Practitioner Case Study – May 2018

Initial Impression

• B.N presents as a 70 y/o F who is in generally good health but has been bothered for many years by vasomotor symptoms including frequent hot flashes, flushing, and vasomotor headaches. She is seeking a functional medicine approach for her issues that she believes are primarily related to female hormone imbalances.
• She has a PMHx of a small bowel lymphoma with a surgical resection 10+ years ago without local recurrence. She had a short portion of her small bowel removed as part of the procedure.
• She has been bothered mostly by vasomotor symptoms and episodes of nausea and occasional emesis often times associated with flushing or headache. She has had no formal evaluation for migraines and denies any visual disturbance during the episodes.
• She reports intermittent constipation more so than diarrhea but overall feels her bowel movements are regular and not a major issue. Some occasional bloating after certain meals.
• She is motivated to try dietary interventions and nutraceuticals to support wellness.
• Given the previous small bowel pathology with resection and a tendency towards constipation, I am concerned about methane predominant SIBO likely secondary to dysmotility and possible adhesive disease. It appears that her episodes of nausea and vomiting are likely related to poor GI motility and potentially exacerbated by anticipatory anxiety.
• Additional considerations on the differential are esophageal dysmotility or obstruction, general dysbiosis, SIFO, hypo/hyperthyroidism, H. pylori infection, gut infection, nutrient deficiency, APCA, Celiac, NCGS. She likely has dysregulated estrogen/progesterone metabolism: methylation and detoxification secondary to dysmotility and constipation leading to the increased enterohepatic circulation of estrogen metabolites.

Food for Thought

• Some interesting research looking at perimenopausal and postmenopausal women experiencing vasomotor symptoms such as hot flashes actually found that those with increased PNS activity as measured by respiratory sinus arrhythmia were more likely to experience moderate to severe hot flashes. Interestingly, there was no association with resting sympathetic activity.

Article: https://www.ncbi.nlm.nih.gov/pubmed/28169914

Editorial: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3185243/

Previous Diets

Has dabbled with removing dairy as she thinks she has trouble with it. Generally eats a whole foods diet with some grains. Has not followed any particular macronutrient restriction or ratio.

Previous Treatments

• She has tried blends of adaptogens for female hormone imbalance with only a mild improvement in symptoms. Currently dosing them multiple times a day.
• Has no history of hormone replacement, antibiotic or herbal antimicrobial use.

Key Physical Finding

• 2/6 Systolic murmur heard best at the right upper sternal border with radiation into the carotids.

Next Steps

• B.N’s heart murmur is suspicious of aortic stenosis, a narrowing of the aortic valve that can cause the decreased cardiac output to the brachiocephalic tree and peripheral circulation. This could be a major contributor to symptoms and would need to be addressed or ruled out prior to further treatment. This may also explain the patient’s mild hypertension requiring pharmacotherapy.
• Will schedule her for an echocardiogram to assess her ejection fraction and for any valvular disease.
• Will obtain outside medical records and previous testing in order to make initial recommendations.

Visit 2 – Testing and Initial Recommendations (returned 1 week later following echocardiogram)

Testing

• An echocardiogram reveals a mild to moderate aortic stenosis with preserved ejection fraction and no evidence of diastolic dysfunction (problems with the filling phase of the heart)
• Previous lab work: CBC, CMP, Lipids, TSH
• LabCorp Serum Chemistry and Urine
  • Iron panel with Ferritin
  • Vitamin D
  • TSH, Free T4, Free T3
  • Homocysteine
  • HS-CRP
  • B12 and Folate
  • Urine Microalbumin/Creatinine Ratio

Rationale

Financial considerations, insurance coverage, availability of testing and desires of the patient all were taken into account when determining to test. Patient desired a minimalist approach and was open to herbal treatments over drugs. Given previous testing and the patient’s complaints, I focused on nutrient status, markers of inflammation and thyroid health. I did not pursue hormone testing as I believed her symptoms would improve as part of a targeted gut approach. I also choose to not test thyroid antibodies and instead elected the initial screen with TSH and free hormone levels.

Recommendations

• Paleo Low FODMAP
• Antimicrobial Pathway
  • Herbal Antimicrobial Regimen + Biofilm + Prokinetic Agent
    1. Biocidin
    2. Interfase Plus
    3. MotilPro
• Supportive GI
  • Probiotics and Digestive Enzymes
    1. Therbiotic Complete Powder
    2. Ideal Bowel Support
    3. Digestzymes
    4. Partially Hydrolyzed Guar Gum
• Continue estrogen adaptogens
• Magnesium Citrate/Glycinate 400-600 mg daily
• Cod Liver Oil 1 tsp daily
• Discontinue Coq10, Red Yeast Rice, Vitamin D, Cal/Mag complex, multivitamin

Rationale

Initial treatment followed an anti-microbial pathway given suspicion for methane predominant SIBO with dysmotility. Treatment was empiric in nature without comprehensive stool testing. Prokinetics and anti-biofilm agents were added given concerns for constipation and the potential for increased efficacy with herbal antimicrobial treatment. The treatment was targeted for 6-8 weeks with reassessments over the next 2 months prior to changes in therapy. A combined dietary and herbal regimen was a good place to start and it was predicted that the patient would show significant improvement.

