I’m feeling a bit conflicted, as prior to us learning about the most accurate labs to use for stool testing and HPA axis dysfunction I used the standard ones taught previously. I have a patient on whom I did a NutriPATH, which is an Australian lab, stool culture with PCR, which came back with nothing detected on stool culture, but positive for giardia, Blasto, and Campylobacter on the PCR. The patient is symptomatic, has a history of antibiotic use, and is in a wheelchair. Wondering your thoughts on what to do in this scenario.He had a very low morning output and then sustained throughout the day with an evening elevation. He also showed high estradiol, estriol, and progesterone on salivary tests with relatively low testosterone. I just wondered if you have any thoughts on whether I should still clinically interpret this or if it’s not enough to give an accurate picture due to testing limitations.

Dr. Amy Nett: OK, so there are a few questions in here. Let’s start with the stool test. The patient had a stool test. It was a culture and a PCR. On the culture nothing came back, and then on the PCR there was giardia, Blasto, and Campylobacter. So a symptomatic patient, what to do? OK.

In this case, we have the normal stool culture and positive PCR. I would trust the positive PCR. I think a false positive is much, much less likely than a false negative stool culture. I hope I said that correctly! I’m not sure that I did, but basically I would trust the PCR. I think that it’s unlikely that you’re going to get false positive results on that PCR, whereas stool cultures can be a little bit less reliable … maybe a lot less reliable. So I would absolutely treat the giardia, Blasto, and Campylobacter. Because you’re dealing with all three of those, I would probably think about starting with an herbal antimicrobial protocol. You mentioned the patient is in a wheelchair, so I’m kind of wondering what else is going on here. You could also think about using Alinia. For Blastocystis, you’re probably going to need a longer course of Alinia, so you might think about doing something even like a 30-day course of Alinia to deal with all three of those. You could either start with the herbal antimicrobial protocol that we suggested for just treating dysbiosis, so that would be something like GI-Synergy, InterFase Plus, and Lauricidin. Get your prebiotics and probiotics in there, as well. Alternatively you could do maybe a longer course of Alinia, depending on what’s going on with this patient, how many supplements you think he’s able to tolerate. Get probiotics in there either way, but, yes, I would treat giardia, Blasto, and Campylobacter based on the PCR.

Your next question is a little bit more about HPA axis dysregulation. I think there is still a lot of discussion around best to test the HPA axis, and I think I would agree that there are probably some limitations to salivary free cortisol. I think we’re still investigating this a little bit more, but at this time, it does seem that the Precision Analytical test is probably most useful because you get to see the cortisol, the cortisone, a much more complete picture. I don’t know that salivary testing is going to have as significant limitations when we’re talking about the estradiol, estriol, and testosterone. Based on this, of course, if money is not an issue, yeah, run the Precision Analytical test. If the person is interested in having the data points, I think it’s something like a $275 test, so if he’s open to having those data points, absolutely run the test. That said, if money is an issue and he’s maybe not that interested in doing all these additional tests, I think what you could do … Let’s see, low morning cortisol. I would correlate it with symptoms. If the patient is feeling a lot of fatigue in the morning and it fits with the profile that you’re seeing, some patients do tend towards cortisol rather than cortisone, so cortisol and cortisone, we’ll talk about this more, but they interconvert back and forth. Some people have a preference for cortisone, other people, cortisol. So in some people a saliva profile is actually fairly accurate. The problem is we just don’t know where people stand in terms of their cortisol-cortisone interconversion. So if the clinical picture fits with the saliva profile, I think you could consider doing some adrenal support, maybe herbal adaptogens, something like ashwaganda, rhodiola, cordyceps. We sometimes use a product from Natura called Vital Adapt. It has a little bit of licorice root in it, as well, which can increase the free cortisol. Alternatively, you could think about adrenal glandulars. That might be another option, so I would correlate with his symptoms.

In terms of the high estradiol and estriol and relatively low testosterone, again, put it with the clinical picture. If he’s a little bit overweight, this might be aromatization. Given that he has the giardia, Blasto, and Campylobacter, he has cause for inflammation. Let me double check. I think you said this is a male patient. Yeah, you did say “he.” Just making sure. He had relatively low testosterone and relatively high estrogen, so that fits with upregulation of aromatase. Put it with the clinical picture, but inflammation can certainly cause upregulation of aromatase, so if he looks like he has features of high estrogens, what you could do is something like DIM Detox, maybe, to lower the estrogen levels. Then you could do a Precision Analytical hormone profile, maybe, in three months. You could support adrenals, maybe do DIM or something to decrease the aromatization, and then see in three months where he’s at. Use the information that you do have for a time, but then come back and do the more complete test.