DUTCH Test Review: Is It Worth It? An Honest Doctor's Guide

What is the DUTCH test?

The DUTCH test is a home test typically ordered by functional and integrative practitioners to test your sex hormones, your stress hormones, your sleep hormones and their metabolites in one test. It is often read alongside your wider clinical picture, your lifestyle and your wellbeing goals, to add context to your symptoms.

The rationale for this test is that hormones such as cortisol and testosterone rise and fall across the day, and female hormones change across your menstrual cycle.^{1, 2} Therefore this method, compared to a blood test taken on a single day, can help better reflect that and create a better understanding of the pattern of symptoms you may be experiencing.

However, at $499, this test is definitely not cheap, especially in some countries.³ You can go to the public system and get a lot of tests done for free under a gynaecologist, urologist, endocrinologist, or local GP.

It is a test that conventional doctors rarely order, because it is not recommended in current medical guidelines.^4–6

Therefore, the most important question for a person who truly wants to get better may be: is the DUTCH test a test that can genuinely help make a long-term difference to their health, is it just an expensive scam to exploit vulnerable patients, or is it somewhere in the middle?

This article is my honest answer to that question.

My genuine interest is that I hope the reader, amongst various other sources of information, can make a more informed decision, take charge of their health, and return to themselves.

What does the DUTCH test measure?

Depending on the panel, the DUTCH test is said to measure roughly 35 markers that fall into a number of categories:⁷

• your sex hormones
• your stress hormone, cortisol
• your sleep hormone, melatonin
• their metabolites: the breakdown products of these hormones once they have done their job
• some of their precursors: the chemicals they are built from

This whole picture is therefore claimed to provide additional information on your hormone levels, on how the hormones are working in your body, and how they are being processed and cleared.

The hormones

• Oestrogen: the three main types are oestrone (E1), oestradiol (E2) and oestriol (E3). Oestradiol is the most biologically active and is involved in reproductive health, mood regulation and bone density.^8–10
• Progesterone: measured through its metabolites (the pregnanediols),^{11, 12} helps to regulate the menstrual cycle and maintains pregnancy.^13–15
• Testosterone and other androgens: including DHT, a more potent testosterone metabolite. It is often thought of as a male hormone, but women need it too, for muscle mass, energy and libido.
• DHEA-S: both a hormone and a precursor. The adrenal glands produce it, and the body converts it into oestrogen and testosterone.
• Cortisol and cortisone: free cortisol (the active form) is measured at four to five points across the day, alongside cortisone, the less active form, and metabolised cortisol, which reflects total output.^{1, 16}
• Creatinine: a byproduct of muscle breakdown, not a hormone.
• Melatonin: measured through one of its metabolites (6-OH-melatonin-sulfate), relevant to how you fall asleep, stay asleep, and wake.¹⁷

The metabolites

This is where the DUTCH test differs from most standard testing, because blood tests tell you how much of a hormone is circulating at one moment. The DUTCH test is said to also show how your body is processing and clearing it.

Functional medicine and integrative doctors would typically argue that this is where the explanation for symptoms lives. A clear example they may use is oestrogen. They would argue that it does not leave the body one way: it is funnelled down three competing pathways (2-hydroxyestrone, 4-hydroxyestrone and 16-hydroxyestrone), and the report measures the metabolites from each.^{12, 18} They would argue that which pathway dominates, and how well your body caps off the intermediates, is information a standard blood test cannot give you.

I will come back to much of this rationale in the sections about sex hormones, HRT and fertility and cortisol.

The organic acids

Depending on the panel, the DUTCH test also includes a small set of organic acid markers, byproducts of metabolism that are claimed to hint at nutrient and metabolic patterns.^{7, 19} I have written more information on the organic acid test, which measures many more of these markers on its own.

How is the DUTCH test done?

