Ashley Lyles
June 16, 2023
EDITORIAL COLLABORATIN
MEDSCAPE&
A proliferation of at-home tests are available to check thyroid function, and other hormones, offering patients the comfort of testing these levels remotely. This availability is expected to grow to a $4.79 billion market by 2030, according to Research and Markets analysis.
The growing demand can be attributed partly to a rise in comfort with testing at home due to the COVID-19 pandemic, which increased people’s confidence in remote healthcare.
But are these tests reliable? And should people be taking them at home?
Medscape asked Hershel Raff, PhD, professor of medicine, physiology, and surgery at the Medical College of Wisconsin, Milwaukee, and Mihail Zilbermint, MD, MBA, chief of endocrinology, diabetes, and metabolism at Suburban Hospital, Johns Hopkins Medicine, Bethesda, Maryland, for their opinions on these tests, based on their backgrounds in research and clinical practice, respectively.
“I really believe that if it’s done for the right reasons by educated people who are not just out to make a profit — I hate to say that, but — if it is really in the best interest of the patient, they can be wonderful,” said Raff when asked about the reliability of these tests.
However, it’s important that patients work with their healthcare providers to ensure the appropriate use and interpretation of the results, noted Raff, has developed salivary cortisol tests with at-home sampling.
What are the most common reasons for patients taking at-home tests? Are they bringing the results to their visits?
Zilbermint: Personally, I do not encourage my patients to use those at-home hormonal tests, but more and more they are ordering them online. Just recently one of my patients told me she ordered a hormonal test online. She was wondering if I could interpret [the results]. I think this is how it should be. I’m glad that the patient wanted me to interpret the test, but ultimately, I have to be very careful to know why she even ordered it.
Although I’ve never asked my patients why they are getting them, I’ll speculate. Obviously, those companies have done a great job at advertising them. You type “at-home hormonal test kits” [into a search engine and] there are dozens, if not hundreds, of companies that offer them. I think people are having a hard time finding endocrinologists. There are only 5000 endocrinologists in the United States, and obviously there aren’t enough to see these patients or reliably evaluate … hormone tests, so patients are [saying], “I’m just going to test it. It’s not too much money. It’s about $100 to $200. I’m going to test it and figure out what is going on.”
There are some hormonal test kits that have been around for a long time, such as ovulation prediction kits. The test uses a urine sample to measure luteinizing hormone levels. It can predict ovulation, when women can more easily become pregnant.
What are the main reasons you see for patients using these tests?
Raff: I’m not a clinician; I’m a lab guy. Doctors send me the results often and ask me to explain them.
I’ve had many doctors send me the adrenal stress indexes and adrenal fatigue indexes, and I’m very skeptical of those. The assays are probably fine, but … the interpretation is dubious, so it’s like any blood test. I had a great mentor who said, “Don’t order a test if you don’t know what to do with the results, because if you order enough tests, something is always going to be abnormal.”
What are some of the pros and cons of these tests?
Zilbermint: Convenience is the biggest pro. Some companies, for example, aim [their tests] at treating hyperthyroid, a very common hormonal problem. People just have to prick their fingers [rather than] go to the lab to have their blood drawn, which can sometimes be painful. They send the test kit back through the mail. The results will [be sent] in a few days and … can be seen by a physician and a patient at the same time. So the convenience factor is such that the patient can mail everything in and jump on a quick televisit to discuss the results.
The challenge is that they are not very reliable. Some of the hormones fluctuate very little, but some can fluctuate a lot— for example, testosterone in males. If you measure it in the morning, you are going to get a more reliable [result] compared to measuring in the afternoon or in the evening. There are certain standards, so obviously, when I talk to my colleagues and see students and fellows and residents, I tell them to make sure that these patients know to make sure this hormone kit is made by a Clinical Laboratory Improvement Amendments (CLIA)–certified lab.
CLIA checks laboratories to ensure that they are delivering quality results. Whatever the results coming back, it’s not just “jump and interpret the results as high, low, or normal.” As physicians, we [need to ask ourselves] why we would even get this test in the first place. What is the history? Before we even start testing hormone levels, [the patient] needs to have symptoms. Does this patient have fatigue, weight gain, or leg swelling? These are the symptoms of hyperthyroidism, and then you check the hormone levels.
It’s okay for the patient to bring the results, and I tell everyone, “Do not dismiss your patients,” but it is important that physicians are the ones that interpret those results.
Are the tests accurate? Do they provide appropriate information for patients?
Raff: That’s an interesting question because there are two answers. One is that if it is done under the guidance of a bona fide doctor — in this case, an endocrinologist — and the patient is taught how to do it properly, and it is being ordered for the right reason, then it is great. If it’s done because you see it in some magazine that says, “Assess your stress levels. Send us 142 samples” — I’m exaggerating; it’s usually 10 or 20 — “and we will figure out what’s wrong with you” without ever seeing the patient or talking to the patient, that becomes very suspect.
Zilbermint: It depends on the test. Let’s start with some very commonly used and basic tests, like hormonal pregnancy tests. Many people use pregnancy tests at home [which measure human chorionic gonadotropin (HCG) hormone]. If positive, then odds are you are probably pregnant, so [this is] super-helpful. Even if you get one positive result, you probably want to double-check with a more certified lab.
It is more challenging to see that some people are googling their conditions, like, “I’m tired, I’m fatigued, I’m gaining weight, [therefore] I must have hypothyroidism. I talked to my neighbor; it’s probably thyroid, so I am going to go and get a kit.” Is this a good thing?
I think it is also important to note that even though a test is CLIA-certified, it doesn’t mean the test results are accurate. There are multiple ways of testing different hormones … but how will a patient [know this]? As a consumer, you would never know the exact methodology behind the test.
How and when should these results guide clinical practice?
Zilbermint: I would use this test not to diagnose the problem but to provide follow-up. Let’s say someone is diagnosed with hypothyroidism with a blood test in a doctor’s office. You start a female patient on a thyroid replacement therapy. As a physician, we know the thyroid medicine, but sometimes it takes months or even a year to titrate to the appropriate dose the patient needs. Do you always need to come do the bloodwork in person? Probably not. If you already have a diagnosis and you want to titrate to the appropriate dose, then I think it’s a reasonable idea to use those [at-home] kits to help titrate the dose of your medication.
What advice do you have for other clinicians who may encounter this with their patients?
Zilbermint: One is, listen to the patient. Physicians should not be ignorant of these tests because they are widely available online, and some of them are even covered by flexible spending accounts. Physicians should be extremely cautious of certain assays looking for so-called adrenal fatigue. You must educate yourself about what’s available in the market. I did some extra research myself today by looking up what is available.
I realized, when I dove deeper, for the male hormone testing [for example], the total testosterone is not measured in the outpatient setting a lot; we would also have to take additional measurements.
If things don’t sound right in the hormone testing, I would advise the patient to go to a specific lab and test the results before assigning a big diagnosis. I would like to always confirm it with a CLIA-certified lab, which is reputable.
Ashley Lyles is an award-winning medical journalist. She is a graduate of New York University’s Science, Health, and Environmental Reporting Program. Previously, she studied professional writing at Michigan State University, where she also took premedical classes. Her work has taken her to Honduras, Cambodia, France, and Ghana and has appeared in outlets like The New York Times Daily 360, PBS NewsHour, The Huffington Post, Undark, The Root, Psychology Today, Insider, and Tonic (Health by Vice), among other publications.
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