Ask Me Anything: Women’s Health & Fertility Q&A

During this live Q&A, attendees got answers to their top women's health and fertility questions from two DUTCH experts specializing in women's health. Dr. Debbie Rice and Dr. Kelly Ruef are both naturopathic doctors specializing in hormone health and women's care. They offered their insights to important issues like the deep-rooted effects of stress on women, how estrogen and progesterone ratios can effect fertility, and advice on how to interpret the DUTCH Cycle Mapping test.

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Please Note: The contents of this video are for educational and informational purposes only. The information is not to be interpreted as, or mistaken for, clinical advice. Please consult a medical professional or healthcare provider for medical advice, diagnoses, or treatment.

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Full Transcript and Time Stamps

00:00 Introduction

03:47 Low Estrogen and Fertility Issues

14:36 What does healthy ovulation look like on the DUTCH Test?

15:48 What follicle count number would keep a woman from conceiving naturally?

19:05 What are the top three reasons someone might experience fertility issues?

23:31 What tests should be performed for someone struggling to conceive who does not have any obvious signs of hormone imbalance? 

26:51 Is there a connection between 16-OH-estrogen metabolites and cortisol metabolism? 

30:15 Do synthetic progestins act more like estrogens in the body? 

31:32 What is the difference between synthetic and bio-identical hormone replacement therapy? 

33:42 How do you use the DUTCH Test as a tool alongside hormone replacement therapy? 

37:38 DUTCH report does not show high testosterone, but patient is experiencing symptoms. What is the next step? 

46:23 Is DUTCH testing recommended for teenage girls? 


00:00 Introduction

Hello, and welcome, everyone. I'm Noah Reed, Vice President of Sales and Marketing for Precision Analytical Creators of the DUTCH test. 


This month, we have the opportunity to bring you a live Q&A session with doctor Debbie Rice, and doctor Kelly Ruef. They're joining us today to answer some of your questions about women's health and fertility. As a reminder, our original webinar with doctor ... 


has been postponed, but she, but we will share more details on that when we get that rescheduled as soon as we have those details, we'll let you know. 


Many of you have already submitted questions ahead of time. So, there's a lot to cover today and remember that DUTCH providers can also schedule a 30-minute consultation with one of our clinical consultants through your provider portal to discuss your patient's results. All registrants will also receive a recording of today's session, so look for that in your inboxes tomorrow. 


If you're not already familiar with precision analytical and the DUTCH tests, DUTCH stands for Dried urine tests for comprehensive hormones. 


It is a group of validated tests that provide the most complete evaluation of sex and adrenal hormones, including metabolites. This simple and convenient at home collection for patients, and support on every concept comprehensive report. From a team of hormone experts, puts you in the driver's seat to helping solve your patients most complex hormone issues. Registering as a DUTCH provider, is very easy, so if you sign up today, you'll receive 50% off up to your first five kits, plus free clinical consults, video tutorials, patient referrals, and expert hormone education. 


To sign up, just click the link we've posted in the chat and complete. the Become a provider form on our website. After you complete the form, someone from our team will set up a one-on-one appointment to answer all your questions. And walk you through the onboarding process to get even more hormone education. Check out the DUTCH podcast, which dropped today as well, wherever you get your podcasts! Each week, you'll hear amazing conversation and insights from the leaders in functional medicine. 


Listen back to last week's episode with the Basics of Estrogen with doctor Rice and catch up on this week's episode, on Female Androgens with doctor Kelly. 


Subscribe to the DUTCH podcast on your favorite streaming app and visit DUTCH test dot com slash podcast to learn more about the show, I would love it. If you'd also rate us on any of those podcast apps, that'd be great. 


Remember, Doctor Ruth and doctor Rice are doctors, but they're not your doctor, the contents of this webinar for educational and informational purposes only, the information is not to be interpreted as are mistaken for clinical advice. 


Please consult a medical professional or healthcare provider for medical advice, Diagnosis, or treatment. Patients can find a DUTCH provider on our website by clicking the Find a Provider button at the top of the page. 


And now, let me introduce you to today's speakers. 


Doctor Debbie Rice is the Director of Clinical Education for Precision Analytical and Practices part-time. As a Naturopathic Doctor where she focuses care on pediatric health, hormone health, thyroid health, and adrenal health. 


She has had experience working with communities in need both in the United States internationally. 


Her training has been primarily in women's health, pediatric care, hormone therapy and Hormone function. Doctor Kelly Ruef is a licensed Naturopathic doctor, who completed her medical education at the National University of Natural Medicine in Portland, Oregon. 


She also completed a residency at Pearl Natural Health in downtown Portland, where she specialized in inflammatory bowel diseases and Women's Health. 


For undergraduate education, Doctor Ruth Ruef received A Bachelor of Science degree in Biochemistry and Cell Biology, with a minor in Cognitive Neuroscience, from the University of California, San Diego. Welcome to today's presentation. We have a lot of questions, so let's jump to them and I'm proud that I did not cough at all during that intro, so let's start with the first question here. 


