The Salivary Hormone Profile in the Clinical Evaluation of Women

Women presenting to primary care physicians may have symptoms consistent with hormonal dysfunction or diagnoses exacerbated by hormonal factors. In my experience, salivary hormone analysis allows accurate and readily accessible evaluation of a woman’s hormonal status. Salivary measurement of hormones has been performed in clinical research for over 30 years, including studies conducted at the National Institutes of Health (NIH), and it has remained a mainstay in clinical research studies. The hormones most extensively investigated1-4 include: estradiol, estrone, cstriol, progesterone, dehydroepiandrosterone (DHEA), testosterone and cortisol. Saliva tests of sex and steroid hormones have moved into the clinical practice arena in the United States within the last decade;5-7 however, although the validity and application of the tests are well supported and Medicare and private insurers offer reimbursement for such testing, they arc not in wide use in the primary care of women. In this article, I present some general background regarding the diagnosis and treatment of hormonally related symptoms and disadvantages and advantages of both saliva and serum testing and discuss other factors for consideration, guidelines for testing and interpretation and clinical application.

Background

Estrogens, progesterone, testosterone, DHEA and cortisol play a vital role in many aspects of a woman’s physiology and quality of life, including body composition, libido, sexual satisfaction, mood, cognition, vasomotor symptoms, sense of well-being, bone density, sleep quality and musculoskelctal pain. However, primary care physicians are often challenged in their clinical evaluation of womens’ hormonal changes. Patients may report constitutional symptoms self-attributed to hormonal changes that significantly impact their quality of life; yet conventional diagnostic testing of metabolic and endocrine status may show them to be in the normal range. Though physicians may suspect sex steroid and steroid influences as contributing to the patient’s symptoms, they may be unable to quantify such associations objectively and accurately through traditional testing methods.

Conditions secondary to hormone elevations or decreases in bioavailability of hormones include:

* Female sexual dysfunction

* Lutcal phase insufficiency

* Perimenopause

* Polycystic ovarian syndrome

* Postmenopausc

* Premenstrual dysphoric disorder

* Premenstrual syndrome6

Other diagnoses that may be impacted by sex steroid hormone changes in women include:

* Asthma

* Chronic pain syndrome

* Connective tissue diseases

* Fatigue

* Fibromyalgia

* Hypothyroidism

* Irritable bowel syndrome

* Metabolic syndrome

* Migraine headache

* Mood disorders

* Obesity

* Seizure disorders8-25

Advantages and Disadvantages of Serum and Saliva Testing

Serum Testing

Perhaps the most obvious advantage of serum testing is that, during medical training, physicians are educated regarding serum hormone evaluation. Tables of normal serum values for sex and steroid hormones are published in reference texts and most physicians have reference laboratories readily available. Thus, this testing vehicle is readily accessible and has established standards for evaluating results.

However, serum testing may not accurately predict hormone bioavailability.26 Conventional thinking is consistent with the concept that only free (unbound) hormones are able to exit the capillary and traverse the cell membrane, thereby triggering intracellular changes. Research has revealed that hormones traveling in the blood in free forms, as well as conjugated by the attachment of a sulphate, glutathione or glucuronide (to enhance water solubility); hormones bound to albumin; sex-hormone binding globulins (SHBGs); and hormones carried by red blood cells (RBCs), all form reservoirs that are available to the tissue (Figure 1). A process known as facilitated dissociation allows protein-bound hormone to be available to tissues, including some that are bound to SHBG.15 Studies27-31 reveal that RBCs with bound hormone serve as a significant circulation reservoir of sex hormone, making up as much as 5% to 35% of total exchange hormones in the bloodstream.

Figure 1. Reservoirs That Are Formed and Available to Tissue as a Result of Hormones Traveling in the Blood.

Most serum tests define the normal range of hormones very broadly, which is a distinct disadvantage to their use, especially for women with levels in the low analyte ranges. After the patient’s blood is drawn, only a portion of the blood sample, called the serum, is used for measuring hormone levels. Most methods only measure a “free” or “total” hormone level or a calculated combination of both, and values have been shown to be inconsistent, especially at the lower ranges of normal. This type of testing is not an accurate reflection of the bioavailable hormone (ie, the amount of hormone that is active in organs and tissues).31-37

Saliva Testing

Salivary hormone analysis is a useful clinical tool in the assessment of women, and scientific evidence supports its use because it offers an accurate and comprehensive reflection of hormone bioavailability at the tissue level.5 Reference values for salivary hormone levels have been established for women. Salivary hormone levels reflect the delivery of hormone to tissue from all mechanisms-free, protein-bound, red blood cell-bound and conjugated.

