovaries respond to that message.
Why Test Estradiol?
During your reproductive years, estradiol or E2 is the predominant form of estrogen. As we transition into menopause, estrone or E1 becomes the most common circulating estrogen. This is important to understand because depending on the phase of life you are in, your estrogen levels and the type of estrogen will vary.
If you are in a phase of life where you should be having periods, you need to check estradiol.
Testing Estrogen Days 19-22 of Cycle
In my medical practice, we check estrogen levels around day three (third day of your period) and in some cases, between days 19-22 or roughly 5-7 days after ovulation.
Evaluating your estrogen levels, especially in relation to progesterone during the luteal phase can help you identify if your symptoms like weight gain, irritability, and heavy periods are related to estrogen dominance.
When you simply test on the day you happen to be in the doctor’s office getting an exam, your levels may be just fine for that particular day. To get a really good understanding of estrogen levels and how they’re affecting your symptoms, you have to test and compare with where they should be based on the timing of your cycle.
When to Test Progesterone
Progesterone levels are highest 5-7 days following ovulation, which is within our luteal phase (the second half of your cycle). This is why testing is recommended days 19-22 of a 28 day cycle.
Even though we’re commonly told that women ovulate like clockwork on day 14 of their cycle, unfortunately, this isn’t always the case. It’s a great idea to track your basal body temperature and evaluate your cervical mucus to get an idea of when and if you are ovulating. Or you can use over-the-counter LH strips which can help you dial in the day you ovulate.
I’ve got a whole article devoted to this practice, but the general idea is pretty simple, but can take some time. When you ovulate, your body temperature rises and your vaginal discharge becomes the consistency of stretchy egg whites. If you keep an eye on these changes to your body, there’s a pretty good chance you can approximate when you’re ovulating.
For a lot of women, this will mean that testing for progesterone should happen on roughly day 19-22 of their cycle. Again, this recommendation could change if you’re not ovulating day 14 of your cycle — which is actually pretty common, or if your typical cycle is shorter or longer than 28 days. Track your cycle for a few months before and talk to your doctor so that they can tell you the best day to test progesterone.
If you feel confused, talk to the provider ordering your test.
When to Test Testosterone
Testosterone is highest in the morning and best tested between 7 a.m. and 10 a.m.
Yes, testosterone is a key hormone to test for women. When testosterone levels are low, this is often when we see low libido, fatigue, and even depression. And when they’re high, as we often see in polycystic ovarian syndrome (PCOS), women experience acne, irregular periods, and hair growth on the chin, chest and abdomen. Elevated testosterone can also lead to hair loss on the scalp.
Testosterone levels vary by age — so results have to be interpreted accordingly. You have to test BOTH total and free testosterone and sex hormone-binding globulin (SHBG) to get a clear picture of what exactly is going on.
You can get your testosterone levels measured any time of the month. This test is best done in the morning because that is when levels are highest.
What Do I Test If I Don’t Have A Period?
If your period has stopped showing up (or never arrived in the first place), this is what is called amenorrhea.
- Primary amenorrhea is when you haven’t gotten your period by age 15 or 16.
- Secondary amenorrhea is when you have had a period, but now it’s gone.
If your regular period is missing for three or more months, or your irregular period is missing for six or more months, this is considered secondary amenorrhea.
Often, doctors will try to prescribe the birth control pill as a means of “treating” amenorrhea. If you begin birth control you will not be able to test FSH, LH, estradiol or progesterone accurately.
The Endocrine Society guidelines clearly advocate against the use of the pill in women with functional hypothalamic amenorrhea solely to restore a period or even improve bone mass. They also recommend educating patients who are currently using the pill that it may mask these issues.