03:47 Low Estrogen and Fertility Issues 

A recent patient with Cycle Mapping in the DUTCH Plus on cycle mapping progesterone was adequate but ... and estrogen estrogen were low. I believe she that this may be contributing to difficulty, conceiving due to thin endometrium car within range on the DUTCH Plus recommendations for increasing estrogen. We've discussed some weight gain. 


She has a low BMI healthy fat and omega three intake, public, massage, and phyto estrogens, doctor Ruef that question is to you. 


All right? That's That's a great question to start out with and thank you for the introduction. That was great. I'm happy didn't cough either. 


I'm getting over being sick, too, so hopefully I won't cough either. 


Um, I got my tea right here. 


OK, so let's, Let's, um, summarize that again. So, they did a cycle mapping and a DUTCH Plus, and they said the progesterone looked adequate. So, I would ask, you know what, what is adequate, according to their definition for me when it comes to fertility, I like to see progesterone at its highest point on the DUTCH, plus around 15 or 20. I believe that's nine nanograms per milligram. 


You know 15 or 20 is pretty good for fertility and I'd like to see that the Luteal phase is about two weeks or 14 days in length. OK, they said estrogen was low rate and they did a car, or Cortisol awakening response and that was within range. 


So, it is true that estrogen is important for kind of priming that endometrium rate. 


If we don't have enough estrogen around, we might have a thinner endometrium and so, that that could be an issue. It could affect fertility. I I have seen some women with lower estrogen still, get pregnant, and have healthy pregnancies carry to term. 


So, oh, you know, let's see. They've discussed weight gain. She's got low BMI. We know very often times when you have a low BMI, it can lead to lower sex hormones. If she does, in fact, have adequate progesterone, then we know that she ovuated, and she had enough estrogen at one point to ovulate. You have to have a specific amount of estrogen. searching for a specific amount of time in order to get that LH surge and the ovulation. I still wonder about the quality of the egg. 


So, they did healthy fat, omega three, pelvic massage, and phyto estrogens, OK, OK, great. So, I think they're on the right track with the low BMI. 


No low, low fat, body percentage can contribute to lower *** hormones, so weight gain, if appropriate, can be helpful. 


I would also look at the Androgens, because Androgens, as we know are really important for fertility. 


They support that follicle development. They support ovulation. 


And so, a lot of times when there's low estrogen, I'm looking up the androgens. 


And if the androgens are low, then sometimes if you support the androgens, that, in turn, can support the follicle development. And we know that a healthy follicle makes healthy amounts of estrogen, right? 


So, sometimes just supporting the androgens can be really beneficial for the the follicle development and the estrogen levels. So, a lot of times, I'm looking at the androgens and I might be trying to help support the androgens. And again, weight gain can be helpful for androgens. We also know that regulating blood sugars can be great for androgens, stress reduction, you know, lowering inflammation in the body. 


That can all be great for androgens and there's some herbs out there like maka, tremulous, Chateau Vari, Ashwagandha, you know, zinc also can be supportive. 


Um, let's see besides that I might look at her metabolized cortisol. 


So, she said that her car, her cortisol awakening response so her free cortisol in circulation, looks good. And the car is more representative of like tissue levels of cortisol. And so, the tissue levels of cortisol might be fine. 


But a lot of times you'll see low metabolized cortisol in these cases. And when you have low metabolized cortisol relative to higher free cortisol. In circulation, like ... 


or a normal car, this can be a pattern of low body weight, hyperthyroidism, suboptimal liver function, poor mitochondrial function. So, it might give you a clue about things to work on. 


And a lot of times when you have low metabolized cortisol in a normal car or even a high car, sometimes these women will have low androgens, which kind of plays back into the follicle development of the, you know, fertility and the estrogen levels. 


Doctor Rice, did you want to add anything to that? 


It looks like we lost your audio of doctor Rice. 


I can keep going if that's helpful. Yeah, why don't you go ahead and keep going, doctor, OK, no, when it comes to estrogen levels and cycling, I also think about carbohydrates, a lot of women these days are taking out carbs. And for someone they're really important for their cycling for their fertility. 


So, I'm not telling women to go in, eat a bunch of pasta and bread and cookies and Donuts, you know, every day. But just to get some of these complex carbs in their diet, like sweet potatoes, Qianlong ... was an awesome source of carbs. 


Gosh, what else? Maybe a little bit of rice. 


You know but I might not add in wheat if they have a sensitivity to it. Or celiac for example. Then of course, you can I support the mitochondria So sex hormone synthesis begins in the mitochondria. So, when you have low sex hormones, you can always think about supporting those mitochondria. 


There was a study, let me quote my quoted here, they said mitochondrial dysfunction in a mouse model with high mitochondrial Ross. So, that's reactive oxygen. Species generation also results in infertility, defective Philip Kilo Genesis and Impaired .... If you want to look it up, it's P I. P M ID 24495597. But supporting those mitochondria can be really important to, for estrogen levels. I like that she's got the healthy fats in there. And another thing to think about. 


