Case Study: Chronic Diarrhea, Fatigue, and Estrogen Dominance

Patient Information

• Sex: Female
• Age: 34
• Presentation Pattern: Severe, persistent diarrhea with systemic symptoms including fatigue, brain fog, mood changes, and hormone imbalances

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Chief Complaints

• Chronic diarrhea: Daily, persistent for 4+ months, unresponsive to dietary interventions and significantly worsened after semaglutide and fluconazole exposure.
• Severe fatigue: Debilitating, worsens by early afternoon.
• Cognitive symptoms: Moderate brain fog, impaired focus, slowed mental clarity.
• Mood changes: Moderate-to-severe depression, anxiety, and withdrawal, particularly in the luteal phase.
• PMS and menstrual pain: Severe dysmenorrhea requiring high-dose ibuprofen, mood lability, fatigue, and increased anxiety prior to menstruation.
• Chronic pain: Moderate, ongoing.
• GI symptoms since adolescence: Longstanding nighttime anal itching and recurrent yeast infections.

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Clinical History Timeline

Adolescence	Onset of nighttime anal itching, recurrent yeast infections begin later.
2009	First major episode of chronic illness with GI symptoms
2015	Second major episode with GI dysfunction, fatigue, and endocrine symptoms. Lost menses for 2 years (age 25-27). Recovered over ~2 years with elimination diet, herbal protocols, acupuncture, and stress reduction.
2021-2023	Frequent travel to Baja, CA → recurrent diarrheal illnesses with suspected parasitic infections. Treated with prescription antiparasitics and herbs. Symptoms lingered after some episodes.
September 2024	Contracted COVID-19 → rapid health decline with new, severe gut dysfunction, fatigue, and brain fog.
Late October 2024	Started semaglutide (GLP-1 agonist) for chronic pain → developed severe diarrhea, abdominal pain, appetite loss, rapid weight loss.
November 2024	Started fluconazole (10-day course, stopped at day 3-4 due to extreme diarrhea and depletion). Symptoms worsened dramatically and have persisted.
Nov 2024 – Present	Persistent daily diarrhea, severe fatigue, low mood, anxiety, and worsened PMS. Unable to maintain regular work hours.

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Key Laboratory Findings

1. SIBO Breath Test 

• Negative: No evidence of SIBO.

2. GI Effects Stool Test

Pancreatic Elastase-1	108 L	Low → pancreatic insufficiency
Cholesterol	4.9 H	Elevated
Beneficial bacteria	Very low/no detectable Lactobacillus, Bifidobacterium, Akkermansia	Gut dysbiosis
Inflammation markers	Normal	No overt gut inflammation
SCFA levels	Low/normal butyrate levels	Some resilience present

3. Cycle Day 19-21 Hormone Panel

Estradiol	333.8 FH	Elevated → estrogen dominance
Progesterone	10 FL	Low → insufficient luteal phase support
Total Testosterone	35	Normal
Free Testosterone	0.8	Low-normal
DHEA-Sulfate	110	Low-normal

Pattern: Clear estrogen dominance with luteal phase progesterone deficiency.

4. Iron deficiency anemia

Ferritin	24 FL	Iron deficiency
Iron Saturation	28%	Borderline low
Iron	30	Lower end of range
RBC	3.87	Functionally low
Hgb	11.9	Functionally low
Hct	35.6	Functionally low

Summary: Iron deficiency contributes to fatigue and worsened PMS symptoms.

5. Low/normal B12

• Serum B12: 497 with high/normal homocysteine of 9.7 (goal < 7)

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Assessment

Key Findings

1. GI Dysfunction

• Persistent diarrhea not due to SIBO.
• Likely multifactorial: dysbiosis, pancreatic insufficiency, and past infections.
• No major gut inflammation but complete depletion of beneficial bacteria.

2. Hormonal Imbalance

• Estrogen dominance + low luteal phase progesterone, correlating with severe PMS and mood lability.
• Symptoms: heavy cramps, anxiety, depressive shifts in luteal phase.

3. Micronutrient Deficiencies

• Iron deficiency (low ferritin, low-normal iron saturation)
• Previous low B12, now corrected with aggressive supplementation.

4. Immune & Post-Infectious Impact

• History of parasitic infections and recent COVID-19 with subsequent GI crash.
• Possible post-viral/post-infectious autoimmunity with positive ANA at 1:40 speckled.