Lab Test to Consider for a Missing Period
- Pregnancy test
- Follicle-stimulating hormone (FSH)
- Luteinizing hormone (LH)
- Estradiol (sometimes docs won't test estrogen, but if you don't, then you're missing info on how the ovaries respond to the brain signals)⠀
- Thyroid panel⠀
- Free testosterone⠀
- Dehydroepiandrosterone-sulfate (DHEA-S)⠀
- Fasting insulin⠀
- Glycated hemoglobin (HgA1C), fasting glucose or glucose challenge⠀
Will you need all of these? Maybe. Maybe not. This is where an experienced clinician can help.⠀
I know that many women experience resistance to their request to have comprehensive hormone testing. I would urge you to seek out a functional medicine practitioner, a naturopathic physician, a reproductive endocrinologist, or a gynecologist. I know it can be super frustrating to try to find a provider that will help you but there are many amazing practitioners out there who can and will help you get the labs you need.
Also — don’t let a doctor convince you that a missing period doesn’t matter because you’re not interested in baby-making at the moment. Amenorrhea is a sign of an underlying issue that needs to be addressed, whether you’re trying to conceive or not. The quality of care you receive should not be dependent on your whether or not you want to have a baby at this moment.
If your period is missing, I’d encourage you to check out my full article on amenorrhea here.
When is the Best Time to Test Other Hormone Levels?
Your sex hormones aren’t the only ones you may need to look at to understand the cause of your hormone symptoms.
When to Test Insulin
If you’re trying to get to the bottom of a PCOS diagnosis, you will need to evaluate insulin. If you have a family history of diabetes or your clinician suspects insulin dysregulation, this is a test they will likely order.
Typically, insulin is tested while fasting along with blood glucose. Because of this, the test is commonly done first thing in the morning.
It is recommended that biotin be stopped at least 72 hours before testing.
Fasting insulin is a good place to start, but you may need to do a glucose challenge as well. Finding out what your insulin looks like after you eat can also be helpful. Your doctor will help determine the right tests for you.
When to Test Cortisol
We can’t always get a full picture of what’s going on with your hormones without looking at the adrenals, which produce the stress hormone cortisol.
Cortisol is involved in your stress response, hair loss, blood sugar regulation and more. In time of stress, the body will shift into preferentially making cortisol over progesterone. Read more about the importance of cortisol here.
Cortisol blood tests are best performed in the morning, along with Adrenocorticotropic hormone (ACTH), because this is when levels are highest. ACTH is produced in the pituitary gland and helps your adrenals to function. For a more comprehensive picture of adrenal function, a 4-point salivary or urinary cortisol is best. Cortisol can be tested at any time of the month.
When to Test DHEA
Dehydroepiandrosterone (DHEA) is a crucial anti-aging hormone that the body can convert into estrogen or testosterone. It is an important marker of adrenal function and is a hormone that declines with age.
DHEA can be tested at any time of the month and is typically done alongside a cortisol test.
When to Test Thyroid Labs
We can’t discuss testing for hormone imbalances without looking at the thyroid. Thyroid testing is best down first thing in the morning and can be at any point in your cycle. We typically add these in when we are testing for other hormones.
It’s important to stop any supplements with biotin at least 72 hours in advance as it can skew results.
At a minimum, I would suggest looking at:
Thyroid-stimulating hormone (TSH)
TSH is a brain hormone that signals to your thyroid to produce T4 (& a little bit of T3). A lot of doctors will test TSH only, which doesn’t give the full picture of thyroid function.
Free Thyroxine (T4) and Free Triiodothyronine (T3)
Thyroid binding globulin (TBG) is a protein that transports thyroid hormone & makes it so your body can't use it. When thyroid hormone is bound it is measured via blood test as Total T4 & Total T3.
Your cells use Free T4 & Free T3. This is why we measure both of these markers in addition to TSH.
Your T4 is inactive and T3 is active. T3 is involved in your mood, menses, metabolism, and gut motility.
Thyroid peroxidase (TPO) and Thyroglobulin (TgAb) antibodies
These are the most common antibodies to see with Hashimoto’s hypothyroidism, the most common cause of hypothyroidism. Often, antibodies will present prior to symptoms of thyroid dysfunction. Read more about Hashimoto’s hypothyroidism here.
Thyroid Receptor Antibodies
These are seen in cases of hyperthyroidism or Graves disease. This condition is less common and so this test is only ordered when clinical suspicion is high. Read more about hyperthyroidism here.
