“Dr. Brett Wisniewski practices a model of diagnostics, natural therapeutics, and true patient partnership. He believes medicine should move beyond symptom suppression and instead focus on understanding the physiology driving the complaint. One of the first question to answer in any condition is, “What shifted in the body to create this pattern?” His work centers on identifying upstream contributors metabolic stress, immune dysregulation, hormonal imbalance, environmental load, and nervous system dysfunction, and developing personalized strategies that restore function and build long-term resilience.”
After nearly 15years teaching doctors and witnessing the amazing growth and interest we have seen in what is now called Functional Medicine, there are a number of things that stand out that really bug me. For one, all of the “fads”- the hydrogen water, the methyl folate cures, methylene blue, cold plunging, expensive salt and the list goes on. Now this is not to say these do not have merit and given the right scenario some can be wildly helpful, but I am afraid our industry has sold out to influencers and the ‘pill for every ill’ mentality. Patients were always at the center of functional medicine and the money would follow. Now everyone wants to be famous or write a book that gets them on the podcast circuit. I don’t know, maybe I’m ‘old school’, maybe its jealousy either way, we have to be vigilant as we comb through all the noise.
Before I say anything else: this article is not a knock on the testing methodology behind DUTCH. We use plenty of tests from Precision Analytical, the company behind the DUTCH panel, in our own clinic, and I have no complaints about the lab work itself. Honestly, you could swap in almost any reputable lab offering urinary hormone metabolite testing and this whole conversation would still apply. DUTCH just happens to be the one that became a household name in functional medicine circles, and frankly, hats off to them for that. Building a brand that patients recognize is no small feat.
That said, we have to talk, and I suspect a few of my colleagues aren’t going to love me for it.
Every week, a new patient walks into my office clutching a stack of paperwork claiming they have run ‘all’ the tests and have just had their hormones tested. In fact, I am often questioned in a slightly judgmental tone, “have you ever heard of the DUTCH test?”. And in more cases than I’d like to admit, their previous provider has already changed their hormone dose based on that test alone.
Here’s the actual problem: that’s not really what the test is for.
Dried urine testing has real, validated uses. What I’m tired of is watching it get used as if it’s a substitute for knowing where your hormones stand right now. It isn’t. And a lot of practitioners either don’t know that or don’t want to slow down long enough to explain it to you. So let’s slow down.
What DUTCH Actually Measures (And Why That’s Different From What Your Doctor Thinks)
DUTCH stands for Dried Urine Test for Comprehensive Hormones, and the name is actually a honest description of what it does. You collect urine on filter paper at several points across the day, it dries, and a lab runs it through mass spectrometry to measure not just estrogen, progesterone, and testosterone, but their metabolites, the broken-down byproducts your liver produces after it’s already processed those hormones and prepared them for the exit.
Let’s translate the word metabolite in this context: a metabolite is what’s left of a hormone after your body has already used it, modified it, and marked it for disposal. Measuring metabolites tells you about hormone metabolism, the pathway a hormone traveled and how efficiently your body broke it down and cleared it. It does not tell you how much active, available hormone is circulating in your bloodstream and reaching your tissues at this exact moment. Those are two entirely different questions, answered by two entirely different biological processes, and conflating them is where the trouble starts.
Blood testing measures circulating hormone, what’s available to bind receptors and do a job right now. Saliva testing, when done well, estimates the free, unbound fraction of hormone that’s biologically active at the tissue level. DUTCH testing measures what your liver already processed and is on its way out the door. If you want to know whether your current estrogen dose is too high, too low, or just right, the metabolite panel is not the tool that answers that question. The blood draw or saliva test likely is (ask you trusted doctor what test is right for your situation). Adjusting a patient’s transdermal estradiol dose based on a urinary metabolite pattern is a little like deciding how much gas to put in your tank by looking at the exhaust. There’s information in the exhaust. It’s just not the information you need to answer, “how full is the tank.”
