Amy Nett: Next question from Amber: “[I want] some guidance on a 38-year-old female with concerns about hirsutism, dysmenorrhea, premenstrual symptoms, [and] difficulty losing the last 10 lb. after her second child …” Okay, I am hoping that means normal fertility, and then it says, “[She has] sudden severe tooth decay, [with] about 14 dental caries in the past year. She’s been on a nutrient-dense Paleo diet for nine months, [and has been] clean eating for 15 years. Potential issues that Amber lists [are] hormone dysregulation or inflammation. [I have] no idea what to make of the tooth decay. With other issues at first, I was thinking PCOS, but periods are regular, [there is] no acne, and [she] became pregnant easily twice, [with] no miscarriages.” I agree, Amber, that makes PCOS a lot less likely. “No DUTCH testing [has been done] yet, but her labs do reveal possible metabolic issues with fasting blood glucose of 102 [and] hemoglobin A1c of 5.5. Her LDH is low at 130, triglycerides [are] low at 45, HDL [is] low at 58, [there is a] high total cholesterol to HDL ratio, post-meal blood sugars look good, [there is] definitely some inflammation, ferritin [is] 146 with normal soluble transferrin receptor, [the] zinc-copper ratio [is] low, TSH [is] a little high at 2.1, [and a] free T4 of 0.8 currently treating SIBO and mild dysbiosis.”
You know, Amber, you mentioned that you don’t have the DUTCH hormone profile yet, but I think you need to get it because of the hirsutism and the premenstrual symptoms. You need to know where hormones are at because with the premenstrual symptoms, I’m wondering if there is an estrogen dominance picture, and so you might want to do something like a diindolylmethane or calcium D-glucarate to help get her estrogens down. You also need to see [if] there [are] high androgens. Are her hormones high across the board? Do you just need to support hormone excretion or sort of hormone metabolism? And, especially, you mentioned her copper to zinc ratio is off, so maybe getting some zinc on board. I don’t know what maintenance supplements you have her on, but certainly magnesium, zinc, just kind of thinking about hormone balance in general, so B vitamins including B6. You mentioned the TSH is a little high at 2.1, so I would get a free T3. You only mentioned the free T4, but I would want to see free T3 and reverse T3. You didn’t mention those or I don’t know if you have them and they’re just completely normal, but I would monitor thyroid function pretty closely, especially with the weight loss resistance.
[Fo] the tooth decay, think about getting some vitamin K2 in there. I wonder if the tooth decay is more associated with nutrient insufficiencies. I’m thinking in part to, remember, I think, it was Weston A. Price, he was actually a dentist, and he was wondering about dental health in the context of nutrition, so really thinking about what her nutrients are looking like. You could also have her, if you have access to a functional or biological dentist locally, I often send my patients for consultation with our local functional dentist. She happens to be amazing, so I’m really lucky to have her as a resource, but she does cone beam CT [computed tomography] to make sure there’s no evidence of chronic infection or capitation, and often also does saliva testing to see what the oral microbiome looks like. You mentioned that this patient has SIBO and mild gut dysbiosis, so there could be kind of like an oral microbial imbalance.
Let’s see here—and, oh, you then mentioned the high fasting glucose and hemoglobin A1c. I think you need to work that up a little bit more. Her triglycerides are low, actually, so [it’s] less likely to be insulin resistance, but that is something I would look at—so what’s her fasting insulin. Again, you could get fructosamine. You could have her use a glucometer, but again, because of the weight loss resistance, think about if there is any insulin resistance-type picture. Do you need to work on tightening her blood sugar control? A single elevated fasting glucose or just fasting glucose being high but glucose being completely normal otherwise throughout the rest of the day postprandial, that’s a lot less concerning for me. But again, you need to work this up a little bit more.
Let me look at the question one more time. I think the things you need to do are, you mentioned getting the DUTCH, so both cortisol and sex hormones, understand what’s going on there, work up the blood sugar piece a little bit more—oh, I’m sorry, you said, “post-meal blood sugars look great.” Yes, look at the cortisol piece then. Is that a high morning cortisol that’s driving up her fasting blood sugar? So, maybe thinking about cortisol because that would also contribute to the weight loss resistance. I think your DUTCH test is the big next step for you on this one.