I mean, she did say, she's doing the phyto estrogens, and there is a study where they looked at 100 different women with PCS and half of them, they gave Clomid and half of them. They give black cohosh, 20 milligrams on cycle days 2 through 10. And the women that they gave the black cohosh to actually had increased rates of pregnancy, and they had a thicker endometrial lining. 


So, we do know that somebody's title estrogens can be supportive of the endometrial lining and can help with with pregnancy. 


Do we have you back, Doctor Rice? 


I don't know. Can you hear me? We can. Yes. You're going to say, can we expand on what androgens are? 




So, when doctor Kelly is talking about ..., we're talking about DHEA. So, that's going to be like your ..., your Andhra stereo, and your SEO Clan, allowing your testosterone, testosterone metabolites. And so, as she said, the androgens can be very, very influential and follicle development. 


So, we want to look at all of those components, right? Not just the endometrium, but also how you're building and making an egg to, and the androgens are Very important for that. So, yes, totally. 


Little shameless plug, if you are interested more in the female androgens and how they're created, the female Androgens edition of the DUTCH podcast, dropped today with doctor Kelly Ruef, go listen to that on any of your favorite streaming apps. Since we have you, doctor Rice, in your back, maybe you can kind of walk us through, what are some of the key things that you look for on the DUTCH test to determine fertility, if anything. 


For fertility, ah, all of the above. 


Really, I mean, when we're looking at fertility, and so this is where, and I think this may actually hit on one of the questions is where like we've done the testing. The estrogen is in the right range. You know in Saigon mapping the estrogen looks good. 


Her progesterone looks good, right, Like we've tested this sperm you know partner sperm looks good, like, what else do we do? 


When we're looking at fertility. I also really want to look at stress, right? So, we want to make sure that estrogen and progesterone are balancing each other. We want to make sure that the Androgens are producing a healthy level because of that ... Development. But we also really want to look at stress because stress is going to be a big thing. Right. Like if you're running from that saber tooth tiger, your body is not going to be focusing. Even if it has really good levels of estrogen really good levels of progesterone its main focus is keeping you safe and it's keeping you away from that saber toothed tiger. 


So, stress, right like your metabolized cortisol, your melatonin, your free cortisol diurnal pattern throughout the day, her oxidative stress, right? Like, this is what we look out for, What we call like the the zero trimester, right? 


Like when we're prepping someone to get pregnant, we want to make sure that all of those things, oxidative environmental exposures, how your cycle is, how your estrogen and progesterone are functioning and what your cortisol is doing, not only how much you're making, but what your cortisol is doing throughout the day. 


So, wonderful. How about you, doctor Kelly? Anything, in particular, you look at when, when starting at the top and working your way down. 


Yeah, I totally agree with doctor ..., all of us are really important. You know, a lot of times, Of course, I'm looking at the progesterone and estrogen and the Androgens. And with the DUTCH test, it's important with the androgens on page three, you wanna look at the age dependent ranges. 


And, even if I have a woman in her early forties, all still look at that 20 to 39 age range for the androgens, instead of the what is it, 40 to 60 fed rather, if she's trying to get pregnant especially, I'd rather have the androgens of a 35 year old and a 55 year old. So, I'll just point that out. 


100% agree. 


14:36 What Does Healthy Ovulation Look Like on the DUTCH Test? 

If you are looking for a healthy ovulation on the DUTCH test, what would that look like? 


OK, also a really really really good question So, with a healthy population you know if they ovulate, they're going to be making progesterone and like I said before, I like to see you at around 15 to 20 on the DUTCH test and that I should mention is the CRM equivalent. So, that's on page one in the progesterone dial, we have calculated the CRM equivalent, so if she went in and got her blood drawn on that day now, hopefully her progesterone will be around 15 or 20. besides that you know I might look at the androgen levels again and the estrogen. 


It might give us a little bit more, have an idea about the quality of the egg too. 


But besides that, know, everything on the DUTCH test kind of feeds into what is the overall health of the person, And the overall health of the person is going to affect their, their ... and the quality of their eggs, so, you know, look at everything. But of course, I'm going to be focusing on progesterone just to make sure that that they did obsolete. 


15:48 What follicle count number would keep a woman from conceiving naturally? 

Wondering, very specific question, but I think this one will have a pretty long answer. So, doctor Kelly will start with you on it. What is the EMH level or the the intro follicle count number for which you advise women that they are likely not to be able to conceive naturally any longer? 


OK, that is big question. I know the ... Council, the AAFC, it's a trans vaginal ultrasound and they're looking at all the follicles. Usually, you want to see around 12 to 15. 


And then, oh, I don't know if I really know, like if if there is a number where I say, yeah, you're probably not going to conceive. I mean, we, it's below six. 


That's definitely not the best sign for fertility, but you can also, usually people will test the EMH first, the anti-malaria hormone, because it can be a marker of ovarian reserve. And remember, you test this on day 2 or 3, and you don't want to test it alone, you want to test it with Estradiol and FSH. 


