Imbalanced—Can hormones be balanced? PART 2
This is a continuation of the discussion started in Part 1 of this blog post. If you have not already read that section, please return here and do so before reading this post.
In Part 1, we discussed why the goal of balancing hormones may be an impossible and unnecessary goal and how hormones in the body are measured. Below, in Part 2, we will discuss the perils of hormone testing and Dr. Dinh’s testing philosophy.
What can go wrong when ordering tests?
Anytime a test is ordered, there is a risk of false positive or a false negative.
A false positive occurs when the test is abnormal, but no disease is present exists.
A false negative occurs when the test is normal but the disease is present.
When selecting the correct patient for the correct test, the risk of a false positive or negative must be considered. Additionally, when a practitioner orders numerous tests or a “complete panel” for a patient, the risk of finding a false positive by random chance significantly increases. These false positives lead to unnecessary testing, imaging, referrals, and treatment.
As an example: A full hormone panel is drawn in the afternoon. Their random cortisol is marked low as compared to the reference range, which is intended to be used on a fasting, AM sample. While this patient actually has normal functioning adrenal glands, they are now diagnosed with adrenal insufficiency and started on steroid replacement. This leads a patient’s normal adrenal glands to go ‘to sleep,’ or reduce production, which will have lasting impact on adrenal function once the treatment is stopped. This testing, therefore, led to both inappropriate initiation of medication AND subsequent adrenal insufficiency.
Therefore, as your endocrinologist, I use my history and physical exam to guide the selection of appropriate tests to give the best information to guide diagnosis and treatment. In some cases, we must make multiple measurements to establish a disease process while, in other cases, a single positive value is sensitive and specific to establish a diagnosis.
How is endocrine pathology established?
Endocrinologists are trained to understand the presentation of endocrine pathology and order the correct diagnostic tests. This is where a thorough history and physical exam is necessary to guide selection of the best tests for each patient. As an endocrinologist, I use my training and experience to do this for each patient; no two patients will get the exact same tests for the same reasons. I am dedicated to making the most accurate diagnosis I believe possible as initiation of therapy can be lifelong. At times, I expect to find more than one test abnormal or supportive of the diagnosis before I will initiate treatment as to avoid the risk of starting an unnecessary or even harmful treatment for a patient.
Endocrinology is fascinating, challenging, and dynamic. When the system is not functioning normally, the lack or excess of hormones will impact the health of the body and the quality of life for the patient. True pathology should be treated as optimally as known by clinical evidence and experience. However, true pathology should be carefully defined, identified, and treated.
What will Dr. Dinh not order?
Given my thoughts above, I will not order a comprehensive hormone panel. I will not order testing I do not believe matches the clinical presentation given. I will not order tests just because the patient or another doctor or nurse practitioner is requesting it. I will not order testing that does not inform a diagnosis or treatment decision (i.e. reverse T3--for more on this topic, read this helpful article).
What will Dr. Dinh order?
When evaluating a patient, I do my best to order the most cost-effective and appropriate test to make or rule out a diagnosis and inform treatment changes or decisions. I often have a first set of tests for more ‘common’ pathologies and a second set to evaluate for rare pathologies, such as a pheochromocytoma or monogenic diabetes. The tests for rare diseases are often more expensive, more complex, and less likely to yield a positive result; therefore, I save them for a second evaluation if the first does not provide an explanation.
If you made it to the end of this long bost, congratulations! If you have questions about this, I am happy to discuss my practice philosophy at a visit. If, after reading this, you are not sure I am the right doctor for you, that is okay—reach out if you have questions! If you have concerns that need an endocrine evaluation (read more here), I’d be happy to see you and recommend clinically-appropriate testing. Learn more about becoming a patient on my website.
