I have a question about my first DUTCH test with a 48-year-old menstruating female with complaints of fatigue and inflammation. She is thin but not overly, eats very healthy. No excessive exercise. SIBO negative. DUTCH was confusing. Low 24-hour cortisol, way low metabolized cortisol, low estrogen and testosterone, normal progesterone, DHEA low normal, 5-α reductase activity high. On the handout regarding patterns, low free cortisol with low total included things such as fibromyalgia, chronic pain, metabolic syndrome, etc. The only thing she does have was a serum borderline hemoglobin A1c of 5.6 and low insulin, so I ran a GTT, glucose tolerance test, and glucose was 91, 74, 67, 75. Insulin was 29, 18, 22, 11. So, I don’t know where to go about the blood sugar issue, or is there one? According to her endocrinologist, no, and/or the other hormone issues.

Chris Kresser:  Some of the conditions I listed in the handout are the ones that have been explicitly identified in the scientific literature. It doesn’t mean that there aren’t many other possible conditions and indications for a certain combination of patterns. This person has low cortisol. She has low free cortisol and very low metabolized cortisol, and her chief complaints are fatigue and inflammation, which is exactly what you’d expect with that kind of presentation. Cortisol, as you know, is an anti-inflammatory hormone, and it’s involved in the resolution of the inflammatory response, so if a patient has low cortisol, both free and total, she is going to be suffering from a chronic catabolic kind of state. She is going to be in this inflammatory state, rather.

Then the low estrogen and testosterone, I’m not sure whether that was low in the menstruating range or low in the menopausal range. Even though she is still menstruating at 48, she is certainly heading toward a time where she won’t be menstruating. I just see Marcie’s follow-up: low in menstruating. That’s typical to see. If you have a woman who is approaching menopause, you’re going to see a drop in the production of those hormones. Sometimes estrogen drops faster. Sometimes progesterone drops faster. Sometimes testosterone drops faster. The tricky part about testing in women of this age is it is natural, at least in my opinion. I know some people who are really into bioidentical hormones believe that menopausal females should have hormones the same level as a 25-year-old female. I don’t believe that.

If you accept that it is natural for hormone production to drop a little bit as a woman approaches menopause, when you see sex hormone levels that are slightly below the menstruating range but still above or within the menopausal range, then the question becomes, is it pathological? Are those sex hormone levels pathological? What I would do in this situation is I would focus on her DHEA and cortisol. I would focus really on her HPA axis using the low cortisol protocols that we talked about. There is not a lot of evidence of significant blood sugar dysregulation from the numbers that you shared, but you could give her some basic blood sugar support as part of the HPA axis protocol. Then when you get her cortisol up into a normal range, if she still has low estrogen and testosterone and is still having symptoms, then you can consider what to do at that point and whether you want to start using some things, some botanicals, for example, that modulate hormone production, sex hormone production. Of course, you want to look at all of the other things that we’ve talked about. You want to look at her gut, and then you want to look at her nutrient status, which we’re going to be going into in detail with the blood chemistry content.