The DUTCH test is done by peeing onto small filter paper strips, or collecting your urine in a clean cup and dipping the strip. This is done at set times across the day. The strips are then allowed to dry fully, sealed into a labelled pouch, and posted back in a prepaid envelope to the laboratory.^{7, 20} You do not need to visit a clinic, so this can all be done at home. Your kit will have detailed instructions, which are the definitive guide.²⁰ Everything below is a typical pattern, so you can understand what you are signing up for.

Before you collect

This applies to the DUTCH Complete and DUTCH Plus. Cycle Mapping is a different story, and the kit instructions are the guide.

If you are a menstruating female with regular cycles, the aim is to collect in the mid-luteal phase, roughly a week after ovulation, when progesterone is at its peak.¹³ In a 28-day cycle, that is around days 19 to 22.^{20, 21} In a 30-day cycle, around days 21 to 24.²¹ In a 26-day cycle, around days 17 to 20.²¹ If you are postmenopausal or a man, any day will do.^{20, 21} If your cycles are irregular or you are perimenopausal, follow the kit’s timing guidance.²⁰

Things to consider stopping before the test

• Melatonin supplements: if a baseline is wanted, stop 2 to 3 days before, because the test measures melatonin metabolites, so supplements can interfere with interpretation.¹⁷
• Prescription medicines: discuss with your practitioner before stopping anything.
• Alcohol for 24 hours before and on collection days, and caffeine beyond one cup (about 240 ml), as this can affect hydration, and any markers that may be affected as a result.^{20, 22}
• Total fluids: drink no more than about 1.2 litres on collection days, and nothing in the 2 hours before a collection, to prevent very dilute urine that can shift the result.^{20, 22}
• Foods such as bananas and fava beans for 48 hours before, as they are rich in amines, which your body converts into neurotransmitter metabolites.²² The current kit also lists creatine supplements.^{20, 22}
• An unusually stressful day: not easy to avoid, but it can affect cortisol levels. It may not be an adequate reflection of your baseline.

The collection day

Four or five samples, at roughly these points across 24 hours:^{7, 20}

• Dinnertime
• Bedtime
• Overnight, only if you wake to urinate
• Within 10 minutes of waking
• 2 hours after waking

After this has been sent to the laboratory, you will receive a thick, colour-coded report of dozens of markers. This is where you can work with a practitioner who understands your context and wider picture, and discuss together whether there is anything worth acting on. If so, why? If so, how?

Which DUTCH test should you choose?

There are three main versions:

1. DUTCH Complete: the flagship, containing roughly 35 markers across the three panels above.^{7, 23}
2. DUTCH Plus: the DUTCH Complete plus a cortisol awakening response. This means a series of saliva samples, on waking and 30 and 60 minutes after waking, to take further measurements of cortisol.^{22, 24, 25} It may typically be considered in fatigue (especially on waking), insomnia, chronic fatigue, depression or anxiety on waking, and a high-stress lifestyle.²⁴
3. DUTCH Cycle Mapping: samples taken across the menstrual cycle to map how hormones rise and fall throughout the whole cycle.²⁶ Typically considered for perimenopause, PCOS and infertility.

The three versions at a glance

What does the DUTCH test claim to show?

The DUTCH test claims to show the following, depending on the panel:^{7, 24, 26}

• Diurnal cortisol rhythm across the day

• Cortisol awakening response, if Plus

• Sex hormone patterns across the cycle, if Cycle Mapping

• Oestrogen metabolite ratios: 2-OH, 4-OH, 16-OH

• Cortisol-to-cortisone and androgen 5α-to-5β ratios

• Melatonin metabolite and selected organic acids

Whilst this test may potentially seem like an obvious choice, the biggest question may still remain: how likely is it to explain what is going on with you? How likely is it to help improve treatment? What is that treatment likely to be? And is that treatment something that aligns with your values and budget? Hopefully, the rest of this article can help answer those questions.

What can the DUTCH test genuinely add?