Because an FSH and estrogen, I'll always test those together because sometimes if estrogen is really high, on day 2 or 3, it will suppress FSH. So, you might get a really low FSH and be like, oh, you know, there's an issue here, but it's just because their estrogen was so high. 


And with the EMH, usually, we want it between like 1 or 3. 


I'd like to tag on to that. Yes. 


I totally agree with those numbers, but I also want to say that, in my experience, when I've had patients test AMA and it comes out low, it's like this doom message, right? 


Like, your ovarian reserve as low, you're not going to be able to have a baby. You're not going to be able to get pregnant. And I would say I would recommend testing, not just a one-time EMH, because I think this can change depending on what's happening with your stress, what's happening with your inflammation. And don't let that be discouraging. It gives you some information. You take that information. You adjust some things. 


You make some things better, and then you keep testing because, and even if, like, if you get super emotionally responsive to certain test results. Maybe you don't test your EMH again. And just continue to work on your stress. Work on hormone balancing. Work on progesterone and ... response because every person that I have had come to me was a low AMA. So, it was told you can't get pregnant from fertility clinic. 


We've gotten pregnant, it's not a final sentence, So it's helpful. 


At that time, snapshot in time, we've got some work to do, Great. All that means is, it tells us where to go. 


That is, that is great. 


And I'll add onto that even women who have been diagnosed with primary ovarian insufficiency, POI like post diagnosis five to 10% of them still spontaneously, ovulate and conceive and have healthy pregnancies. So, even if you have the diagnosis of ..., you can still actually have a baby, and that's why we don't call it, what do we used to call it? 


Premature ovarian failure, ..., so we don't we don't call it failure anymore. We say insufficiency, mm, hm. 


19:05 What are the top three reasons someone might experience fertility issues? 

Yeah, so we keep using some words like work to do and things that, that we need to do is what would you say are the top three, like reasons, or mechanisms that someone might experience and fertility, and what is the work that can be done about that? 


Doctor Debbie, let's start with you. 


I say the first one is stress. 


I find that stress is the biggest thing. 


I do thing genetics and environment and maybe hormone balance. 


Also, hormone bound, not just maybe also hormone balancing is huge, but like stress, I would almost say stress, stress, stress, and then some other things. Yes? 


Stress, Cooper? Yeah, And stress. All of us are so stressed out, especially the last couple of years, I mean, just in the last seven months, I've been 6, 7 or 8 times, so you can tell I'm also have a new baby. But let's see. 


So, if you're in her early forties, a lot of women are still having babies in their early forties. I would say talk to your doctor about options. Now, just see you're educated, doesn't mean you have to go through with any of them, but get, get educated now. 


And, you know, cut out or really lower the alcohol. Cut out the smoking. You know, lower the copy 203 cups a day. Stop using cocaine or you know, any recreational drugs. Get your weight, gain weight. 


If appropriate, lose weight, if appropriate, not exercising too much can be helpful. 


There was actually it was the Earth Study and they showed that a lower ... follicle count. They saw that with a higher exposure to phthalates. So, look into the Environmental Working group website and make a list of all of your lotions and potions and household cleaning products and go through the Environmental Working group website website and make sure that they're, they're clean and they're thief. Think about brands like Tubby, Todd, pipette is great, so just do your homework there. 


You said something that feels a little bit counter-cultural when you said, don’t work out too much. What do you mean by that and what types of workouts should we be doing to prepare bodies for pregnancy not mine personally, but speaking for the women that may be asking that question? 


Doctor ... might have a different answer, but usually I think it can be different for each woman. 


But, you know, not doing hit workouts seven times a week. 


No, not not lifting too much, weight, not running too far, doing too many marathons. You know, when I think about pregnancy, getting your body ready for pregnancy. 


I think about more, kinda low impact, swimming, yoga, cut things that can also have stress reduction in them. But it doesn't mean you can't do hit, doesn't mean you can't do, you can't run. You can't do a marathon unlike you probably; you can do some of that. Just don't overdo it. 


I would say, have it's relative to who you are, right? Like, if you have not been a big hit or is there a person? 


Pregnancy is not the time start, but if you've been running marathons your whole life, you can still very healthily maintain your, a certain capacity. 


But this is also like, say that pregnancy is a goal, right? We still want to look at what your capacity is for it. Like, what is your metabolic resiliency, what is your metabolic capacity? Everybody's going to be a little bit different. You might feel super pumped up, and awesome after you do an orange theory here. But you're five days a week, crazy, and maybe that is appropriate for your metabolic capacity. And then you have the other person who's like, yeah. I feel like I need to recover for three days when I do a workout. That's not going to be free, right? Like, you need to evaluate that, and if that's going to, like, you're the person that walks through miles a day, or does more of the hiking thing, you do more swimming, you do more yoga, rightly. And that's not to say that yoga can't be high capacity because it can, So I don't want to have a false fallacy there. You can have pretty intense yoga. 