Visit 3 – Lab Interpretation and Treatment Evaluation (4 weeks after initial appointment)

Lab Interpretation:

• Previous Labs
  • Lipid Panel: TC 194, Tg 101, HDL-C 55, LDL-C 119, TC/HDL ratio: 3.5; Tg to HDL ratio: 1.8
  • CBC: wnl, no signs of anemia
  • CMP: Fasting glucose 82, AST/ALT, Alk Phosp, Cr all wnl
  • HbA1c: 5.2
• Vitamin D: 35, low normal
• Vitamin B12: 1357, above the reference range
• Folate: 18.4, wnl
• TSH: 2.2
• Free T4: 1.07, low normal
• Free T3: 2.6, low normal
• TIBC: 266, low normal
• UIBC: 209, wnl
• Serum Iron: 57, wnl
• Iron Sat: 21%, wnl
• Ferritin: 100 wnl
• Homocysteine: 11.6, non-optimal
• HS-CRP: 1.08, wnl
• Urine Microalbumin/Creatinine ratio wnl

Summary

Overall no signs of anemia on CBC, normal liver and kidney function on CMP, fasting glucose of 82, HbA1c of 5.2 and Tg/HDL-C ratio less than 2 is supportive of good cellular metabolism. Iron levels are within normal limits and patient does not appear to need any intervention for anemia or iron overload at this time. Thyroid function is suboptimal but not requiring intervention at this time. Inflammation, as measured by HS-CRP, appears low. A suboptimal homocysteine and elevated B12 may indicate some disturbances in methylation, B vitamin metabolism. Given concerns for impaired estrogen metabolism and detoxification as well as increased need/suboptimal absorption in the small intestine given concerns for SIBO, the patient likely will benefit from a period of targeted B vitamin supplementation.

Subjective Assessment:

• Patient has been quite strict with low FODMAP diet and feels it is helping. Has had less frequent headaches hot flashes and night sweats
• Has been on the herbal anti-microbial regimen for 2 weeks with no noticeable side effects
• Improved:
  • Headaches, hot flashes, night sweats, bowel movement, overall energy
  • Reports only one episode of nausea, bloating and a small episode of vomiting
• Same:
  • No noticeable change in bowel movements
• Worse:
  • N/A

Impression:

• The patient appears to be responding very well to initial dietary intervention and the first 2 weeks of herbal antimicrobials. Patient has tolerated the full dose of herbals and probiotics without noticeable side effects.

Recommendations:

• Vit D/K2 liquid, 3 drops daily
• Curcumin 500 mg daily
• Methylated B Complex daily
• Encouraged to eat Vit K rich foods in addition to the supplement given concern for aortic stenosis with sclerotic changes – abnormal calcification
• Continue with previous recommendations for 4 more weeks for a total of 6 weeks of treatment with follow-up in 4 weeks

Visit 4 – Follow-Up (4 weeks later, 8 weeks after initial appointment)

Subjective Assessment:

• The patient is doing extremely well, reports hot flashes, nausea, episodes of vomiting, night sweats and headaches nearly entirely resolved. She is having regular bowel movements without straining, no bloating. Reports dietary modifications have been challenging but she has followed them ~95%. Has been using estrogen adaptogens less frequently.
• Improved:
  • Nearly all initial symptoms as described above
• Worse:
  • N/A

Impression:

• Patient has responded extremely well to the anti-microbial pathway over 6 weeks. Vasomotor symptoms appear to be entirely resolved. This appears to be a major clinical win with empiric herbal antimicrobial treatment for suspected methane predominant SIBO. The patient will likely need on-going maintenance with occasional “trimming” treatments and will also likely do better on a baseline lower FODMAP diet. Recurrence is possible given previous surgery and possible underlying adhesive disease so considerations for additional herbal agents and / or manipulative treatments may be considered in the future.

Recommendations:

• Continue with the current anti-microbial regimen for an additional two weeks
• Begin food reintroduction given low FODMAP template – patient desiring to reintroduce butter, ghee or additional low lactose dairy
• Follow-up via messenger for response to the reintroduction

Visit 5 – Follow-Up (3 weeks later via email )

Subjective Assessment:

• Maintaining previous gains. Completed herbal antimicrobial course. The dairy reintroduction was not well tolerated. Has been able to introduce other foods without complaint.

Recommendations:

• Discontinue herbal antimicrobial and anti-biofilm agent
• Continue with probiotics, digestive enzymes, and PHGG
• Patient desiring to continue with prokinetic
• Continue food reintroduction given the low FODMAP template
• Continue with additional supplementary recommendations
• Follow-up in 3-6 months for check-in and repeat serum chemistry testing

Take Home Points

1. Empiric treatment for a clinically suspected gut pathology can be used in a controlled environment with a willing patient and proper medical oversight.
2. Comprehensive and expensive hormone testing, as well as hormone replacement, is not always indicated for individuals with symptoms of female hormone imbalance as a targeted gut therapy may likely improve their symptoms without further testing or hormone replacement therapy.
3. “Traditional” medical diagnosis must not be overlooked and functional medicine providers should thoroughly review past medical history and work closely with traditional providers or specialists when further imaging, testing or treatment is indicated.
4. A diet and gut centric minimalistic approach can be a cost-effective way of practicing functional medicine and may reduce total cost of care for the patient and the overall healthcare system.

Dr. Ruscio’s Comments

Again, an excellent case study which illustrates a few important concepts:

• Dysbiosis can be treated empirically
• Female hormone imbalance can be treated empirically
• The above are considerations when motivation and financial resources are limited
• Functionally low fT4 and fT3 do not usually require direct treatment when occurring in the presence of normal TSH
• Conventional and alternative medicine should work together, rather than in an ‘us verse them’ mentality

Thank you, Dr. Abbot, excellent work.

I’d like to hear your thoughts or questions regarding any of the above information. Please leave comments or questions below – it might become our next practitioner question of the month.

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