The benefits of this test are that you do not have to go into a clinic: you can do it at home. It can measure hormones across a full day or your full menstrual cycle, as opposed to a snapshot in time via blood tests. And it can help create a wider picture of the levels of your sex hormones, adrenal hormones and organic acids, as well as how your body is processing and clearing them. These can all be read together, in the context of your wider clinical picture.

Convenience and access: Having worked myself in both the public and private conventional medical setting, I have seen how patients who were seen faster in the private setting, could be treated before the consequences of their condition got worse. Therefore, being able to do this test at home and see all of these results in one go can potentially provide additional value to any other tests you may have been ordered separately by your GP, your endocrinologist, your gynaecologist or your andrologist. You can see these results at the same time, ideally assisted by a practitioner who understands how all of these interact, as opposed to seeing each of them separately, at different times.

A rhythm, not a snapshot: Measuring four or five samples of urine over 24 hours, or multiple samples across your entire menstrual cycle, does make sense. We do a 24-hour ECG and urine collection in conventional medicine for example when indicated, to get a more comprehensive picture of what is happening in the body. This test applies the same logic to hormones.^{11, 19}

Metabolites as a hypothesis, not a diagnosis: Functional medicine and integrative practitioners will typically use terms such as adrenal dysfunction, oestrogen dominance and impaired hormone metabolism, based on metabolite patterns, to identify what they describe as the root cause. I think a better way of thinking about it is that this tool can be used to generate a hypothesis, based on how your body is processing and clearing hormones. For example, pathways such as the relatively protective 2-OH pathway vs the more proliferative 16-OH route, as well as ratios such as cortisol to cortisone, androgen 5α to 5β, and oestrogen metabolites can be read in the context of how each person metabolises hormones uniquely.^{18, 27}

Hormones in context: Reading results such as your cortisol, your DHEA and your sex hormones: these all affect each other. Whilst they can provide an explanation for a person struggling with fatigue or burnout, mood swings and low energy, it is best understood as helping to understand the wider picture, as opposed to a diagnosis. The wider picture, in the context of other factors: your environment, nervous system, Ayurvedic and Chinese medicine diagnosis as well as your mind-body-spirit-energy system (from my perspective).

Monitoring treatment, with cost caveats: Just like in conventional care, you could use the test as a baseline and then retest at a certain point later, combined with your clinical presentation and how you feel,²⁸ to get objective feedback on whether certain interventions are working, and to help tailor conversations about further management if needed.²⁹ What needs to be taken into consideration here is the further cost that comes with further testing, treatment and practitioner appointments. This is a decision that should be made by yourself first and foremost, and with any practitioner you choose to work with.

What are the limitations and evidence gaps?