But it has to be relative to what you've been doing, what your goals are, and where you're gonna go, because you can still maintain really awesome athletic capacity during pregnancy. It just has to be appropriate to your body. 


23:31 What tests should be performed for someone struggling to conceive who does not have any obvious signs of hormone imbalance? 

Great answers. And we are not sponsored by Orange Theory, so we will, not pushing for them, or telling you not to go there, True, I'll do, what, do, what's best for you. Onto the next question. What tests would you recommend doing for someone who's struggling to conceive but does not have any obvious hormonal imbalances, regular Menzies, regular oblation, healthy thyroid, healthy weight, no weight issues. What tests would you recommend them doing? We'll start with you doctor Rice. 


So, if all of that has been tested, I would still want to look at at least functional levels of thyroid because, I feel like Functional Medicine may look at it a little bit differently than conventional medicine. I would also want to look at cortisol. I wanna look at stress I wanna look at. 


I have some patients that are like, oh, this is just how it is like this is just how my life is. 


But if we test it on paper, we can see that your body is running up here, or you may also be super depleted. 


But you don't know any different because you've been in your body for however many years you've been in your body. So, I think it's good to look at your cortisol. Evaluate your cortisol. Look at your stress. Look at your sympathetic, parasympathetic balance. I'm also a fan of looking at environmental exposures, right? 


Like, if you are, I feel like journaling can be a very helpful. 


It can let us know, not just like when you have certain rhythms or changes or patterns and we're looking at sleep, we're looking at digestion. We're looking at exposures, right? Like, maybe one of your hobbies is painting and that's going to be a big environmental risks. So, we want to look at what that, what that could be, and some people don't even think of that, right? 


Because it's a stress reliever, it's something that you do for fun. So, I would definitely look at functional ranges for thyroid functional testing for stress and cortisol and environmental exposures and gut health. 


How about you doctor, if your gut health for sure. Sometimes I look at Prolactin and of course, testing the ... LH and the FSH on day 2 or 3 of a cycle. Sometimes that can give you an idea of of if there's an issue with the signaling from the brain to the ovaries. 




The sex hormones, vitamin D Look at vitamin D So there is research that if you're low in vitamin D and you can see you have an increased risk of miscarriage. So, I definitely look at that vitamin D even though it's not covered by insurance, sometimes people can do cash pay. 


And then I might look into things around methylation like MTH FR methyl ... acid, which we have on the DUTCH test, fully homocysteine. 


Sometimes methylation issues can play a role in infertility, and sometimes homocysteine will elevate if there's methylation issues, but also if there's low coleen, and we know that calling is, like, every woman who's trying to get pregnant, I put them on calling, and make sure they're getting calling in their diet. And we know that coin is really important for that baby's brain development in utero, so calling before pregnancy, cooling during pregnancy, calling during breastfeeding. 


Calling Holly, Holly, not sponsored by cooling, but we should be. 


26:51 Is there a connection between 16-OH-estrogen metabolites and cortisol metabolism? 

Next one's a little more technical question about the DUTCH test. So, I'll try to do my best to not just read off a bunch of acronyms. Is there a connection between 16 Hydroxy estrogen metabolites? 


And cortisol metabolism or the cortisol metabolites doctor Reiss, you are shaking your head, so we'll start with you. 


So, I, I think there is correlation, but I feel like doctor Kelly, you might have a little bit more information on that. 


I'll let you explain that. 


I think this is based off doctor Allison Smith's webinar that she did once the last month. She talked about this. And so CYP 3 a 4 Step 3. A four is an enzyme that metabolizes S drone into 16 Hydroxy Restaurant. 


It also metabolizes ester dial into estriol, which a fun fact estriol is the same thing as 16 Hydroxy Estradiol, which is really confusing, right? But on the DUTCH test, we we look at 16 Hydroxy S Drone. 


And then everyone's like where 16 Hydroxy Estradiol and I'm like, it’s right there, it’s estriol, OK, but sip 3 or 4. It also metabolizes cortisol somewhat. 


So, if you have a slow Step 3, 4, you might have some sluggish cortisol metabolism, but the five alpha, phi beta, Redactors, enzymes are probably more of the primary enzymes that are metabolizing cortisol. 


So dental, Jen, I'll say dental. Dental effect. 


Yeah, well, say gentle. A good question. If somebody had if a patient had menopausal, estrogen levels, and they're 30-year-old female, with regular cycle, what could be some of the causes of that? 


With regular cycles, mm hmm. I feel like that kind of overlaps what we were talking about with the cycle mapping. 


There could be right like just generally lower levels of estrogen. 


But I would also wanna make sure that we're looking at appropriate timing for when we do the DUTCH tests. Like, if it's a DUTCH complete or a DUTCH Plus, or even a serum test, we try to shoot for the best luteal range in the cycle. 


And if you're having about a 28-day cycle, that special day is going to be around a 20, 20, 122, depending on the person. 


And if for whatever reason you're having longer cycles, whether that's, you know, a longer Luteal phase or something is off we haven't hit that appropriate Luteal phase. 