One advantage to salivary hormone testing is that it is easy, as well as more convenient for the patient. Tn evaluations of biurnal and diurnal cortisol levels secondary to patient circadian rhythms or luteal-phase hormonal changes, physicians and patients are often frustrated in their attempts to have phlebotomy performed at precise times of the day or the menstrual cycle. In contrast, saliva can be easily obtained at desired times without disrupting laboratory schedules for phlebotomy stations. Furthermore, since saliva collection is typically performed at home or in the workplace, there is high patient compliance. For women who work in an occupational setting, followed by 24 to 40 hours per week of tasks related to childcare, cldercare, household duties, community and/or volunteer work, being required to go to a laboratory 1 to 4 times during a day or at specific phases of her menstrual cycle may well be impractical and inconvenient.

Studies15,34,35 also reveal that some patients are significantly stressed when undergoing phlebotomy, and changes induced by venipuncture stress can significantly affect serum values. Thus, the serum value may not be an accurate measure of the patient’s usual endogenous hormone level. In contrast, saliva testing has not been shown to cause a stress response in patients.

Some physicians have criticized salivary testing for inaccuracy in measuring hormone levels after transdermal hormone replacement therapy (HRT), since there is a discrepancy in serum and salivary hormone levels immediately after dosing. Salivary levels are much higher than serum levels following topical administration of hormones. This phenomenon is explained by the important role of crythrocytes in steroid hormone transport. Some studies33,36,38 demonstrate that, when progesterone is delivered topically, serum testing of steroid hormones may not accurately reflect tissue bioavailability. Saliva-testing laboratories with technical expertise have established expected ranges for oral and transdermal dosing. When sex hormones are delivered topically, saliva provides a more accurate hormone activity at the tissue levels.

Another advantage of salivary testing is cost. The cost of salivary hormone analysis is markedly less than that of serum testing. For example, a single hormone test for salivary estradiol averages less than one-fourth the cost of a single serum level. Considering that patients usually undergo evaluation of more than one hormone, such cost differences can be pronounced.39

However, salivary testing does have some disadvantages. First, College of American Pathologists (CAP) and American Association of Bioanalysts (AAB) proficiency standards have not been established specifically for salivary testing. Laboratories that offer such testing may be Clinical Laboratory Improvement Amendments (CLTA)- certified; however, this is based on serum testing procedures. In addition, salivary hormone assays are technically challenging, which limits the number of laboratories capable of offering this assay. Furthermore, contamination of saliva samples may occur during sample collection, resulting in falsely elevated hormone levels. This may occur through the patient’s use of topical substances (eg, facial scrums, lipsticks) on the face, lips or hands, and care must be taken to ensure that the patient follows test collection instructions to avoid such contamination. The patient must also avoid eating, drinking, chewing gum, flossing and brushing teeth 2 hours prior to saliva collection, as these activities may affect hormone levels. Finally, the route of administration (oral, sublingual, topical, vaginal) of hormone supplementation must be considered prior to saliva sample collection for laboratory application of appropriate reference ranges.

Table 1. Physical Symptoms and Associated Health Risks of Hormone Imbalance in Women.

