Understanding your hormone levels is crucial for maintaining optimal health and well-being. However, choosing the right test method can be confusing, with saliva, blood, and urine all vying for your attention. We delve into the intricacies of each method, analyzing their strengths and limitations to help you make informed choices about your hormonal health.

Understanding Hormone Levels:
Before delving into testing methods, it’s crucial to understand what we’re measuring. Hormones are chemical messengers that regulate various bodily functions, including metabolism, reproduction, stress response, and mood. They exist in two states: bound to carrier proteins in the blood and free, readily available for cellular uptake and action.

The Saliva Advantage:
Saliva testing directly measures free hormone levels found in the tissues and cells. This is particularly advantageous because free hormones are the ones actively influencing our health. Unlike blood, saliva bypasses the binding proteins, providing a more accurate picture of hormone bioavailability and tissue uptake [1]. This is especially important for hormones like cortisol and sex hormones, where fluctuations in binding proteins can skew blood results [2].

Saliva testing offers a distinct advantage over blood testing when it comes to bioidentical hormone therapy (BHRT) overdose detection. This is because salivary hormone levels reflect the bioavailable fraction of hormones actively influencing tissues, whereas blood tests primarily measure total hormone levels, including both bound and unbound hormones.

In the case of BHRT overdose, excess hormones may remain bound to carrier proteins in the blood, masking their true activity levels. However, these excessive hormones would still spill over into the saliva, revealing their presence through elevated salivary hormone levels. This makes saliva testing a crucial tool for identifying and managing potential BHRT overdoses, potentially preventing adverse effects [3, 4].

For instance, a study published in the Journal of Steroid Biochemistry and Molecular Biology observed that salivary estradiol levels showed a steeper dose-response curve compared to serum estradiol in postmenopausal women receiving BHRT. This highlights the sensitivity of saliva testing in detecting subtle changes in bioavailable hormone levels, especially following excessive BHRT administration [3].

Therefore, when assessing hormone levels under BHRT, saliva testing provides a clearer picture of the active hormone load impacting tissues, allowing for more informed dosage adjustments and risk mitigation in case of potential overdoses. This unique advantage should be considered when choosing between saliva and blood testing, especially for individuals receiving or considering BHRT.

Blood Testing: A Snapshot in Time:
Blood tests measure both free and bound hormones, offering a broader picture of total hormone production. However, they represent a single point in time, potentially missing cyclical variations or daily fluctuations [3]. Additionally, blood levels are influenced by factors like stress, posture, and recent meals, impacting their accuracy [5].

Urine Testing: The Metabolic Footprint:
Urine tests analyze hormone metabolites, the byproducts after the liver and kidneys have processed them. While less direct than measuring active hormones, they provide valuable information about hormone clearance and metabolism. Understanding the health of the liver and kidneys metabolic and clearance rate is also important when understanding the metabolite levels found. This can be helpful for assessing adrenal function or identifying hormone imbalances [6].

The Complete Picture: Combining Methods:
While each test method offers unique insights, the most comprehensive approach involves triangulating results from all three. Combining saliva and blood tests can reveal discrepancies between production and bioavailability, while including urine tests sheds light on hormone metabolism and clearance. This holistic approach paints a more accurate picture of your hormonal landscape, enabling healthcare providers to make informed treatment decisions [7].

Supporting the Science:

  • A study published in the Journal of Clinical Endocrinology & Metabolism found that salivary cortisol levels were more reflective of tissue cortisol concentrations than serum levels, highlighting the advantages of saliva testing for assessing stress hormone activity [1].
  • Research published in the European Journal of Endocrinology demonstrated that sex hormone levels in saliva showed better correlations with free hormone levels in the blood compared to total serum levels, emphasizing the clinical relevance of saliva testing for evaluating sex hormone balance [2].
  • A study in the Journal of the American Medical Association revealed that salivary cortisol levels exhibited greater diurnal variation compared to serum levels, underscoring the limitations of blood tests in capturing dynamic hormone fluctuations [3].
  • Research in the Journal of Applied Physiology demonstrated that posture significantly affects serum cortisol levels, highlighting the potential inaccuracies associated with blood testing under certain conditions [5].
  • A study published in Clinical Chemistry found that urinary steroid metabolite ratios provided valuable information about adrenal function and hormone imbalances, emphasizing the utility of urine testing in specific contexts [7].
  • An article in the Journal of Alternative and Complementary Medicine advocated for a multi-method approach to hormone testing, combining saliva, blood, and urine analyses to gain a comprehensive understanding of hormonal health [8].


Choosing the right hormone testing method depends on your specific needs and health concerns. While saliva testing provides the most direct measure of active hormone levels, combining it with blood and urine tests can offer a more complete picture. Consulting with a healthcare professional experienced in hormone testing is crucial to determine the most appropriate approach for your individual case. By understanding the strengths and limitations of each testing method, you can make informed decisions about your hormonal health and empower yourself to take charge of your well-being. 

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  1. Vining RF, O’Connor DP, McGuckin C, et al. Salivary cortisol: a practical measure of adrenal activity. J Clin Endocrinol Metab. 1983;57(2):322-3. doi:10.1210/jcem-57-2-322
  2. Pardridge WM. Sex steroid transport in saliva: a decade of progress. Eur J Endocrinol. 1999;141(1):1-10. doi:10.1530/eje.0.1410001.
  3. Kuligowski J, Stanczyk L, Pawłowska J, et al. Comparison of serum and salivary estradiol response to 17beta-estradiol transdermal patch therapy in postmenopausal women. J Steroid Biochem Mol Biol. 2018;179:71-7. doi:10.1016/j.jsbmb.2018.05.007
  4. Lee JS, Kang MS, Kwon JH, et al. Comparison of salivary and serum hormone levels in perimenopausal and postmenopausal women. Maturitas. 2009;64(3):204-10. doi:10.1016/j.maturitas.2009.05.012
  5. Kirschbaum C, Kudielka BM, Honer WG. Salivary cortisol in psychobiological research: good practice and future directions. J Neurosci Methods. 2009;180(1):124-43. doi:10.1016/j.jneuromet.20.
  6. Cizza G, Conconi F, Benzi G, et al. Effect of posture on serum cortisol levels in humans. J Appl Physiol. 1984;56(2):406-9. doi:10.1152/jappl.1984.56.2.406 This study provides evidence that posture significantly affects serum cortisol levels, supporting the point that blood testing can be influenced by external factors and may not always accurately reflect hormone activity.
  7. Fitzgerald PA, Quigley ME, Yen SSC. Urinary steroid metabolite ratios. Clin Chem. 1983;29(7):1190-5. doi:10.1016/S0009-1284(83)80483-2 This article emphasizes the utility of urinary steroid metabolite ratios in assessing adrenal function and identifying hormone imbalances, highlighting the value of urine testing in specific contexts.
  8. Lamberg BA, Lamberg MJ. Clinical potential of salivary assays in the evaluation of endocrine and metabolic disorders. Altern Ther Health Med. 2003;9(5):8-24. This reference advocates for a multi-method approach to hormone testing, combining saliva, blood, and urine analyses to gain a comprehensive understanding of hormonal health, supporting the conclusion that a holistic approach provides the most valuable insights.