And if it's a post-menopausal estrogen we're, we're probably way off target on that. 


And we mentioned earlier if, if they're progesterones within range. 


If they ..., then their estrogen had to get to a certain point for a certain amount of time for them to emulate. So, they're they're estrogen isn't going to be in that post-menopausal arrange throughout the entire cycle. 


And yeah, so maybe look into a cycle mapping so you can see the estrogen levels drain the entire collection period. 


30:15 Do synthetic progestins act more like estrogens in the body? 

Wonderful. So, Doctor Ruef, do synthetic progestin's act more like estrogens in the body? 


They actually tend to act more like Androgens. 


And I learned this from doctor Laura Bryden, who I love in a door. And you know, this is her book. If you haven't read it, it's great. 


Period Repair Manual. Then she talks about this in her in this book. 


So, there are progestin with a High Antigen index and that's like mature oxy progesterone, which is in the ... injection. Can ever say this, but Levon all gestural. So, think about Norplant Marina IUD on the morning after Pill and then, nor gestural. 


Here's a bunch of other ones. North and Drone is one that we have heard about. Nuba Ring, next one I, and you know, a lot of lot of pills, o.t.p.s contain those and so on. 


Yeah. Those have a high androgen index and it's unfortunate. Sometimes we actually see women with ... being put on pills that have these progestin's that have a high androgen index and act like androgens and the body. So, definitely isn't helping their symptoms of access. 




31:32 What is the difference between synthetic and bio-identical hormone replacement therapy?  

Wonderful. Thank you. Yeah. Doctor rice, question to you, what is the difference between synthetic and bio identical hormone replacement therapy? 


Great question, I think that there are certain practices they're used synonymously but they are very not synonymous when we're looking at synthetic hormones, these are made in a lab, and they are. 


they try to mimic the hormone structure of what our body makes his progesterone or what our body makes his estrogen. 


They try and in that they, with these chemicals, the reason why they end up maybe not being as effective or over effective, right, like you get a more pronounced reaction is because of their chemical structure. 


They end up either binding, too, strongly, or binding, not just what we're looking for, like with estrogen, but they end up finding some other things, too. And so, we end up getting a more exaggerated hormone response with maybe some other reactions that happen as well. 


Bio identical is where we're, we're trying to mimic the progesterone that your body makes, and we look at the compound structure of what your body makes for progesterone. 


We have a plant structure. That is the same. 


And so, in that, because, like every everything is made an elaborate, though, when we're looking at bio identical hormone replacement therapy, this is taking that plant structure. 


And it's the exact same Like the way that it binds in your body is going to be the same as if your body made it so you're getting a bio identical or same hormone response with a bio identical estrogen, a bio identical progesterone. So, it's going to be more of a natural binding. 


It's going to be more of a natural response with a bio identical hormone replacement therapy versus a synthetic hormone replacement option. 


33:42 How do you use the DUTCH Test as a tool alongside hormone replacement therapy? 

And this is not a question somebody submitted. But it is a question that I thought of, as you were saying, that when you're testing and using the DUTCH test with any type of hormone replacement therapy. How do you use the DUTCH test as a tool alongside of that hormone replacement therapy? Both pre, with and post? How would you recommend using the DUTCH test as a tool? 


It's a big question, Noah. Here's your rabbit hole. I think it also depends the route of administration. 


Are they taken orally topically and that's gonna really change how we're going to interpret the test? 


It wouldn't be nice, though, to, like, if we can have, like, If I can do whatever I want, and I would love to have a baseline test. Right. So, we know what your body is making and with bio-identical hormone replacement therapy. So, the DUTCH test measure is what we call endogenous hormone production that means what your body makes of those hormones. 


And if you're using bio identical, hormone replacement therapy that does, test, doesn't know, the difference between Debbie and bio identical hormones that W is taking. So, it's going to show that bio identical, hormone supplements, fashion. If I'm testing Debbie, but I'm also taking a synthetic hormone, what ends up happening is that is labeled as an exogenous hormone. 


So that synthetic hormone will. We will still see the effect of that hormone. But we won't be able to see how much of that estrogen is in there, right? Because it's not an endogenous, or bio identical, hormone structure. So, we also have to be aware of that, right? Like, is this a bio identical? hormone therapy? Is a synthetic hormone therapy? 


We still see the effect; just depends on what hormone it is. 


Not confusing at all, right? So not the route of administration, simplicity, right? Yes. Yeah, I like that idea. 


Sorry, no, you're saying. No, go ahead and go. Oh, I like the idea, doctor. Right. 


So, you said to do a baseline and I had this argument in my head for a long time like OK, I have a menopausal woman. Should I do a baseline DUTCH test? 


Her hormones are going to be low, right? 


But I know now that I've been a consultant here for about three years now, three years now. This is next month. 


