Bridging the Care Gap: Increasing Inclusivity in Endocrine Laboratory Testing

Joely Straseski, PhD, MT(ASCP), DABCC, only receives a scant few pieces of information about patients when she provides results for testosterone or estrogen tests. Those pieces generally don't provide enough clinical context for her to understand a patient's journey. For transgender or gender-diverse individuals, knowing whether they are receiving hormone therapy and for how long, and their gender identity and biological (or legal) sex, are important pieces of the puzzle. Such information is necessary to select the right test, test method, and reference interval to accurately interpret each patient's hormone levels.

“I can only provide a reference interval based on the information I have, but many clinical factors may affect result interpretation,” Straseski said. “There is no one-size-fits-all laboratory test or reference interval for these clinical situations. It’s incredibly complex.”

According to Straseski, section chief of Chemistry and medical director of Endocrinology at ARUP Laboratories, the challenge becomes how to help providers, who do have the necessary clinical context, understand how to choose the right test when measuring testosterone and estrogen in transgender and gender-diverse individuals to ensure their patients get the right results.

Straseski will address how to select the appropriate laboratory test and interpret test results for transgender individuals at two upcoming medical conferences: the 2023 National Transgender Health Summit (NTHS), held in San Francisco from May 5–7, 2023, and the Mountain West Transforming Care Conference held in Salt Lake City on the University of Utah campus from May 22–24, 2023.

“Clinical providers don’t need to become laboratory scientists, but I hope to help them understand that the test they order matters and that certain tests will be better for different populations,” Straseski said.

Straseski has worked closely with her colleagues, Jenna Rychert, PhD, medical director of Operational Informatics and Microbial Immunology, and Kelly Doyle, PhD, DABCC, FAACC, medical director of Special Chemistry and Endocrinology, to increase the education available to providers and to improve ARUP’s internal processes to better guide test selection.

Last year, Straseski, Rychert, and Doyle led an effort to aid appropriate test ordering for all patient populations, including those in the transgender community and other patient populations who may be on hormone therapies, such as those used to treat breast or prostate cancer.

ARUP offers total, free, bioavailable, and fractionated testosterone and estrogen testing using two methods: immunoassay and mass spectrometry. Although mass spectrometry is more sensitive and can detect smaller amounts of the hormone, it often costs more. An immunoassay can offer a more cost-effective test for patients with expected higher hormone concentrations.

“The best test to order depends on the expected concentration of that hormone,” Straseski said. “Our goal is to make it easier for clinicians to determine the best test and how to interpret the results based on their patients’ needs.”

As part of the project, test names, ordering recommendations, and interpretive comments for ARUP’s 15 testosterone and estrogens tests were updated to better indicate the clinical use for each test. ARUP created enhanced educational resources to help providers select the best test, which are available on ARUP’s online decision support tool, ARUP Consult^®. These resources include the ARUP Testosterone Tests Comparison and ARUP Estrogen Tests Comparison tools.

The medical directors have also updated the exception criteria that previously prevented tests from being performed in certain situations.

“Before this project, a testosterone test ordered for a person whose administrative sex is female may have been flagged and canceled. Now, to be as inclusive as possible, we perform those tests and provide interpretation guidance with the result so that the provider can best use them in each clinical situation,” Rychert said.

In the year since the project’s completion, ARUP’s Client Services department has seen a 68% reduction in inbound calls related to test ordering for testosterone and estrogen tests when comparing three-month data extracted from 2022 with data from 2021. The Exception Handling department, which reviews flagged test orders, has seen a reduction of 90% of related exception cases.

As a final thought, Straseski said, “Ultimately, our priority is to provide all patient populations with the testing and results they need to receive appropriate medical care.”

 

Kellie Carrigan, kellie.carrigan@aruplab.com