Other Factors for Consideration

Follicle-Stimulating Hormone Testing

The fo\llicle-stimulating hormone (FSH) test is often used as the primary indicator of a woman’s hormonal status. A properly conducted FSH test requires that blood be drawn three times at sixty-minute intervals beginning precisely at 8:00 AM.40 Follicle-stimulating hormone reference ranges are based on the average of the three levels in a properly performed test, Follicle-stimulating hormone directs the maturation of ovarian follicles and the release of cstrogen. It also prepares the uterus for the changes that occur during the first half of the menstrual cycle. The FSH test is frequently used to determine the hormonal status of premenopausal patients who may complain of hot flashes, mood ranges, or other symptoms identified in Table 1. It may be concluded that a patient’s symptoms are not related to hormones because her FSH test is normal. The FSH test should not be used as an accurate measure of sex hormone production or an indication of reproductive status for most women because the level of FSH fluctuates widely during the decade preceding menopause.41 Follicle-stimulating hormone is a clinical marker for inhibin, which is secreted by ovarian follicles; and a decrease in inhibin levels begins around age 35 and accelerates after age 40 due to follicle damage, atresia and senescence. Follicle-stimulating hormone should not be used as a measure of endogenous sex hormone production or reproductive status because women may experience ovulation with normal follicle release between the age of 40 and menopause.

Patient History

The patient’s history is critical in determining both the selection of hormones for testing and the time of testing. The physician may ask the patient to complete a questionnaire or may elicit information by questioning the patient. Numerous studies and books37,42-44 have documented the psychoendocrinc sequelae along with physical symptoms related to hormonal factors (Table 1). An example of the importance of history taking would be the case of a patient who reports moderate-to-severe palpitations and abdominal bloating that interfere with her quality of life, with onset 7 to 10 days prior to menses and the absence of such symptoms in other phases of her menstrual cycle. This patient should be tested for estradiol, progesterone and testosterone in the lutcal phase when her symptoms occur.45 Another patient might report daily fatigue with consistent onset at midday, followed by some lifting of fatigue in the evenings, coupled with nocturnal-associated anxiety contributing to sleep disturbance. Appropriate testing in this patient would include cortisol salivary collection on awakening, at noon, in the afternoon and in the evening, along with sex steroid levels. Another typical example is a woman in her 40s who has had a hysterectomy and bilateral salpingo oophorectomy and reports chronic constitutional symptoms of fatigue, low libido, cognitive changes, centripetal weight gain, body aches and decreased stamina. Salivary hormone analysis in this patient should include measurement of estradiol, estriol, estrone, DHEA, testosterone, progesterone and diurnal cortisol.46-49 Assessment of the hypothalamic pituitary adrenal axis via salivary testing is helpful in the evaluation and treatment of patients with mood disorders.50-55

Physical Exam

Women with symptoms possibly related to hormonal changes should also undergo a physical exam, including a breast exam and genital exam. Examples of physical findings related to hormonal changes are listed in Table 2.

Guidelines for Testing

For primary care physicians who desire to integrate saliva testing into their clinical setting, collaboration with a laboratory that has proficiency and expertise in this area is necessary. Although CAP and AAB have not established proficiency standards for salivary testing, CLIA certification may be helpful as a starting point. The laboratory can furnish the physician with saliva test kits, which include patient instructions and mailing supplies that meet current postal standards for shipping. Laboratories with medical directors and knowledgeable staff in this discipline should be available to consult with the ordering physician.

Interpretation and Clinical Application

A CLIA-certified laboratory with technical expertise in salivary hormonal assays will provide a hormone evaluation report that will serve as a guide for understanding how hormones can affect a patient’s health and well-being. An example of such a report can be accessed on the International Journal of Pharmaceutical Compounding’s website. Physicians may wish to consult with testing laboratory consultants in the initial phases ot interpretation. During a follow-up appointment, the patient should he educated by the physician regarding laboratory findings. The visit should include a discussion of nutrition, exercise, lifestyle issues and pharmacotherapy. Patients are usually highly satisfied with this individualized approach, and such satisfaction contributes to patient motivation and spousal and family support for lifestyle changes, exercise and nutritional modifications.

Table 2. Physical Findings in Women with Hormonal Imbalance.

Findings56 of the Women’s Health Initiative have caused patients and physicians to proceed with caution in the use of HRT in postmenopausal women. However, despite findings that HRT may increase the risk of heart disease, stroke, venous thrombosis and breast cancer, many women with severe mcnopausal symptoms have chosen to continue HRT due to quality-of-life issues. Physicians may use the salivary assay as a quantitative measurement of hormone changes in prescribing effective treatment strategies, rather than guessing about hormone doses or relying on serum testing results, which may conflict with patient-reported symptoms. Such patients and their physicians may appreciate salivary hormone assays for evaluating the effects of exogenous hormones to achieve a goal of normal physiological levels and to more closely mimic an endogenous state, rather than creating or exacerbating hormonal imbalances.

