You are scrolling Instagram at 10 p.m. because you cannot sleep. Again. You see another ad for a $500 DUTCH test. The caption says it will "finally reveal what your hormones are really doing." You screenshot it. The next morning, you bring it to your doctor. She glances at your phone and says, "That is not necessary. We can just do blood work."

So you get blood work. A week later, the portal message says "normal." But you do not feel normal. You are still waking up at 2 a.m. Still exhausted. Still wondering if you are losing your mind.

So you call a friend who swears by her functional medicine doctor. That provider says, "Saliva testing is way more accurate than serum. It shows what is actually bioavailable."

Now you are sitting at home with three different opinions, a growing credit card balance from supplements that are not working, and zero clarity about which test will actually tell you what is happening in your body.

Listen. This is not your fault. This confusion exists because no one is explaining to you that these tests are measuring different things. Blood, saliva, and dried urine are not interchangeable. They answer different questions. And the question that matters is: which one tells me what I actually need to know?

Let me walk you through it.

WHAT EACH TEST ACTUALLY MEASURES

Before we talk about which test is "best," you need to understand what each one is looking at. Because the whole controversy exists because people are comparing apples to oranges and acting like they are the same thing.

Blood Testing: Total Hormones, Bound Plus Free

When you get blood drawn for hormones, the lab measures everything circulating in your bloodstream. Bound hormones and free hormones together.​

Here is the part that matters. About 95 to 99 percent of your steroid hormones are stuck to carrier proteins, mostly something called sex hormone-binding globulin, or SHBG. That bound fraction is not doing anything. It is just sitting there, attached to a protein, waiting to be released.​

The free hormones, the ones actually getting into your cells and doing work, make up maybe 1 to 5 percent of what shows up on your serum test.​

So when your doctor says your estradiol is "normal" based on blood work, they are telling you the total is normal. They are not telling you how much of that estradiol is free and available versus how much is locked up and useless.

If your SHBG is high, which happens with stress, oral estrogen, thyroid issues, and just aging, your total estradiol can look fine while your free estradiol is tanking.​

You follow what I'm saying? The test is not wrong. But it is not telling you the whole story.

Blood testing is useful. I use it all the time. It gives me thyroid markers, FSH and LH, metabolic health, a solid baseline. If your doctor orders serum, that is fine.​

But if your serum comes back normal and you still feel terrible, that does not mean you are imagining things. It might mean we are looking at the wrong piece of the puzzle.

Saliva Testing: Free Hormones, The Ones Your Body Actually Sees

Saliva measures the hormones that are not bound to proteins. The free fraction. The hormones that are actually getting to your brain, your bones, your sleep regulation centers.​

This matters when SHBG is high.

Let me give you an example. Your serum estradiol is 80 pg/mL. Looks normal. But your SHBG is elevated because you are on oral birth control, or your thyroid is overactive, or you are under chronic stress. Most of your estradiol is bound. Your free estradiol might be 1 pg/mL.

Serum says you are fine. Saliva says you are starving for estrogen at the tissue level. And your symptoms, the brain fog, the hot flashes, the sleepless nights, they line up with saliva, not serum.

Saliva also gives me cortisol curves. You collect samples at home. When you wake up. Thirty minutes later. Noon. Before bed. That four-point curve tells me if your stress response is functioning or if it has flatlined, which is critical when I am trying to figure out why you cannot sleep.​

For women on topical hormones, creams or gels, saliva may better reflect what is actually being absorbed because those hormones are entering through the skin, not being processed through the liver first.​

Saliva testing is not "alternative medicine." It is physiology. Free hormones matter. And if your doctor dismisses saliva without even checking your SHBG to see if it is an issue, they are guessing just as much as anyone else.

Dried Urine: Hormone Metabolites and Breakdown Pathways

DUTCH testing measures how your body breaks down hormones. Estrogen metabolites, progesterone metabolites, androgen pathways, cortisol patterns.​

This can be useful when I need to see if you are metabolizing estrogen down inflammatory pathways or if your body is favoring androgen pathways that drive hair loss or acne.​

Research shows dried urine is comparable to serum for measuring estradiol and progesterone, and the four-collection method gives you a daily snapshot without needing a 24-hour urine jug.​

But here is the problem. DUTCH tests are expensive, usually $400 to $600. They are almost never covered by insurance. And interpretation is not as standardized as serum, which means you need a provider who actually knows how to read the results and apply them clinically, not just hand you a colorful report and sell you supplements.​

I use DUTCH. But not on Day 1. I use it when baseline testing raises questions I cannot answer with serum or saliva. When HRT is not working the way it should and I need to see metabolism. When symptoms suggest something is off in how you are processing hormones, not just how much you have.

If someone is selling you a $600 DUTCH test before they have checked your insulin, your thyroid, your inflammation, or your SHBG, pause. Ask why.

WHY THIS CONFUSION EXISTS AND WHO IT HURTS

Here is what makes me furious.

Your conventional doctor says serum is the gold standard. And they are not wrong. Serum has decades of research, standardized ranges, clinical validation. It works.​

Your functional medicine provider says free hormones matter more than total, and if you only look at serum, you miss what is happening at the tissue level. And they are also not wrong. Free hormones drive symptoms.​

So why are they fighting?

Because the research establishment moves slowly. Because insurance does not cover saliva, so mainstream doctors cannot order it without you paying out of pocket. Because a lot of the validation studies for saliva were funded by the labs that sell it, which creates skepticism even when the physiology is sound.​

And because some functional medicine providers oversell advanced testing and skip the basics, which makes conventional doctors dismiss the entire approach.