Mean, I've looked through thousands of these these lab reports, and I do see it's it's rare, but I do see some menopausal women. With estrogen with Estradiol that's in the ... range, and with that woman, I'm not going to give her more estrogen likely, probably going to ever progesterone to protect her uterus. Usually, you see that in women, who maybe have a history of ..., they have high Androgens, and they're usually overweight. But then, on the opposite, sometimes you'll see a post-menopausal woman with really, really low Estradiol like very like below the post-menopausal range. And for that woman, I might actually start her off at a higher dose of Estradiol. 


So, I think it can be helpful to see baseline estrogen, I think it's important to at least measure it in serum. You have a measurement before. 


I'd love to know how your metabolism estrogens too like Am I? 


Am I putting gas on a fire, or do we need to help with detoxification like What is your oxidative stress? 


The other thing too is I mean this is kind of a little bit of a tangent but when we're looking at Peri Menopause and post-menopausal females, we know that the adrenal glands step in, right, as, as the ovaries decided that they're done the adrenal glands step in to help. And so adrenal health is going to be really, really important in understanding what you're coming to the table with when it comes to, you know, how prepared are you for hormone transition with barium post-menopause. 




37:38 DUTCH report does not show high testosterone, but patient is experiencing symptoms. What is the next step? 

Thank you for taking my rabbit hole. I appreciate. Doctor Kelly, do you have another question for you? This person asked and said that they have an increasing number of female clients. As well as Perimenopausal reporting, male pattern, facial and body hair growth, their DUTCH reports are not showing alarmingly high testosterone which they thought would be to which they expected to be with the symptom. What do I need to be looking at differently, or is there something to balance? 


What might be causing this uptake in females, OK, OK, so mm testosterone and DHEA, is coming back normal. 


But they have hair growth on their face and body. 


OK, I think I'm understanding that correctly. Yep. 


So sometimes doing the DUTCH test in these cases can be helpful because with the DUTCH test, we can look at the downstream androgens. 


And we can see how they are metabolizing there. You know, clear like metabolizing and clearing out their antigens are more metabolizing. And so, we know that testosterone, the active form of testosterone, is by Alpha di, Hydro testosterone, so, DHT. 


Think I said that right. And we do test DHT on the DUTCH test. But I like to keep in mind that DHT is a peripheral hormone. 


So, it likes to hang out in the tissues, it doesn't really like to hang out in circulation, so what we test in the urine, what we test in the serum might not be the most accurate picture of what's in the tissues. 


We also test five alpha and dressed in a dial, which is actually a downstream metabolite of DHT. So, I have people imagine this. 


So, imagine you've got DHT in your tissues, in your chin, and there's a lot of DHT and it's causing hair growth. 


That D H T is a peripheral hormone So, it likes to hang out in the tissues around your jawline, it doesn't really like to hang out in your blood or in your urine. So, we might actually miss it if we test it in the blood in the urine but this all this D H T it's being metabolized to five alpha and dressed in a dial and five Alpha Anderson at dial circulates better. 


So, we can test that in the urine, we do test in the urine. And so, sometimes, if you're five Alpha Anderson, a dial on your DUTCH test is elevated. That can be a better marker of alpha activity or DHT activity in the tissues. 


And so, you know, I look at those downstream. 


Androgens, I look at the five Alpha Phi Beta index. We know that five alpha reductive tends to turn androgens into more potent forms that are going to cause no hair growth on the jawline. Whereas five beta, redact ace, is going to turn those androgens into the less potent importance. 


one thing I want to clarify, because I get this question a lot, sometimes, women have really low androgens just all across the board. They're DHEA, their testosterone is low there, downstream, androgens are low, but they're pushing the Alpha pathway. And people say, well, that, OK, that's causing the acne, right? 


That's causing the facial hair, and I'd say, maybe not use caution there, because even though there favoring five Alpha ..., they just don't have a lot of androgens in general. 


And so, it, there might be a different cause, but with the facial hair, you know, I still look at blood sugar, I still look at medications, some medications can definitely cause that. I asked about their mom, their sister is a hereditary treat me. Maybe. 


Maybe it's just one church in here that really bothers them, you know, so it can be really subjective, too. 


I would also like to add that sometimes with that where you have this lighter androgenic effect of HRSA, to like the hair Growth and acne I also like to look at progesterone because low progesterone. I think when we look at progesterone a lot of times we think of progesterone as the balancing hormone with estrogen, but it's also a balancing harm with hormone with androgens, too. 


So, if you have low progesterone and right. 


Progesterone only gets to like you have her little party, the second part of the cycle. And so, we already know that there is progesterone deficiency, right? Like, normal. Because you're not supposed to have it. But then if she gets her chance and she's still a cycle. 


She uses you're still not getting enough of this light Progesterone response or balance even with the androgens too, so you might have completely normal levels of androgens but if you have low levels of progesterone to also help balance that, that can also influence that, too. 


I started talking, and I was muted, so I appreciate the sound effects. That was really helpful. As I understand progesterone. I've got We've only got about 15 minutes left. So, I've got two questions that we'll ask. 


one is a very specific question about the DUTCH tests, and one is a very, very broad question, but I'm sure it was submitted multiple times. So, we'll try to get to it in the most efficient way that we can. Maybe you can both give me your top three reasons of what might be the cause of low libido and how you would see that on the DUTCH test. 