Occasionally, spurious results occur, as the salivary hormone test is a highly sensitive assay. In such a case, the physician should question the patient regarding compliance with instructions and might also wish to discuss the results with the medical director of the testing lab. Clinical correlation is mandatory, as there is variability in each patient’s hormone receptor affinity, sensitivity and pharmacokinetics that cannot be measured in the clinical practice setting; however, the majority of patient symptoms closely correlate with the salivary profile. In my experience in working with thousands of hormonal assays on women, salivary hormone testing has enhanced diagnostic and therapeutic decision making.

Summary

The adaptability of the salivary hormone assay to the clinical evaluation of women can be beneficial to primary care physicians in diagnosing and treating conditions secondary to hormonal excess or deficiency or conditions exacerbated by such hormonal changes. In comparison with scrum testing, the saliva test offers significant advantages and can be easily integrated into the primary care setting. Furthermore, patient acceptance, compliance and satisfaction are high and may result m increased compliance with physician-recommended regimens for nutrition, exercise, lifestyle changes and pharmacotherapy.

References

1. Dabbs JM. Salivary testosterone measurements: Collecting, storing, and mailing saliva samples. Physiol Behav 1991; 49(4): 815- 817.

2. Dabbs JM. Salivary testosterone measurements: Reliability across hours, days, and weeks Physiol Behav 1990; 48(1): 83-86.

3. Dabbs JM, Campbell BC, Gladue BA et al. Reliability of salivary testosterone measurements: A multicenter evaluation. Clin Chem 1995; 41(11): 1581-1584.

4. Petsos P, Ratcliffe WA, Heath PF et al. Comparison of blood spot, salivary and serum progesterone assays in the normal menstrual cycle. Clin Endocrinol (Oxf) 1986; 24(1): 31-38.

5. Riad-Fahmy D, Read GF, Walker RF. Salivary steroid assay for assessing variation in endocrine activity. J Steroid Biochem 1983; 19(1A): 265-272.

6. Read GF, Walker RF, Wilson DW et al. Steroid analysis in saliva for the assessment of endocrine function. Ann NY Acad Sci 1990; 595: 260-274.

7. Lipson SF, Ellison PT. Development of protocols for the application of salivary steroid analyses to field conditions. Am J Human Biol 1989; 1: 249-255.

8. Finn MM, Gosling JP, Talion DF et al. The frequency of salivary progesterone sampling and the diagnosis of luteal phase insufficiency. Gynecol Endocrinol 1992; 6(2): 127-134.

9. Lu Y, Bentley GR, Gann PH et al. Salivary estradiol and progesterone levels in conception and nonconception cycles in women: Evaluation of a new assay for salivary estradiol. Fertil Steril 1999; 71(5): 863-868.

10. Lu YC, Chatterton RT, Vogelsong KM et al. Direct radioimmunoassay of progesterone in saliva. J Immunoassay 1997; 18(2): 149-163.

11. Sumiala S, Tuominen J, Huhtaniemi I et al. Salivary progesterone concentrations after tubal sterilization. Obstet Gynecol 1996; 88(5): 792-796.

12. Campbell BC, Ellison PT. Menstrual variation in salivary testosterone among regularly cycling women. Horm Res 1992; 37(4-5): 132-136.

13. Harris B, Lovett L, Newcombe RG et al. Maternity blues and major endocrine changes: Cardiff Puerperal Mood and Hormone Study II. BMJ 1994; 308(6934): 949-953.

14. Heim C, Ehlert U, Hanker JP et al. Abuse-related posttraumatic stress disorder and alterations of the hypothalamic- pituitary-ad renal axis in women with chronic pelvic pain. Psychosom Med 1998; 60(3): 309-318.

15. Lo MS, Ng ML, Azmy BS et al. Clinical applications of salivary cortisol measurements. Singapore Med J 1992; 33(2): 170.

16. Pruessner JC, Hellhammer DH, Kirschbaum C. Burnout, perceived stress, and cortisol responses to a wakening. Psychosom Med 1999; 61(2): 197-204.

17. Stones A, Groome D, Perry D e\t al. The effect of stress on salivary cortisol in panic disorder patients. J Affect Disorders 1999; 52(1-3): 197-201.