Meanwhile, you are caught in the middle. Your symptoms are real. Your sleep is wrecked. And two smart providers are telling you opposite things.

That is the part that makes me furious. Not the tests. The fact that no one is explaining to you that both can be true at the same time.

THE SHBG FACTOR: WHY THIS GETS SO CONFUSING

SHBG is the protein that binds to sex hormones in your bloodstream. When SHBG is elevated, more of your hormones are bound up and unavailable. Your total hormone levels on serum can look completely normal, but your free levels, the ones doing the actual work, are low.​

SHBG goes up with oral estrogen, hyperthyroidism, aging, and chronic stress. For women in perimenopause dealing with stress, thyroid dysfunction, or already on oral HRT, SHBG can be a major factor.​

This is why you can have "normal" serum estradiol and still feel terrible. Your total is fine. But your SHBG is high, so your free estradiol is low. Serum does not show you that unless your provider also measures SHBG and calculates free hormone levels, which most do not.​

Saliva sidesteps this because it only measures free hormones.​

So who is right? Both. They are measuring different things, and both pieces of information can be useful depending on what I need to know.

WHAT I ACTUALLY USE IN MY PRACTICE

I am not dogmatic. I use the method that answers the clinical question I am trying to solve.

Here is what that looks like.

I start with a combination of saliva and blood.

• Saliva for cortisol curves and free reproductive hormones if I suspect SHBG is high or you are on topical HRT.​
• Blood or dried blood spot for thyroid markers, metabolic health (insulin, HbA1c, hs-CRP), FSH and LH, and total reproductive hormones for baseline.​

That gives me 80 percent of what I need. Cortisol patterns. Free and total hormones. Thyroid. Metabolic function. I can build a treatment plan from that.

I add DUTCH when:

• You are already on HRT and it is not working, and I need to see if you are metabolizing hormones too fast, too slow, or down problematic pathways.​
• Your symptoms suggest estrogen or androgen metabolism is off and baseline testing does not explain it.​
• We have done everything else and I still have unanswered questions.

DUTCH is not where I start. It is an add-on when I need more detail.

And I never make treatment decisions based on labs alone. I look at your labs, your sleep data, your symptom patterns, your nervous system load, your lived experience. That is how I decide what your body needs.

HOW TO PROTECT YOURSELF FROM DISMISSAL AND OVERPRICED TESTING

If you are trying to figure out which test makes sense, here is my guidance.

If your doctor orders serum and says that is all you need:

Fine. Serum is useful. But if your results come back normal and you still feel terrible, ask about SHBG. Ask if they measured it. Ask if they can calculate free hormone levels.

If they say "saliva is not validated," ask if they have checked your SHBG to see if bound versus free might be an issue. If they dismiss that question, you might need a different provider.

If a functional medicine doctor orders saliva:

Also fine. Saliva measures free hormones and cortisol curves, which are clinically relevant. Just make sure your provider is interpreting the results in context, not just handing you a supplement protocol based on a report.​

If someone leads with a $600 DUTCH test before checking the basics:

Pause. Ask what clinical question they are trying to answer. Ask why baseline testing will not give that information. If they cannot give you a clear answer, that is a red flag.

Start with the basics. Add advanced testing if you need it. Not the other way around.

THE BEST TEST IS THE ONE THAT ANSWERS YOUR QUESTION

There is no single best hormone testing method.

Blood, saliva, and dried urine all measure different things. What matters is whether the test you are using answers the clinical question you are trying to solve.

If I need your cortisol curve, I use saliva. If I need your thyroid or FSH, I use blood. If I need to see estrogen metabolism pathways, I might add DUTCH.​

Most of the time, I use both saliva and blood. That gives me free hormones, total hormones, cortisol patterns, thyroid function, metabolic health. That is enough to get started.

And I never treat labs in isolation. I treat the woman in front of me. Her symptoms. Her sleep. Her stress. Her history. Her nervous system. The labs are information, not the whole story.

You deserve a provider who understands that. Not someone who dismisses saliva because "it is not validated." Not someone who sells you $600 testing before checking your insulin or SHBG. Someone who uses the right tool for the right question and interprets it in the context of your life.

That's all I'm saying.

GET TESTED, THEN LET'S TALK

If you have labs and you are not sure what they mean, or if you want to figure out which testing approach makes sense for you, that is what the 90-Minute Deep Dive Consult is for.

We look at what you have. We decide what else we need. And we build a plan that makes sense for your body.

Book a 60-Minute Clarity Call (TX, CA and OH only)

If you want to understand the five most important biomarkers before we talk, download the 5 Biomarkers Guide. It walks you through what the numbers mean and what optimal actually looks like.

Download the 5 Biomarkers Guide →

And if you are ready to order baseline labs, browse the Lab Shop. I offer panels that give you clinical information without the guesswork. Browse the Lab Shop →

THE BOTTOM LINE

You do not need to pick a side. You need a provider who knows when to use serum, when to use saliva, when to add dried urine, and how to interpret all of it in the context of your whole story.

Blood gives you total hormones, thyroid, metabolic health. Saliva gives you free hormones and cortisol curves. Dried urine gives you metabolite pathways.

All of them can be useful. None of them is the whole answer.

Your body is not a lab result. It is a story. And the best testing strategy is the one that helps me understand that story so I can build a treatment plan that actually works.

That's all I'm saying.

P.S. Still confused about labs? Download the 5 Biomarkers Guide. It breaks down what matters most and what your numbers are actually telling you.

Get the Guide →

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