Case Studies. Robyn Kutka ND Lylen Ferris, ND Labrix Clinical Services, Inc

Transcription

1 Case Studies Robyn Kutka ND Lylen Ferris, ND Labrix Clinical Services, Inc

2 Alyssa, 18 yo premeno F History/Symptoms CC: Oligomenorrhea Onset of menses at age 14; have never been regular with menses q 3-6 months. LMP 4 months ago Athletic leaving in 2 weeks for freshman year of college on a swimming scholarship. Swims 2 hours 5 days per week; however, has had last several months off d/t shoulder surgery BMI normal/not underweight (21.8) Denies hirsutism & acne. Reports irritability and lack of patience. RK

3 Alyssa, 18 yo premeno F Serum work up reveals: Within range TSH (2.14), HgA1c (5.4) and prolactin (8.6). Unremarkable CBC Remarkable for low range B12 (389) and less than optimal Vit D (48 ng/ml) RK

4 Alyssa, 18 yo premeno F Salivary testing: Elevated T suggestive of evolving insulin resistance Phase 3 adrenal gland dysfunction RK

5 Alyssa, 18 yo premeno F Treatment (ovulation and blood sugar support): Vit D 4000iu daily Herbal formula I: 2 dropperfuls am & pm days Herbal formula II: 2 dropperfuls am & pm days (picking day of choice as day 1) Hydrocortisone: 10 mg am, 5 mg noon B Complex with methyl B12 & methyl folate q am Dysglycemia/hyperandrogenism oral formulation: 2 capsule tid cc Counseled dietary and lifestyle management for adrenal support and blood sugar control. Included seed cycling in daily foods. RK

6 Alyssa, 18 yo premeno F Follow up: Three months later mother reports patient has had 2 cycles (approx 30 days apart) since leaving for college. RK

7 Brandon, 34 yo M History/Symptoms Severe anxiety, excessive worry (10/10) Obsessive thoughts Poor sleep (4/10) Restlessness No motivation

8 Brandon, 34 yo M Serotonin Syndrome? Pt prescribed Lexapro by his MD for symptoms of depression and anxiety After one week of taking it, pt presented to ER with anxiety. He felt he was dying (stress test, EKG all wnl) A few days later experienced a weekend of diarrhea and vomiting Then describes himself as being so out of it would just walk or rock for hours. He has little memory of this. MD diagnosed serotonin syndrome and d/c Lexapro

9 Brandon, 34 yo M Test Results Upper range serotonin Low GABA Low range dopamine, low norepinephrine, low range epinephrine Low glutamate

10 Brandon, 34 yo M Treatment L-theanine: 100mg q am DopaLift: 2 caps q am Probiotics, fish oil, Vitamin D Began seeing a therapist

11 Brandon, 34 yo M Follow up Feeling great Anxiety is much improved (4/10) [Previously 10/10] Sleeping better. As my anxiety has improved, so has my sleep. Says 100mg theanine helps him to relax and focus Motivation is better. He wants to go out and do things.

12 Olivia 44 yo premeno F 10/2013 CC: Mood concerns new onset, we ve been working together for 2 years Mother of 2, maintains household & job outside the home Reports irritated by things that would not normally cause issue; set off easily by kids Mood is up and down Current BHRT use Sublingual progesterone hs days 7-menses Adrenal support program (adaptogenic herbs, B5, B6, Vit C, Vit E) RK

13 Olivia 44 yo premeno F Test Results Serum labs remarkable for: slightly low range ferritin (26) low WBC (persistent history of leukopenia) slightly upper range MCV (92.7) slightly suboptimal Vit D (56) RK

14 Olivia 44 yo premeno F Test results - 10/2013 Reasonably well balanced hormone levels Pan low to low range NTs with exception of epinephrine (likely a stress response) RK

15 Olivia 44 yo premeno F ROF Visit: Reports son was diagnosed with MTHFR variant. Plan: NT Uplift 1 capsule TID (B6, L-tyrosine, GABA, L-glutamine, Inositol, taurine, 5-HTP) MTHFR variant testing Vitamin D 4000iu qd Iron citrate 25 mg qd x 3 months RK

16 Olivia 44 yo premeno F MTHFR findings: Heterozygous for both A & C variants Plan: Continue NT Uplift 1 mg methylfolate and 1 mg methylcobalamin, titrating to 3 mg methylfolate and 3 mg methylcobalamin over 3 weeks Follow up NT testing in 12 weeks, prn RK