18. Vedhara K, Hyde J, Gilchrist ID et al. Acute stress, memory, attention and cortisol. Psychoneuroendocrinology 2000; 25(6): 535- 549.

19. Scott LV, Salahuddin F, Cooney J et al. Differences in adrenal steroid profile in chronic fatigue syndrome, in depression and in health. J Affect Disord 1999; 54(1-2): 129-137.

20. Unger J, Cady R, Farmer-Cady K. Migraine headaches, part 3: Hormonal factors. The Female Patient 2003; 28(7): 31-34.

21. Vliet E. An approach to perimenopausal migraine. Menopause Management 1995; 4(6): 25-33.

22. Beynon HL, Garbett ND, Barnes PJ. Severe premenstrual exacerbations of asthma: Effect of intramuscular progesterone. Lancet 1988; 2(8607): 370-372.

23. Backstrom T. Epileptic seizures in women related to plasma estrogen and progesterone during the menstrual cycle. Acta Neurol Scand 1976; 54(4): 321-347.

24. Herzog AG. Intermittent progesterone therapy and frequency of complex partial seizures in women with menstrual disorders. Neurology 1986; 36(12): 1607-1610.

25. Stomati M, Monteleone P, Casaros E et al. Six-month oral dehydroepiandrosterone supplementation in early and late postmenopause. Gynecol Endocrinol 2000; 14(5): 342-363.

26. Vining RF, McGinley RA, Symons RG. Norm ones in saliva: Mode of entry and consequent implications for clinical interpretation. Clin Chem 1983; 29(10): 1752-1756.

27. Koefoed P, Brahm J. The permeability of the human red cell membrane to steroid sex hormones. Biochim Biophys Acta 1994; 1195(1): 55-62.

28. Hiramatsu R, Nisula BC. Uptake of erythrocyte-associated component of blood testosterone and corticosterone to rat brain. J Steroid Biochem Mol Biol 1991; 38(3): 383-387.

29. Sannikka E, Terho P, Suominen J et al. Testosterone concentrations in human seminal plasma and saliva and its correlation with nonprotein-bound and total testosterone levels in serum. Int J Androl 1983; 6(4): 319-330.

30. McCracken JA, Schramm W, Einer-Jensen W. The structure of steroids and their diffusion through blood vessel walls in a counter- current system. Steroids 1984; 43(3): 293-303.

31. Krzymowski T, Katwica J, Stefanczyk S et.al. Steroid transferfrom the ovarian vein to the ovarian artery in the sow. J Reprod Fertil 1982; 65(2): 451-456.

32. Rosner W. Measurement of and rogens: Methods and pitfalls. In: Androgens in Women: Physiology, Deficiency, and Emerging Therapeutic Potentials. Chevy Chase, MD: The Endocrine Society Continuing Medical Education Services; 2000.

33. Devenuto F, Ligon DF, Friedrichsen DH et al. Human erythrocyte membrane. Uptake of progesterone and chemical alterations. Biochim Biophys Acta 1969; 193(1): 36-47.

34. Swinkels LM, Ross HA, Smals AG et al. Concentrations of total and free dehydroepiandrosterone in plasma and dehydroepiandrosterone in saliva of normal and hirsute women under basal conditions and during administration of dexamethasone/synthetic corticotropin. Clin Chem 1990; 36(12): 2042-2046.

35. Vining RF, McGinley R, Maksvytis JJ et al. Salivary cortisol: A better measure of adrenal cortical function than serum cortisol. Ann Clin Biochem 1983; 20(Pt. 6): 329-335.

36. Levine H, Watson N. Comparison of the pharmacokinetics of crinone 8% administered vaginally versus Prometrium administered orally in post-menopausal women. Pert Steril 2000; 73(3): 516-521.

37. Lee JR. Natural Progesterone: The Multiple Roles of a Remarkable Hormone. Sebastopela, CA: BLL Publishing; 1993.

38. Miles RA, Paulson RJ, Lobo RA et al. Pharmacokinetics and endometrial tissue levels of progesterone after administration by intramuscular and vaginal routes: A comparative study. Fertil Steril 1994; 62(3): 485-490.