There are published papers on dose-response studies on this exact question. Their research on transdermal estradiol gel and patch therapy found that urinary estrogen output rises in a dose-dependent way as the topical dose increases. That’s a real finding, and it’s not surprising, put more hormone into the system, and eventually more metabolite comes out the other end. That’s mass balance. What that dose-response relationship does not establish is whether the hormone reached and saturated receptors at the tissue level along the way because urine, by definition, only captures hormone after the liver has already pulled it out of circulation and marked it for disposal. Total output going up tells you more hormone entered the system. It doesn’t tell you how much of it was bioavailable to your breast, uterine, bone, or brain tissue in the meantime. That’s still a question for saliva or the free/bioavailable fraction of serum, not for the metabolite panel.
Circulating Hormones vs. Bioavailable Hormones — They’re Not the Same Number
Before we go any further, we need to draw a distinction that most patients have never been taught, because it changes everything downstream: “how much hormone is in your blood” and “how much hormone your tissues can actually use” are two different numbers, and the gap between them can be huge.
Here’s why. Most steroid hormones, testosterone, estradiol and progesterone travel through your bloodstream mostly hitched to a transport protein. For testosterone, that’s largely sex hormone-binding globulin, or SHBG, with a smaller amount loosely riding on another protein, albumin. Only a small sliver, typically less than 3% for testosterone, floats around unbound or “free”. That unbound fraction, plus the loosely-albumin-bound portion that can detach easily, is what we call bioavailable: the hormone that’s free to leave the bloodstream, enter a cell, and do something. Total testosterone tells you the size of the whole shipment or your savings account. Free and bioavailable testosterone tell you how much of that shipment is getting delivered to the door.
This matters enormously in practice. Two patients can have identical total testosterone and wildly different symptoms, because one of them has high SHBG locking most of it away.
Saliva testing occupies an interesting niche here. Because saliva largely reflects the unbound, bioavailable fraction of steroid hormones diffusing out of capillaries, it can be a reasonable proxy for free hormone status, when collection is done correctly, with attention to contamination sources (vigorous tooth-brushing before collection can spike readings from gum bleeding, and certain collection swab materials cross-react with steroid assays). It is not, however, a reliable stand-in for total circulating hormone, and its real value shows up somewhere very specific, which I’ll get to below. You can also assess hormones in the blood and I would ask your doctor for “free/unbound” fractions to go along with the “total” hormones they customarily run.
Where Does the Hormone in Your Urine Actually Come From?
This is the piece that ties the whole article together but there is a bit of biochemistry here.
Your steroid hormones, estradiol, testosterone, progesterone, cortisol, don’t just circulate indefinitely and then vanish. Once they’ve done their job, or even before they get the chance to, your liver goes to work on them through two sequential steps generally referred to as Phase I and Phase II metabolism. Phase I, run largely by cytochrome P450 enzymes, chemically modifies the hormone, this is the hydroxylation step that produces the 2-OH, 4-OH, and 16-OH estrogen metabolites I mentioned earlier. Phase II then takes that modified molecule and attaches something to it — a sulfate group, a glucuronide, a methyl group, to make it water-soluble enough to actually leave the body. Fat-soluble steroid hormones can’t just be flushed out as-is; they have to be chemically repackaged into something your kidneys can filter and your urine can carry away.
That repackaging step is why liver and kidney function matter so much when you’re trying to interpret a urinary hormone panel, and why this is where DUTCH-style testing (or other urinary hormone metabolite testing) runs into trouble for a lot of patients. If your liver’s Phase I or Phase II conjugation pathways are sluggish — from genetic variation in enzymes, nutrient deficiencies that starve those pathways of methyl donors or glucuronic acid, or simple hepatic congestion, hormone metabolites can back up, shift toward alternate pathways, or simply take longer to appear in urine at all. And if kidney function is reduced, the filtration and excretion step itself slows down, regardless of how well the liver did its job upstream. In either case, what shows up in a 24-hour or 4-spot urine collection isn’t a clean readout of hormone production anymore, it’s a readout of hormone production filtered through however well your liver and kidneys happen to be functioning that week.
Compare that to a blood draw, which measures the hormone directly, upstream of any of that hepatic or renal processing. A serum estradiol level isn’t affected by whether your detox enzymes are running slow. A urinary estradiol metabolite level absolutely can be. This is a big part of why I don’t love urinary metabolite testing as a stand-alone readout of hormone status in patients with any degree of liver dysfunction, chronic kidney disease, or even just significant gut and detoxification burden, you’re no longer measuring one variable, you’re measuring two variables tangled together, and the test can’t tell you which one moved.