1. The chemistry vs the interpretation. Whilst measuring metabolites in dried urine using LC-MS/MS is well established,^{30, 31} and the cortisol daily rhythm and basic sex hormone metabolites seem well supported,^{1, 11, 19, 32} the interpretive framework, and what should follow from it, is where the evidence becomes variable. Using it to guide HRT dosing, or to make decisions from a particular oestrogen metabolite ratio, we simply do not yet have evidence that decisions based on these urine measurements improve outcomes.^{5, 6, 33}
2. Founder-led studies and lack of RCTs: All published validation studies on the DUTCH test have been led by its founder, Mark Newman, and his company.^{1, 11, 19, 29} It has not been cleared by the FDA,^{5, 34, 35} and there are no large randomised controlled trials validating its use in the way medicine normally demands. Some gynaecological societies advise against urine or saliva hormone tests to guide hormone dosing, and it does not appear in clinical practice guidelines, most likely for many of these reasons.^4–6 It simply does not have the decades of long-term research behind it that many traditional tests have.
3. Guidelines and regulatory status: It should not be used as a substitute for conventional care. Not to diagnose medical conditions such as Cushing’s syndrome, Addison’s disease or PCOS, which require conventional investigation, such as the ACTH stimulation test for Addison’s disease.^36–38 Not to predict breast cancer risk, which uses conventional pathways such as family history and genetic testing, with breast screening where indicated.³⁹ Not to guide HRT decisions, which are based on symptoms, age, menopausal status, risk profile and clinical judgement.^{4, 6} And it cannot diagnose adrenal fatigue, which is not a recognised medical diagnosis.^{40, 41} It is intended to provide a wider clinical picture, and patients should genuinely understand its purpose before spending anything.
4. Cost, variables and reliability: It is expensive, and typically will not be covered by insurance or any government pathway.²³ The at-home collection needs to be done properly, as day-to-day variables such as diet, hydration, medications, supplements and collection technique can change the result.²⁰
5. Timeframe: a day or cycle vs weeks, months and years: Compared to a single blood draw, four or five samples across the day, to me, seems like a genuine improvement. But most people’s question is not what has been happening to me yesterday or today. The question is what has been going on in my body over the last few weeks, months and years. If a stressful day can change the cortisol pattern, or if a number of foods can change the organic acid markers, how accurate and reliable is this test to truly add additional information?
6. Overinterpretation: treating numbers instead of the person: Imagine someone with years of stored trauma, poor sleep and exhaustion. They spend thousands on tests and supplements when the simpler, deeper solution was nervous system and stress work. The test should add context to the person’s story, not replace it.
7. The Practitioner Factor: They need a genuine understanding of the biochemistry in depth, of the methods and limitations of this test, and of the extent to which the results are most likely contributing to this patient. Whether it is important to add something, change something, or do nothing. That comes from the practitioner and their genuine determination and curiosity to understand all sides of this argument.

What the DUTCH studies tested

Why the evidence gap exists

I think innovation is definitely needed to drive the medical profession forward. Pharmaceutical companies have very large budgets to fund the randomised controlled trials needed to determine the efficacy of medications, but is the same level of funding used to trial supplements, protocols and clinical judgement? Whilst it is understandable that evidence is needed, it is also worth understanding the value of interpretation and rationale from the practitioner, and whether a randomised controlled trial is even the best research method to determine the efficacy of a treatment, considering the level of personalisation that would truly be required to enable healing.

Blood vs saliva vs dried urine: which is best?

There is no single best test. Each test can be the best one to order in certain situations, depending on the question you want answered:

• Blood tells you what is circulating at that moment.
• Saliva tells you what is unbound and available at that moment, for some hormones, such as cortisol.^{37, 42}
• Dried urine tells you what your body did with its hormones across the day.^{11, 19}

These are different answers to different questions, and they can be used together.⁴³ It does make sense that they could provide a more complete picture of what may be going on.

Blood is often the right tool for acute problems, and to diagnose specific conditions such as premature menopause or testosterone deficiency.^{2, 4} It is what most guidelines are built on. It is standardised, inexpensive, and can often be done free through government healthcare systems.

Saliva can be done at home. It measures the free form of some hormones, and is used in certain medical guidelines, for example to screen for Cushing’s syndrome,³⁷ and has been studied in relation to coronary calcification.⁴⁴ Food and oral hygiene may affect the sample,²² and it may not capture every hormone reliably.⁴² Some practitioners who use it to dose topical testosterone may end up underdosing patients.⁴⁵

Dried urine is the one that shows you both the hormones and what your body is doing with them.

