Overview

Hormones are chemical messengers produced by the human body’s endocrine system. They control important bodily functions.¹ An imbalance of hormones occurs when there is too much or too little production of these hormones, leading to various symptoms.² 

Diagnosing hormonal imbalance involves evaluating symptoms, conducting physical exams, and performing targeted laboratory and imaging tests. This article provides a detailed explanation of how hormonal imbalances are diagnosed.

Understanding hormonal imbalance

People of all ages and genders may experience hormonal imbalance. The main causes of hormonal imbalance include chronic stress, poor diet, environmental toxins, pre-existing medical conditions and certain medications.

Hormones play a significant role in bodily functions. Accurately diagnosing the cause of hormone imbalance is essential for maintaining long-term health.

Diagnosis of hormonal imbalance

Diagnosing hormone imbalance can be complex because clinicians need to consider the involvement of multiple organ systems.³ An endocrinologist (hormone specialist) will take various steps to ensure an accurate diagnosis. These usually involve:

• Taking a patient history
• Physical examination
• Blood tests and scans are used to diagnose and monitor hormone-related conditions

Case history

Taking a case history is the first step in diagnosing a hormonal imbalance. A clinician will ask about current symptoms, duration, and possible family history. Listening to the patient and asking the right questions can give valuable clues, even in early stages where symptoms may not be obvious.³ Thorough history-taking ensures no important details are missed, as one hormonal disorder can increase the risk of others.

Physical examination

A thorough physical examination is the next important step in diagnosing a hormonal imbalance. 

Hormones affect many organ systems, and changes in certain body functions can indicate specific imbalances.

For example, a rounded face, fat around the neck, and purple stretch marks may indicate Cushing’s disease.⁴ Likewise, changes in eye structure might suggest thyroid eye disease⁵ or a pituitary tumour.⁶ For diabetics, foot examination can be done to check for circulation or nerve damage.⁷ In some cases, muscle strength, reflexes, and sensation are checked, as some hormone imbalances cause weakness of the muscular system.⁸

The above two steps help clinicians make an early diagnosis and reassure patients that their problems can be resolved.⁹

Evaluation by laboratory and radiology techniques

The next step in diagnosing hormone imbalance is through laboratory and imaging tests. Laboratory tests like blood, urine, and saliva tests can measure secretions from endocrine glands (organs that make hormones). Imaging tests such as ultrasound and MRI can be used to examine the glands, as most endocrine glands are located deep in the human body and are inaccessible to physical examination.

Blood testing

A blood test is one of the best methods for determining hormone levels. Depending on the suspected medical condition, the clinician can order a series of tests which can measure the hormonal levels in the blood samples. 

The principle behind the blood testing is usually based on Enzyme-Linked Immunosorbent Assay (ELISA), High-Performance Liquid Chromatography(HPLC), Radioimmunoassay (RIA) or Mass Spectrometry (MS) techniques.

Some standard blood tests for hormonal imbalance include:

• Thyroid panel: Consists of thyroid-stimulating hormone (TSH), Free T3, Free T4, to assess thyroid function¹⁰
• Adrenal hormones panel: Cortisol and ACTH (Adrenocorticotropic hormone) are checked for adrenal gland function and to rule out Cushing's or Addison's disease. DHEA (Dehydroepiandrosterone) investigates cases of suspected adrenal fatigue or PCOS (polycystic ovarian syndrome)^11,12
• Sex hormone panel: Oestrogen and Progesterone tests investigate menstrual irregularities, infertility, and menopausal symptoms. Testosterone to check libido, energy, muscle mass, and mood in both men and women^13,14
• Pituitary hormone panel: Luteinizing Hormone (LH) and Follicle Stimulating Hormone (FSH) levels check for fertility issues and menstrual irregularities. Prolactin is used to check for pituitary tumours^15,16
• Pancreatic hormone panel: Insulin and Glucose to check for insulin resistance or diabetes, which is often linked to hormonal disorders like PCOS^17,18

Special sample testing

Usually, standard blood tests are commonly used to diagnose hormonal imbalances. However, they may not always capture a complete understanding of hormonal activity. In such cases, more specific tests are required. These special tests use biological samples like saliva, urine¹⁹, and bone. 