This is considered inactive thyroid hormone that can be elevated in times of stress, both physical and emotional.
>> The goal here is to measure at minimum TSH, Free T4 & T3 so you get a picture of what the brain says, how the thyroid responds, & then the body's ability to activate the thyroid hormone you actually use.
It’s extremely important to work with a doctor to interpret your thyroid test results. Abnormal thyroid labs don’t necessarily indicate a thyroid problem. Sometimes, other things going on in your body can actually look like thyroid dysfunction. If there’s a deeper issue at play, simply evaluating your thyroid and stopping there could lead to an insufficient diagnosis.
As important as lab tests are, it’s crucial to also make sure you have a qualified licensed practitioner actually feel your thyroid. A physical exam of the thyroid can reveal much about your thyroid health, such as nodules or an enlarged thyroid — which can exist even if your labs have been normal. With that said, sometimes nodules are so small or positioned in a way that even your doctor may not be able to feel them either. If your provider suspects abnormalities they will likely order imaging such as ultrasound.
The Pill And Your Thyroid
It’s important to note that the pill's role in elevating TBG, Sex Hormone Binding Globulin (SHBG) & Cortisol Binding Globulin (CBG) is well recognized. In fact, it is how researchers can verify who is & isn't actually taking the pill in clinical trials.
It's also listed in prescriber handbooks as a change we expect to see in labs. When TBG goes up, total thyroid hormone levels go up and free thyroid levels can go down.
Now, if you thought that total thyroid hormone was what the body utilized & that is all you measured then you might think, “thyroid function is improved on birth control.” However, FREE thyroid hormone is what you use, and not bound thyroid hormone (TOTAL).
This is why I test thyroid hormones in my patients before they start the pill and we continue to monitor symptoms & labs to ensure it is working best for them. Yes, some of my patients decide to use the pill for birth control or other reasons and I support them in doing that.
From the research, it appears progesterone, progestin, & topical estrogen do NOT elevate TBG. It is oral estrogen that influences the increase in binding proteins.
If you want a deep dive into the Birth Control-Thyroid Connection, then you can read all about it in this article.
How Can I Get My Hormone Levels Checked?
In my naturopathic medical practice, we use serum or urinary testing depending on what is being ordered, insurance, and accessibility.
If you need direct access to blood work or a Dutch panel, you can visit Your Lab Work to order labs.
Many hormone tests can be done via blood and some are best tested this way.
The following hormones are can be done via blood:
- Thyroid testing
DUTCH Hormone Testing
The DUTCH Test® (Dried Urine Test for Comprehensive Hormones) from Precision Analytical Inc. is a revolutionary model of hormone testing using four simple, dried urine collections in 24 hours to give a comprehensive assessment of sex and adrenal hormones and their metabolites. It also includes daily, free cortisol pattern, organic acids, melatonin (6-OHMS), and 8-OHdG.
You can order this test for yourself online, but it’s important to have a licensed healthcare professional interpret your results for you. Precision Analytical can provide you with a list of practitioners in your area who regularly use their testing and know how to read results to create a custom treatment plan for your unique situation. When you are testing insulin, adrenals, brain, and thyroid, your doctor can order these labs for you.
Advocate for Testing
If you’re getting resistance from a doctor who’s unwilling to order labs or is gaslighting you (telling you it’s all in your head), seek out another doctor. I know it is daunting to have to resort to doing even more work to get to the bottom of your issues, but it’s the framework we have to operate within for now.
You can also explore ordering lab testing for yourself.
If you’re looking for how you can support your hormone imbalances (no matter what they are!) from the comfort of home, I would encourage checking out my free hormone starter kit. It’s full of in-depth educational material and even includes a killer recipe guide and meal plan. You can download it for free here.
Westhoff CL, Petrie KA, Cremers S. Using changes in binding globulins to assess oral contraceptive compliance. Contraception. 2013;87(2):176‐181. doi:10.1016/j.contraception.2012.06.003
KEEPING IT REAL, WHILE KEEPING YOU EDUCATED
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