The right test depends on the patient’s situation. Factors such as significant kidney impairment, pregnancy, being on HRT or the contraceptive pill, or certain medications should all be taken into account, as well as cost, when deciding whether the patient needs one of these methods or multiple, to get a wider picture.^{12, 46}

Cortisol and stress: where DUTCH may add context

With stress, burnout and lifestyle overwhelm now so common, I do think cortisol dysfunction is heavily underrecognised in conventional medicine. It can mimic and magnify symptoms such as fatigue, sleep disruption, anxiety and weight gain whilst going undetected in the conventional setting. Heart disease, one of the world’s biggest killers, can be associated with a flattened stress rhythm.^{44, 47, 48} The HPA axis, from my perspective, can be completely dysregulated as a result of stress. Conventional medicine can test the reserve of the HPA axis, through an insulin tolerance test, though that is impractical for routine use.⁴⁹

The most important question here is: what would be the solution? I think the biggest value of this test is reassurance to a patient that it is not all in their head, which, I do not underestimate at all, can be hugely relieving, especially after years of being palmed off.

However, I would take it one step further. I would argue that a lot of the patients that come to me already know they are stressed. I just listen to them and I can see what has caused certain issues. I can feel their pulse from a traditional Ayurvedic and Chinese medicine perspective to see what meridians are blocked. I listen to their story, which may stem from early life, to see where stress may have accumulated in their body, understanding this from an Ayurvedic and Chinese medicine diagnostic framework combined with modern science.

The truth is, I do not need a test to believe what a patient is saying to me. The solution from a functional medicine doctor, from my perspective, might be:

• cut down on coffee
• reduce stress
• spend time in nature
• take some herbs and supplements

I am not against any of this. If anything, I use it. I advise a lot of it myself. But I do not need this test result to advise them.

To me, the solution is far deeper, as explained in my method. I think sometimes the genuine solution comes down to restoring your ability to truly react to stress, so you can react in a way you once may have been able to, and removing the stressor where practical. I have often got involved with speaking to the sources of the stressors myself, and I have seen powerful clinical results in the patient in front of me when I have done so. I do not need any of these test results to resolve the root cause in these instances. I think these are far more powerful methods of resolving underlying stress than any supplement, or cutting down on coffee, can provide.

However, I do understand the powerful benefit a patient can receive from seeing objective markers before and after a treatment intervention. I am probably shooting myself in the foot here when I say this, because testing this, from my perspective, would strengthen the validation of my own method. I would rather not spend the patient’s money to prove something to myself, and to others.

Sex hormones, HRT and fertility: what I would personally want to know

As a doctor trained in conventional medicine, I myself have not taken a single medication or undergone any surgery for over 20 years, for as long as the choice has been my own. Therefore I think what follows should be taken into account with this in mind.

Whilst I am aware of various conventional medical guidelines and recommendations, if it were my own body, I would be very cautious before taking treatment such as the oral contraceptive pill, testosterone replacement therapy, hormone replacement therapy, or IVF. I would personally be very cautious about starting female hormone replacement due to concerns such as breast cancer,^50–52 stroke,^51–53 blood clots^{51, 53, 54} and dementia,^{51, 55, 56} even knowing these risks vary with the type of hormone and how it is taken,^{6, 51, 54, 57} testosterone replacement due to concerns such as cardiovascular complications,^{58, 59} including atrial fibrillation and pulmonary embolism,⁶⁰ even though the largest trial found no rise in heart attacks or strokes,^{60, 61} and IVF due to long term concerns both secondary to excessive ovarian stimulation and to my own child.^62–65

Therefore, if it were my own body, I would want to make an as informed choice as possible.

Irrespective of what guidelines say, if it were my own body, and I were to take any of the above, I would personally want as much information as possible, specifically because of my concerns about the risks of taking all of this. I know the evidence for using these results this way is still at the research stage, so this is my personal preference, and I would weigh it alongside the conventional evidence.⁵ I would want to measure things like:

• the diurnal pattern of free cortisol, to see how my stress axis is behaving, knowing it has been linked to heart health^{44, 47}
• DHEA, to see how my stress hormones and androgens are balanced
• my melatonin, knowing that stress and cortisol can suppress it¹⁷
• signs of oestrogen dominance which could explain some symptoms
• my oestrogen metabolite pattern, if I were about to start oestrogen, as one more piece of information while the evidence develops^{18, 27, 33}