39. Pricing comparison of saliva versus blood serum hormone testing [internal document]. Portland, OR: ZRT Laboratory; 2003.

40. Bakerman S. Bakerman’s ABC’s of Interpretive Laboratory Data. 4th ed. Bakerman P, Strausbauch P, eds. Scottsdale, AZ: Interpretive Laboratory Data, Inc.; 2002: 251-252.

41. Berg G, Hammar M, eds. The Modern Management of the Menopause: A Perspective for the 21st Century. New York, NY: Parthenon Publishing Group; 1994: 103-109.

42. Lee JR, Zava DT, Hopkins V. What Your Doctor May Not Tell You About Breast Cancer: How Hormone Balance Can Help Save Your Life. New York, NY: Warner Books; 2002.

43. Gillson G, Marsden T. You’ve Hit Menopause, Now What?: 3 Simple Steps to Restoring Hormone Balance. Calgary, Alberta, Canada; RMA Publishing; 2003.

44. Vliet E. Screaming To Be Heard: Hormonal Connections Women Suspect and Doctors Ignore. New York, NY: M. Evans and Company; 1995.

45. Rodriguez I, Kilborn MJ, Liu XX et al. Drug-induced QT prolongation in women during the menstrual cycle. JAMA 2001; 285:1322-1326.

46. Ehrenreich H, Halaris A, Ruether E et al. Psychoendocrine sequelae of chronic testosterone deficiency. J Psychiatr Res 1999; 33(5): 379-387.

47. Apperloo MJ, Van Der Stege JG, Hoek A et al. In the mood for sex: The value of androgens. J Sex Marital Ther2003; 29(2): 87-102.

48. Jensen MD. Androgen effect on body composition and fat metabolism. Mayo Clin Proc 2000; 75(Suppl): S65-S68.

49. Sowers MF, Beebe JL, McConnell D et al. Testosterone concentrations in women aged 25-50 years: Associations with lifestyle, body composition, and ovarian status. Am J Epidemiol 2001; 153:256-264.

50. Kirschbaum C, Hellhammer DH. Salivary cortisol in psychoneuroendocrine research: Recent developments and applications. Psychoneuroendocrinology 1994; 19(4): 313-333.

51. Almeida OP. Sex playing with the mind. Effects of oestrogen and testosterone on mood and cognition. Arch Neuropsiqiatr 1999; 57(3A): 701-706.

52. Fink G, Sumner BE, McQueen JK et al. Sex steroid control of mood, mental state and memory. Clin Exp Pharmacol Physiol 1998; 25(10): 764-775.

53. Weber B, Lewicka S, Deuschle M et al. Testosterone, androstenidione and dihydrotestosterone concentrations are elevated in female patients with major depression. Psychoneuroendocrinology 2000; 25(8): 765-771.

54. Davis SR, Tran J. Testosterone influences libido and well being in women. Trends Endocrinol Metab 2001; 2(1): 33-37.

55. Rohr UD. The impact of testosterone imbalance on depression and women’s health. Maturitas 2002;41(Suppl): S25-S46.

56. The Writing Group forthe Women’s Health Initiative. Risks and Benefits of estrogen plus progestin in healthy postmenopausal women. JAMA 2002; 288: 321-333.

57. Kendall J, Loriaux DL. Disorders of the adrenal cortex. In: Internal Medicine. 4th ed. St. Louis, MO: Mosby-Year Book; 1994.

58. Selye H. The Stress of Life. Revised ed. New York, NY: McGraw Hill; 1976.

59. de Bruin VM, Vieira MC, Rocha MN et al. Cortisol and dehydroepiandrosterone sulfate plasma levels and their relationship to aging, cognitive function, and dementia. Brain Cogn 2002; 50(2): 316-323.

60. Vgontzas AN, Zoumakis M, Bixler EO et al. Impaired nighttime sleep in healthy old versus young adults is associated with elevated plasma interleukin-6 and cortisol levels: Physiologic and therapeutic implications. J Clin Endocrinol Metab 2003; 88(5): 2087- 2095.

61. Turner-Cobb JM, Sephton SE, Koopman C et al. Social support and salivary cortisol in women with metastatic breast cancer. Psychosom Med 2000; 62(3): 337-345.