Some of the special samples which can be used to test hormonal imbalance include:

• Saliva: This is a non-invasive way to assess free hormones (hormones not bound to a protein). It can be used to check cortisol, oestradiol, and testosterone levels^19,20,21
• Urine: This test collects samples over time, giving an overall picture of hormonal levels throughout the day. In some cases, a dried urine test (DUTCH test) is used to evaluate variations of adrenal and reproductive hormones^19,22,23
• Bone: Oestrogen, parathyroid hormone (PTH) and cortisol levels determine bone mineral density (BMD) and bone turnover markers. These hormones are actively involved in bone remodelling and density, and can help understand how imbalances affect long-term skeletal health^24,25

The above tests are the standard investigations used to evaluate hormonal imbalances. These tests can also be called static tests, as they only provide information about hormone levels or other markers at a given point in time. 

However, these tests don’t always shed enough light when baseline hormone levels fall within the normal range. In such conditions, dynamic tests can be used to detect hormonal imbalances.

Although they use similar samples, the key difference between static and dynamic testing lies in their testing principle.

Dynamic testing

These tests examine hormonal feedback mechanisms. They check endocrine gland response by either stimulating or suppressing hormone production. These tests help identify if there is a hormonal imbalance in real time. Dynamic tests can help clinicians determine which glands are not working correctly and choose the proper treatment. Types of dynamic testing include:

• Stimulation tests: Used to check suspected hormone deficiencies. For example, the Adrenocorticotropin (ACTH) stimulation tests adrenal gland insufficiency²⁶
• Suppression tests: Used to check suspected hormone overproduction²⁷
  • For example, Dexamethasone suppression test (DST) is used to diagnose Cushing's syndrome

Imaging studies

In some cases, even after the dynamic testing, due to contraindication of the results, the hormonal imbalances need further evaluation. This is where the clinician can consider the Imaging tests. This can be considered as the final step in the diagnosis of hormonal imbalance.²⁸

Imaging studies are based on organ function, structure or both. Clinicians can use both imaging methods alongside other tests to gain a complete picture of gland health.

Functional imaging

In some methods, such as CT and PET scans, small amounts of radioactive tracers are used to check the function of the endocrine gland suspected of causing the hormonal imbalance. These scans help even when structural changes of the glands are not visible.²⁹

The following are the different scenarios where functional imaging scans are performed for diagnosis:

• Thyroid scans use radioactive iodine or technetium to check hyperthyroidism, hypothyroidism, and thyroid tumours
• Adrenal scans use Metaiodobenzylguanidine (MIBG) to check adrenal medulla tumours such as pheochromocytomas and adrenal hyperfunction in Cushing's disease
• Pituitary scans use 18f-fluorodeoxyglucose (18F-FDG), and thallium-201 (201Tl) to check for pituitary tumours and hormone overproduction conditions like prolactinomas

Structural Imaging uses magnetic fields, radio waves, or X-rays to generate high-resolution images of the endocrine glands. These scans can be beneficial in diagnosing hormone imbalances caused by tumours or gland enlargement.³⁰

The following are different examples where structural imaging scans can be used for diagnosis:

• MRI is used to visualise the pituitary gland. It can help detect microadenomas or macroadenomas
• CT scans and MRI are used to identify adrenal gland tumours
• Ultrasound, CT and MRI are used to check goitres and suspected tumours

During investigations, clinicians need to consider that hormone levels are affected by various physiological and external factors. Hormone levels can be influenced by age, assigned sex at birth, time, food, stress levels, and medication. A change from normal hormone levels does not always mean an imbalance. Test results should be interpreted considering the patient’s symptoms and medical history.

Summary 

Hormonal imbalances occur when the endocrine system produces too much or too little hormones, affecting body functions.

Diagnosing imbalances involves individual case history, physical examination, and running laboratory and imaging tests.

Standard tests use blood, urine, saliva, and bone to assess hormone levels, while dynamic tests check how the endocrine glands respond to stimuli. Imaging can detect structural or functional abnormalities in the endocrine system. 

A holistic approach is required for effective diagnosis and treatment, as a single test cannot confirm hormonal imbalance due to various factors.