Cardiovascular Disease Risk Assessment: How the DUTCH Test Applies

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In our second heart health webinar for American Heart Month, Doreen Saltiel, MD, JD, walked through two case studies from actual DUTCH results for a male and female patient. She identified the warning signs hidden in sex hormone and adrenal results, so you can discuss CVD (cardiovascular disease) risks more effectively with your patients. Looking into the research and debunking the myths, she sheds light on the facts about hormone replacement therapy while examining the hormone markers you need to be aware of when assessing cardiovascular disease risk factors.

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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

0:04 – Webinar Introduction

3:33 – Webinar Begins

5:28 – The Patient History

15:50 – Physical Exam and Treatments

21:57 – Case Studies – Peter

42:11 – Case Studies – Maggie

1:04:51 – Final Thoughts


0:04 – Webinar Introduction

Welcome, everyone. I'm Noah Reed, Vice President of Sales and Marketing for Precision Analytical Creators of the Dutch test. Thank you all for joining us again for our second Heart Health Webinar during American Heart Month.


Today, we have Doreen Saul Till M D with us. Again, exploring to Dutch test case studies of a female in a male patient. As she goes through these two Dutch reports, she'll share insights on what markers you should be looking for when assessing your patients cardiovascular disease risks.


If you missed last week's presentation, you can find the replay, a dutch test dot com, and by clicking the banner on the homepage.


If you're not already familiar with precision analytical and the Dutch test, dutch stands for Dried Urine Test for comprehensive hormones are validated for spot dried urine tests provides a complete evaluation of sex and adrenal hormones, including the tablets for both baseline hormone testing and Effective HR Team Monitoring.


We offer simple and convenient at home collection for patients, and an easy drop ship option for providers. Our advanced testing methods help providers answer the most complex clinical questions with the most reliable and trusted results.


Registering as a Dutch provider is easy. If you sign up today, you'll receive 50% off your first five kits plus free clinical consorts video tutorials, patient referrals, an expert hormone education to sign-up. Just click the link that we've posted in the chat and complete that 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 your questions and walk you through the onboarding process.


If you are a current provider with us, we encourage you to join the Dutch test provider support and networking group on Facebook by clicking the same link posted in the chat.


By joining this group, you'll receive exclusive access to case studies from our clinical team plus, peer-to-peer collaboration with other duch providers.


Before we get started, Please note we've posted today's slides in the handout section of the GoToWebinar control panel below, and we will send the recording and slides to everyone tomorrow. If you have questions along the way, please add them to the questions section of the control panel.


If you don't already, follow us on Instagram and stay tuned for an Instagram live, where doctor ... will answer as many questions as she can.


And now let me and now allow me to introduce today's speaker.


... MD JD has practiced medicine for 40 years. She is a board certified practitioner with a cardiology fellowship and has practiced interventional cardiology for more than 25 years.


Doctor Saltz, he'll completed advanced fellowship training and metabolic and nutritional medicine from MMI, as well as their advanced certification and endocrinology and cardiovascular health.


She currently practices functional medicine with an emphasis on hormone health and preventative cardiology, and has co-authored multiple peer reviewed papers.


Along with the founder of precision Analytical Mark Numan. She recently presented hormone testing research to the North American Menopause Society at their 2021 annual annual meeting.


We're very excited to have doctor ... back with us today, to add to her amazing presentation from last week. So with that, I'd like to turn it over to doctor Doreen Saltier to start your presentation.


Thanks, No way, you're always so kind. When you introduce me, I think I'll have you back every single time.


Sounds great.


He'll be back regardless of whether I want him back or not.

3:33 – Webinar Begins

Alright, we're going to do something just a little bit different today.


Because there's a lot of information here that I wanted you to have.


I want to emphasize the case studies, and most of that you can read on your own, and look up the studies and read the studies that I have here for you.


But let's get started, and then we're going to jump ahead to the treatment's stuff.


There's the disclaimer.


And here are our objectives.


We're going to talk about the nuances or I have the nuances for you, the necessary laboratory testing, which is in here, and treatments, both non pharmacological and pharmacological rajat.


As you recall, our goal is to prevent cardiovascular events in those individuals at risk and in those individuals with subclinical vascular disease. And we also want to prevent secondary event and those individuals who had a prior event. Last week we reviewed the HPA access and its role in cardiovascular events in mortality. We talked about glucose dysregulation and its effect on the endothelial, like, OK, looked in the end, the feeling.


We talked about how hormone deficiencies increased potential for adverse cardiovascular outcomes and how menopausal hormone therapy, and testosterone therapy likely improve cardiovascular outcomes. We also mentioned you've got this ... and a sad diet, how they preached ... an independent predictor.


We mentioned what an ohmic nervous system, imbalance, and how which associated with increased event rates and one's inability to detoxify, which we're going to focus a little bit today on increases information. And I'm gonna go through this very quickly, and then we're going to get to the bottom line.