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Treatment Plan

1. Hormonal Support

• Start oral progesterone days 14–28 to address luteal phase deficiency.
• DIM Detox to promote healthy estrogen metabolism and lower estrogen dominance.
• Support hormone balance through anti-inflammatory diet and stress reduction.

2. Gut Restoration

• Replace pancreatic enzymes (Digestive Enzyme Ultra) before meals.
• Pre-, pro-, and post-biotic regimen to restore beneficial flora.
• Gradual diet expansion with gut-supportive foods.
• Continue anti-inflammatory diet as foundational support.

3. Iron and Nutrient Repletion

• Proferring Clear or IRONsmart to raise ferritin and improve oxygen transport and energy.
• Add in Trifolamin lozenge daily.

4. Sleep and Mood Support

• L-Theanine at night to improve sleep quality and reduce anxiety.
• Magnesium glycinate for relaxation and sleep support
• Monitor for further mood support needs if depression persists.

5. Pain Management

• InflamAway as a natural alternative to ibuprofen for menstrual cramps and systemic inflammation.
• LDN: titrated to 4.5 mg nightly

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Dietary and Lifestyle Interventions

• Anti-inflammatory reset diet emphasizing meat, poultry, seafood, eggs, vegetables, fruits, nuts, seeds, and healthy fats.
• Avoids gluten, dairy, grains, legumes, added sugars, and processed foods.
• Stress management and restorative exercise.
• Guidance on gradual diet expansion to support gut microbiome diversity.

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Summary of Clinical Course

This patient experienced a gradual, multi-system health decline over time, with symptoms emerging from a combination of factors rather than a single event. Her health history includes recurrent gastrointestinal infections, periods of severe stress, viral illnesses, repeated travel with possible parasitic exposure, and long-standing hormonal imbalances. Over the years, these cumulative stressors have layered together, progressively weakening her digestive capacity, immune resilience, and hormonal balance.

Recent events — including a significant viral illness (COVID-19), digestive system stressors, and chronic inflammatory patterns — appear to have tipped her system past a threshold, resulting in persistent gut dysfunction, fatigue, mood changes, and worsening menstrual symptoms.

Testing ruled out SIBO but highlighted multiple areas of concern:

• Profound dysbiosis with severe loss of beneficial bacteria and microbial diversity
• Low pancreatic enzyme output, impairing digestion and nutrient absorption
• Estrogen dominance with inadequate luteal phase progesterone, consistent with PMS, fatigue, and mood lability
• Iron deficiency, contributing to fatigue, brain fog, and heavy menstrual cycles

The treatment plan focuses on a comprehensive, layered approach to:

• Rebuild gut health by restoring digestion and microbial diversity
• Support hormonal balance through progesterone therapy and enhanced estrogen metabolism
• Correct key nutrient deficiencies such as iron and B12
• Improve energy, mood, and overall resilience, aiming to restore optimal function and long-term stability.

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Clinical Outcomes and Progress

Over the course of treatment, the patient experienced significant improvements across multiple systems, indicating a positive response to the comprehensive care plan:

• Digestive Function: Marked reduction in diarrhea frequency and improved stool consistency as digestive enzymes and probiotics supported gut repair and improved nutrient absorption.
• Energy and Fatigue: Fatigue improved by approximately 80%, with greater stamina throughout the day and less mid-afternoon crash.
• Cognitive Function: Mild but noticeable improvements in brain fog and mental clarity, especially in the morning hours.
• Hormonal Balance and Menstrual Health: Cycles became more regular and predictable, with improved sleep quality and less menstrual pain, reducing the need for high-dose pain medication.
• Iron and Nutrient Repletion: Significant improvements were observed in iron levels, red blood cell indices, and ferritin, correlating with enhanced oxygen delivery and energy.
  • B12 levels rose into optimal range with regular injections and supplementation.
  • Homocysteine decreased into a healthier range, reflecting improved methylation and cardiovascular support.
• Mood and Resilience: Noticeable improvements in overall mood stability and outlook, supported by hormone balancing and targeted nutrient therapy.
• Gut Health Restoration: Gradual return of gut resilience with progressive improvement in stool quality, reduced urgency, and greater tolerance for a broader variety of foods.

Overall, these changes reflect multi-system healing, with steady progress toward restoring energy, digestive function, hormonal balance, and long-term systemic health over a 3–6 month period.