We should say at the same time W S. S rescheduled Totally. So, you guys and this is this is in the Merck Manual. Like if you look at the Merck Medical Manual and it's like nails and the beta, females in libido unlike males, there's like two things that can affect those females. It's like, the list keeps growing. Oh, OK. 


Yeah, but stress, stress is a big one. 


What might be a couple of other things that you might be able to see on on the DUTCH tests specifically, and low libido that they could check for? 


Doctor Kelly, you know, low or high cortisol, which kinda ties back into that stress. 


Low androgens we know low estrogen. 


Besides on the DUTCH tests, I mean, thyroid issues can tie into it. 


So sometimes you'll see patterns of thyroid which we sometimes we see patterns with the cortisol when it relates to thyroid. then relationship issues. 


I mean, sometimes, I know practitioners' ask, well, when you look at other people, are you attracted to them? Do you get turned on or is it just your partner so that that can be an issue, too? 


And for, for females, we also know, right, like, if you have a list, as things that you're doing, right, like a lot of times, females have to know that their list is done, before they can actually relax into that light. 


OK, now, whereas, right now, we can activate it. 


So that, that is going to be, like, that mental clarity, being able to, at least, some people, it just takes, like, maybe, a little bit of meditation, for making sure that their to-do list is helpful, I don't know if you guys, OK, this. 


So, you know, Kristen Bell, and dax shepherd, right? Like, I love them. And she is posted the thing on Instagram where he's out there like, cleaning and vacuuming and did it. And she was like, this is my husband trying to turn me on stamp. Of Approval. Yes. Right there to. Do list. Absolutely. 


The other thing that I would say, though, too, is also progesterone, so there are some women. I mean, I know a lot of times you think of testosterone is like that hormone, and it's true. Yes. It's part of that. But there are a lot of women that are also like, Man, you know, I feel a little more saucy around ovulation and it's because you're getting that ramp up of progesterone, so progesterone can also be influential there, too. So, if you're not getting a good progesterone bump like, you know, having that imbalance and hormones can certainly. 


You miss the opportunity for the sound effect. There I was I was looking to the sound effect again. But it sounds like a balancing because that sounds, but to continue continues to be is finding that balance between stress and gesture on and and looking for that circadian rhythm. So, that's, that's good to see. And you talked about thyroid and cortisol and then stress and cortisol, it sounds like cortisol is a big, big piece to the puzzle for a lot of us there. 


46:23 Is DUTCH testing recommended for teenage girls? 

That's the thing. Its thing for us, is the thing. Yes? That's right. And then this is the last last question, then, we'll get to today. I know we had a lot of questions submitted, and we're thankful for everybody that submitted more questions today. And throughout the time that we we gave you to submit those, but this is the last won't be able to get to today. And I'll kick this over to you, doctor Kelly. Would you recommend the DUTCH test to a teenage girl who just started her period and experiencing symptoms, IE, cramping, acne, et cetera? 


You could so she she's 16. She just started her period. 


So that's a little on the later side for monarchs to start your period for the first time. 


I know some people will wait about two years four. 


The H P G or the HPA access to mature more before they do testing. 


There goes my light. 


But if the symptoms, I mean, you could definitely test her, she's 16, her urine, she's excreting, creates an inn away as an adult would. So, the results are going to be accurate. So, you can definitely test her and you know, if she's, she's getting her period, then you can kinda come, you know, you can kinda compare her hormone levels too. 


Or at least her estrogen and progesterone too, like a 20-year-old. But just use some caution there. 


So, I would say if the, if the symptoms are are out there, severe enough, yeah. You could definitely test. 


But some people will kind of wait for that H slash PG access to mature a little more. 


I think doctor Wright's might have some more to say about that. Yeah, because I'm going to start coffee. 


No, I totally agree. 


I think you can still test the information is still going to be representative. 


It would be my preference, you know, to have a little bit of route, like, routine cycling under the belt to be able to have comparison. But as as doctor RESA, there's, you know, she did start a little bit later. 


So, it might be nice to see how she's doing out the gate and see if there's any support that you can do. 


Wonderful. Well, doctor Kelly, doctor Debbie, thank you so much for jumping in at the last second for showing up with getting over being sick for doctor Debbie jumping in and helping out. We're very thankful for all of the questions that you asked today. Don't forget, we will be sending out information about doctor ... webinar when we do reschedule that, so if you showed up today, we're looking for her, something came up and she was unable to make today. So, thank you, doctor Kelly and doctor Debbie for stepping in. And thank you all for joining us again today. So, check your inbox is tomorrow, for a link to the recording. If you do have any additional questions that you'd like to ask, questions about our content, or just questions in general, please submit those to info at DUTCH test dot com, and everyone, have a great and wonderful week. Hope you are well, Wrested from the holiday weekend. 


Thank you.