Dr. Amy Nett: That’s good. It sounds like her iron needs to come up quite a bit. You mentioned iron is low at 17. I’m wondering if that’s ferritin or serum iron, but I would definitely get a full iron panel. You want a serum iron, iron saturation, TIBC, UIBC, and ferritin. Then definitely use strategies to increase iron, like cooking with cast iron, taking vitamin C—just plain ascorbic acid—with iron-rich meals, and then supplement with something that doesn’t contribute too much to constipation. We often use something called Proferrin. People tend to do pretty well with that. I’m glad you’re working on the iron levels.
Then you said, “Her stress levels are low, although morning cortisol was the only marker that was low. She sleeps well. Kids have all moved out, so she has time to focus on her health.” You said, “She’d like menopause to come soon.” Unfortunately, I don’t think we can necessarily bring on menopause any sooner, but certainly it sounds like there is some hormonal imbalance if she is 52 and at the high end of all the estrogen markers, so I would be a little bit curious as to what hormone tests you’re doing and which hormone levels you measured.
If it’s a picture of estrogen dominance—so higher estrogen relative to progesterone—you might consider, and especially, too, if you’re doing a test like Precision Analytical’s, you can also look at the estrogen metabolites. In particular, you can look at the 16-hydroxyestrone, 4-hydroxyestrone, and 2-hydroxyestrone. The 2-hydroxyestrone is going to be the most favorable pathway. If you’re seeing too many of the metabolites or a majority of the metabolites going down the 16-hydroxy or 4-hydroxy pathways, then you might think about doing supplementation with DIM, diindolylmethane. You could use something like DIM Detox—I think that one’s from Pure Encapsulations—and maybe calcium D-glucarate to shift the estrogen metabolism. Again, it sort of depends on what markers you’re specifically talking about here, but the Precision Analytical profile is nice because you get to look at the hormone metabolites. I think the Genova hormone profile also does the metabolites. To lower estrogen levels, if that’s what’s high, I would think about going to DIM Detox or calcium D-glucarate.
If her androgens are also high, you could think about looking at her 5-alpha pathway. If her 5-alpha reductase is upregulated, you might want to think about things to decrease the 5-alpha reductase activity.
Again, it depends a little bit on what the hormone picture looks like more specifically, so it’s hard for me to address that more specifically, but really I think what your biggest question is is hormonal imbalance—what do we do? With hormonal imbalance, look for inflammation. Even if she’s not complaining of GI issues, I would still think about doing the SIBO breath test and the stool testing. Just make sure you’re not missing the gut issues, which are sort of the lowest hanging fruit in a way. So many people have gut issues, and they either are asymptomatic or they’ve lived with these symptoms for so long that they don’t even realize that they’re abnormal anymore. Do the basic gut testing. If you haven’t already done a complete hormone profile, then I would look at all of those markers to see if there’s some more specific tweaking you can do.
We talked about the iron there, and then stress. Yeah, even if she feels her stress levels are low, remember that there are internal sources of stress, too. You can be living in Hawaii, independently wealthy, no external sources of stress, but you can still have something like chronic infection or dysbiosis that’s causing significant enough internal sources of stress that that could contribute to HPA axis dysfunction. Depending on what her internal sources of stress are, it might still be good to bring in a meditation or mindfulness practice because you’re mentioning that she has a lot of fatigue. Do think about the lifestyle pieces in terms of a mindfulness or meditation practice to support the HPA axis.
If fatigue is a predominant picture, also think about chronic viral infection. That doesn’t necessarily go with her heavy menstruation that you mentioned, but if you bring the iron back into a normal range, and she no longer has anemia and still has significant fatigue, I might think about viral infection there.
In terms of the thyroid panel, again, I’m not sure what that free T4 is. To me, the free T3 that you listed looks perfectly normal at 3.13 and the TSH of 2.4. I don’t think I would go down the pathway of hypothyroidism there. You could certainly do some gentle thyroid support, which might be something like kelp tablets. You could do NOW brand kelp tablets. They have 325 mcg ones. Have her take three of those daily just for gentle thyroid support.
Hopefully we covered everything there for that patient.