17 Olivia 44 yo premeno F 3 month follow up 3/2014 Mood: level; denies ups and downs and irritability as previous Would like to address libido; not as high as when younger and is 10% better since starting B vitamins and NT Uplift taking 1/3 rd of what was prescribed as forgets second and third dose Plan Repeat NT testing Serum testing: repeat CBC & ferritin RK

18 Olivia 44 yo premeno F Test Results 3/2014 WBCs within range! First time she s ever recalled seeing this. Ferritin optimal at 51 RK

19 Olivia 44 yo premeno F Test results 3/2014 Persistent pan low to low range NTs with exception of epinephrine (likely a stress response) RK

20 Olivia 44 yo premeno F Plan Encourage all 3 doses of NT Uplift and Methyl Bs. Try setting an alarm on phone for a reminder Future considerations should concerns and pan low NTs persist: Discontinue NT Uplift and replace with 5-HTP Thrive qhs and DopaLift qd GI support (we have done this previously and treated for H Pylori) RK

21 John, 29 yo M History/Symptoms Manages a busy country store. Diagnosed with low T by another physician. Receiving bimonthly injections (200mg testosterone cypionate q 2 weeks). MVA age 20. Complications from the accident led to a double hip replacement in January No motivation. No energy. Says he has never has the energy his friends had. Sleep apnea. Insomnia. Wakes 5-6 x per night due to pain in hips and back. Weaning down from opioids used to manage post-op pain. Constipation and hemorrhoids Eats a very simple diet, mostly meat and potatoes. He tries to eat veggies but gags on them and spits them out. Hates the texture, not the taste. 5 yo son recently diagnosed with a sensory processing disorder.

22 John, 29 yo M Symptoms Motivation 1-2/10 Energy 1-2/10 Pain 8/10

23 John, 29 yo M Test results Estrogen dominance Testosterone within supplementation range Phase III adrenal gland dysfunction

24 John, 29 yo M Treatment Hormones: Progesterone 10mg qd Continue testosterone, but instead of 200mg q 2 weeks, try 100mg q week. Hydrocortisone 10mg qam, 5mg noon Adaptogenic herbs and nutrients Probiotics, Fish oil, vitamin D

25 John, 29 yo M Calls me to tell me he has been feeling depressed and his PCP wants to put him on an SSRI Depression 9/10 He s hoping there is something else that I can offer Insomnia and pain continue to be big issues.

26 John, 29 yo M Test results

27 John, 29 yo M Treatment Neurotransmitters FiveHTP Thrive (100mg): 1 cap bid DopaLift: 2 caps bid GABAcholacalm: 3 caps bid PSI Nighttime: 2 caps qhs Contains vitamins, minerals (including Cu), White Willow, Passionflower, Bromelian, Wild Yam, Valerian, Black cohosh, Hops, glutamic acid Melatonin: 1mg qhs Monitor diet for foods containing glutamic acid Taurine: 500 mg bid

28 John, 29 yo M Follow up visit Sleeping better Feels noticeably better when taking aminos. If he doesn t take them, he can t wait to get home and get in bed. Emotionally stronger. Still rates energy as 3/10 Motivation is improved 5/10 (was 1-2/10) Pain also improved 5/10 (was 8/10) I m not where we started, but I m not where I want to be Asked if he could have a beer with a friend. Told me he was going to go hunting the following weekend. Has started dating again

29 Mary 49 yo premeno F 08/2011 Cc: Persistent low libido. Reports: low libido, 10 pound weight gain over 12 months, tired all the time. Stress is high CFO of restaurant that is currently undergoing buy out Sleep: Easy to fall asleep; wakes at 2 am for 1 hour Has recently been evaluated by another practitioner, including bloodwork. Reports being told all was well and she should light candles and get sexy lingerie Plan: ROR for recent bloodwork and salivary hormone testing RK

30 Mary 49 yo premeno F Test results Estrogen dominance, phase 1 adrenal dysfunction ROR lab review reveals CBC and ferritin labs overlooked RK

31 Mary 49 yo premeno F Plan 08/2011 Serum labs: CBC, ferritin Revealed: Iron deficiency anemia with a ferritin of 2 ng/ml 100 mg iron citrate qd Transdermal progesterone: 30 mg to thin skin days 7-28 Adrenal support: Strive for 5-7 servings fruits and veggies daily Avoid excess sugar, caffeine and alcohol Stress management: 10 min self time daily. Deep breathing throughout the day (Brugger s exercise) Combination adrenal supplement (adaptogens, vitamin B5, B6, C & E) AM & noon RK