62. Sephton SE, Sapolsky RM, Kraemer HC et al. Diurnal cortisol rhythm as a predictor of breast cancer survival. J Natl Cancer Inst 2000; 92(12): 994-1000.

63. Elenkov IJ. Systemic stress-induced Th2 shift and its clinical implications. Int Rev Neurobiol 2002;52: 163-186.

64. Elenkov IJ, Webster EL, Torpy DJ et al. Stress, corticotrophin-releasing hormone, glucocorticoids, and the immune/ inflammatory response: Acute and chronic effects. Ann N Y Acad Sci 1999; 876: 1-13.

65. Elenkov IJ, Chrousos GP. Stress, cytokine patterns and susceptibility to disease. Baillieres Best Practices Clin Endocrinol Metab 1999; 13(4): 583-595.

66. Kunz-Ebrecht SR, Mohamed-Ali V, Feldman PJ et al. Cortisol responses to mild psychological stress are inversely associated with proinflammatory cytokines. Brain Behav Immun 2003; 17(5): 373-383.

67. Black PH. The inflammatory response is an integral part of the stress response: Implications for atherosclerosis, insulin resistance, type II diabetes and metabolic syndrome X. Brain Behav Immun 2003; 17(5): 350-364.

68. Sephton S, Spiegel D. Circadian disruption in cancer: A neuroendocrine-immune pathway from stress to disease? Brain Behav Immun 2003; 17(5): 321-328.

69. Black PH, Garbutt LD. Stress, inflammation and cardiovascular disease. J Psychosom Res 2002; 52(1): 1-23.

70. Huang Z, Willett WC, Colditz GA et al. Waist circumference, waist:hip ratio, and risk of breast cancer in the Nurses’ Health Study. Am J Epidemol 1999; 150(12): 1316-1324.

71. Formby B, Wi ley TS. Progesterone inhibits growth andinducesapoptosis in breast cancer cells: Inverse effects on Bcl- 2 and p53. Ann Clin Lab Sci 1998; 28(6): 360-369.

72. Mohr PE, Wang DY, Gregory WM et al. Serum progesterone and prognosis in operable breast cancer. Br J Cancer 1996; 73(12): 1552- 1555.

73. Nagata C, Shimizu H, Takami P et al. Relations of insulin resistance and serum concentrations of estradiol and sex hormone- binding globulin to potential breast cancer risk factors. Jpn J Cancer Hes 2000; 91(9): 948-953.

74. Liehr JG, Ricci MJ, Jefcoate CR et al. 4-Hydroxylation of estradiol by human uterine myometrium and myoma microsomes: Implications for the mechanism of uterine tumorigenesis. Proc Natl A cad Sci U S A 1995; 92(201:9220-9224.

75. Dalton K. The Premenstrual Syndrome and Progesterone Therapy. 2nd ed. Chicago, IL: Year Book Medical Publisher; 1984.

76. Nelson HD, Humphrey LL, Nygren P et al. Postmenopausal hormone replacementtherapy: Scientific review. JAMA 2002; 288(7): 872-881.

77. Zeleniuch-Jacquotte A, Bruning PF, Bonfrer JM et al. Relation of serum levels of testosterone and dehydroepiandrosterone sulfate to risk of breast cancer in postme\nopausal women. Am J Epidemiol 1997; 145(11): 1030-1038.

78. Bachmann G, Bancroft J, Braunstein G et al. Female androgen insufficiency: The Princeton consensus statement on definition, classification, and assessment. Fertil Steril 2002; 77(4): 660-665.

79. Notelovitz M. Hot flashes and androgens: A biological rationale for clinical practice. Mayo Clin Proc 2004; 79(4 Suppl): S8-S13.

80. Moller J, Einfeldt H. Testosterone Treatment of Cardiovascular Diseases. Berlin: Springer Verlag; 1984.

Kenna Stephenson, MD, FAAFP

Women’s Wellness Center

University of Texas Health Center

Tyler, Texas; and Northcentral University

Prescott, Arizona

Address correspondence to: Kenna Stephenson, MD, FAAFP, 11937 US Highway 271 North, Tyler, TX 75708. E-mail: kenna.stephenson@uthct.edu

Copyright International Journal of Pharmaceutical Compounding Nov/ Dec 2004