I would do the above in addition to following any recommended conventional care tests and measures. I would do my best to understand why functional or integrative medical practitioners may sometimes take a differing and/or complementary stance to conventional specialists and medical societies. I would also become more informed of the alternative solutions they may provide to conventional care such as gut healing programmes, detoxification protocols, progesterone creams, supplements, repeat testing and further appointments. And I may compare this to more ancient forms of healing such as Ayurveda and Traditional Chinese Medicine to see their more natural solutions to the same issues. I would then make a decision on which approach, or combination of approaches, I would wish to apply to my own body.

After understanding all of this, I would try to meet with a specialist who is genuinely, truly informed on all of this, who can match, at the very least, the research I have done by myself and ideally help me make a more informed decision on top of that. I may end up seeing multiple specialists, which may include an andrologist, a gynaecologist, a functional medicine doctor or an integrative medicine doctor, or ideally one who I truly trust, depending on the competence of such a practitioner in my country and their availability.

I would scrutinise their approach. Are they geared towards following conventional guidelines? Are they likely to prescribe a protocol of never-ending supplements, diets and compounded hormones, with repeated testing under the guise of monitoring? What is their commercial incentive? What would most likely be the options they recommend to help me? I would be cautious about their incentive to help me, and I would tend to follow my own intuition during this process.

Is the DUTCH test worth it? My verdict

Whilst most medical bodies and medical specialists may not advise this test, especially for diagnosis and to guide medical treatment, based on the information above I do believe the chemistry underlying this test is valid.

And currently if a patient would prefer to take replacement hormones or IVF, I would refer down the relevant pathways. However, patients rarely see me for this.

For these reasons, I do not use it routinely, nor do I currently advise it as a first-line test. But I would consider it in specific contexts. What would change my mind?

1. If I were to ever start prescribing replacement hormones for patients to help obtain a wider picture of what may be happening at a biochemical level and guide better as part of a holistic treatment plan.
2. If the patient made an informed decision that the likely benefits of having this test outweigh the cost for a more comprehensive understanding of their hormonal levels in addition to conventional pathways.
3. If more reliable data were to be released, ideally from third parties, in relation to the efficacy of treatment based on DUTCH testing and its components.

After this, however, from my perspective, the gold standard of scientific inquiry going forward may have to include rigorous n = 1 trials alongside larger trials, to help move personalised medicine forward.⁶⁶

Who I would consider it for, and who I wouldn’t

My primary goal is to create the best results for patients.

That being said, if I were going through any of the following myself, I would consider this test if:

• I were perimenopausal, menopausal or postmenopausal, to explore hormone patterns alongside menopausal care.
• I had multi-system symptoms which standard labs did not explain.
• I had chronic stress, sleep issues and fatigue.
• I had done blood work and still wanted answers.
• I had cyclical or mid-cycle symptoms.
• I was about to start the pill, HRT or testosterone and wanted a fuller picture before deciding.

I would not consider the DUTCH test if:

• I purely wanted a medical diagnosis.
• I was undergoing an acute medical crisis.
• I had significant kidney impairment.⁴⁶
• I was pregnant or breastfeeding.
• I was a child or adolescent.
• I thought I might have a hormone-producing tumour.
• I was looking for a diagnosis of adrenal fatigue.^{40, 41}
• I knew I had a significant likelihood of severe health anxiety as a result of what this test might show, which could make underlying health anxiety significantly worse.
• I wanted to start HRT, testosterone, DHEA or the contraceptive pill based purely on one test.
• I wanted to stop conventional medical treatment based purely on one test.
• I wanted to launch an extensive supplement regimen based purely on one test.
• I wanted to blindly follow the advice of a conventional, functional or integrative medicine specialist, without doing my diligent research first.
• I was on a tight budget, where the same money may be better spent on treatment and intervention.

What I would do if I were in your position