32 Mary 49 yo premeno F Phone message 4 weeks later Phones office reporting menstrual irregularities, moodiness/weepiness, breast tenderness Pt instructed to decrease progesterone to ½ dose (15 mg) at this time RK

33 Mary 49 yo premeno F Follow up 11/2011 Reports feeling 1000 times better. Feels as if she s 10 years younger. Energy now 9/10. Sleep much improved; sleeping through nights more often than not Libido no change Mood calmer Stress still high; has taught entire company Brugger s exercise RK

34 Mary 49 yo premeno F Follow up plan 11/2011 Increase progesterone back to original dose (30 mg) in one month Herbal libido support: 2 capsules 3 times daily Formulation contains L-arginine, ginseng, ginko, damiana, B complex, zinc, calcium, vitamins A, C, and E CBC due in 1 month RK

35 Mary 49 yo premeno F Follow up 01/2012 Has been using full dose of progesterone for 2 months Mood great; no concerns Energy remains 9/10; no concerns. Anemia resolved Stress much less, company has sold and is not working Libido much better; no concerns. No longer using herbal support as it overworked and she couldn t stop thinking about sex while using it Future considerations: Repeat hormone testing in 2 months with yearly testing/prn testing thereafter. RK

36 Mike, 37 yo M History Hardworking father of 3 (ages 2-11). Works as an engineer and a contractor. Very smart guy. Can do complicated math in his head. Fell off of a roof 9 months earlier and sustained injury to shoulder and elbow. Height 5 11 ; Weight: 268 = BMI 37.4

37 Mike, 37 yo M Symptoms Reports joint pain, not only in elbow and shoulder (7/10). Insomnia. Cannot get to sleep, and when he does sleep, he wakes frequently due to pain (8/10). Energy (4/10) Cognitive function has declined significantly. Ability to do calculation in his head is gone. He has trouble remembering where he left his car keys. (2/10 10 = great) BM: 6-8 watery stools per day. Cramping. Conventional doc diagnosed IBS. These symptoms are severe on symptom questionnaire: Increased forgetfulness, foggy thinking, stress, anxiety, irritability, decreased mental sharpness, morning fatigue, afternoon fatigue, evening fatigue, difficulty staying asleep, increased muscle aches, sugar cravings, food cravings, burned out feeling, sore muscles, increased joint pain, neck and back pain.

38 Mike, 37 yo M Test results

39 Mike, 37 yo M Results Summary Hormones Estrogen dominant Elevated progesterone is transference from wife. Suboptimal testosterone Phase III adrenal dysfunction

40 Mike, 37 yo M Results Summary Neurotransmitters Except glutamate, all neurotransmitters are low Low serotonin has been associated with anxiety/depression, insomnia, body aches Low GABA may be associated with anxiety and decreased sleep quality Low dopamine associated with decreased cognitive abilities and cravings. Low norepi and epi associated with depression, mood changes, fatigue, difficulty concentrating, and diminished drive.

41 Mike, 37 yo M Hormone Treatment Progesterone 5mg, Testosterone 10 mg in troche Hydrocortisone 10mg qam, 5mg noon Adaptogenic herbs and nutrients

42 Mike, 37 yo M NT Treatment 5 HTP 100mg bid DopaLift 2 caps bid N-Acetyl-L-Tyrosine, Macuna, P5P, Green tea extract L-theanine 3 caps bid PSI Nighttime Contains vitamins, minerals (including Cu), White Willow, Passionflower, Bromelian, Wild Yam, Valerian, Black cohosh, Hops, glutamic acid Anti-candida diet + anti fungals

43 Mike, 37 yo M Follow up symptoms Energy (7/10 was 4/10) Pain (3-4/10 was 7/10) Insomnia (5/10 was 8/10) Cognitive abilities (8/10 was 2/10) Mood is much better. Anxiety and irritability much improved. Motivation and libido improved. BMs: 1-2 well-formed stools per day Weight: 227 = BMI 31.7

44 Mike, 37 yo M Follow up test

45 Mike, 37 yo M Treatment 5 HTP 50mg qam, 100mg qhs Continue DopaLift 2 caps bid Vitamin C: 3g qd Continue L-theanine 3 caps bid Continue PSI Nighttime Melatonin 1mg qhs Continue progesterone and testosterone D/c hydrocortisone, but continue adaptogenic herbs