5:28 – The Patient History

You want to do a day in the life What a typical day looks like. You want to assess traditional risk factors and non traditional risk factors.


In addition, there are certain things we need to ask about what is adverse pregnancy outcome?


Gestational diabetes, pre-eclampsia, CLABSI and pre-term deliveries are all associated with increased future heart disease risk, chronic inflammatory disorders, like auto immune diseases.


You should, you should ask about what to immune diseases in men, but they're much more common in women, increase MI and CVD mortality risk two to threefold. And, you know that steroids are often the first line of treatment. And, as we are aware of, it, increases metabolic syndrome and premature atherosclerosis, osteopenia or osteoporosis is associated with cardiac events. Again, we should ask about this in men, but women are more prone to this.


And remember, well, vitamin D, which is more common in women, is associated with a 1.62 times increased cardiovascular event rate, but no, vitamin D doesn't decrease event rates.


Then we talked a little bit about ... cardiomyopathy, which is highly prevalent in post-menopausal women, it's associated with endothelial dysfunction, micro vascular dysfunction in the absence of critical coronary disease.


And these women have a higher cardiovascular morbidity and mortality when compared to their peers without Takasu BU's.


Marital stress in women is associated with three times increased coronary event risk. Despite controlling all other risk factors. And depression in women, less than 55 is associated with increased cardiovascular mortality when compared to men.


And Bazel Motor Symptoms are linked to adverse cardiovascular risk factors. You're just study by Rebecca Thurston, and this is a sub study of the Large Swan study study of Women's health across the nation. And they look to determine whether frequent and or persistent visual motor symptoms were associated with the risk of increased non fatal and fatal cardiovascular event. It was a longitudinal study, over 20 years.


Pre and early perimenopausal women were enrolled, and they were followed.


Visual motor symptoms were categorized as non 1 to 5 days every two weeks and greater than or equal to six days, every two weeks, and you see: remember: these were not done using l.c.m., SMS was done doing an immunoassay.


And the Ashford, I, all levels are really not that much different, but what they found was that frequent or persistent visual motor symptoms were associated with a 50 to 77% increased risk of future events. And you can see this here years from, you know, enrollment and hears the CBD event.


So they also determine that more studies are needed, so frequency and and or persistent visual motor symptoms are more than an annoyance. They are associated with increased cardiovascular events.


Then Graham Jackson in the early 2013 timeframe said this, erectile dysfunction should be considered a vascular disease until proven otherwise Edye and Cardiovascular disease share the same set of risk factors.


ED is an independent risk marker, ED may indicate subclinical vascular disease in otherwise asymptomatic males, and it's not surprising that CVD patients are more likely to Edye. And patients with erectile dysfunction are more likely to develop cardiovascular disease. And interestingly, there's typically a 2 to 3 year time lag between EB onset and cardiovascular disease symptoms.


That doesn't mean they don't have subclinical vascular disease. It just means they don't have overt cardiovascular disease. And the first cardiovascular disease may be sudden cardiac death.


And as you can see here, the severity is correlated with disease burden, and it has been independently associated with events.


And this is a meta analysis done by Tao, where they looked at about 154,795 males and about 25 studies. And they set out to assess whether erectile dysfunction was an independent risk factor.


And what they found was severe, erectile dysfunction, predicted higher cardiovascular disease and all cause mortality.


And when they compared to men without ED, men with ED had just had a statistically significant increase in cardiovascular disease, by 43% coronary disease, by 59%, stroke by 34%, all cause mortality by 33% and they concluded that CVD coronary disease stroke and all cause mortality may be significantly increased in men with ED, especially severe ED.


So, all men with erectile dysfunction should undergo cardiovascular risk stratification, regardless of their risk factor profile or cardiovascular symptoms.


And here is the IEEE five questionnaire that's been validated regarding erectile dysfunction in every single male that you see in your practice should take one of these questionnaires. And you see as the numbers decrease, erectile dysfunction gets more severe.


And you also want to think about low testosterone. And so you want to also have them do the atom questionnaire.


And so when you look at the Mesa study, this is a sub study. They looked that the association between baseline, subclinical vascular disease and subsequent development of ED this is typically backwards, right. Typically, patients have E D, and then we go searching. This was the first study to reveal that sub clinical Cardiovascular disease isn't a reptile dysfunction predictor and will determine the temporal relationship.


This is 862 men. Their mean age was 60 at enrollment. They had no known CVD. They then went under a battery of vascular studies, calling your caching MCI and T they looked at in the allele dysfunction, vascular stiffness, APIs, et cetera, et cetera.


And what they found was that men who develop E D had a higher baseline prevalence of vascular abnormalities except APIs.


When compared to men without erectile dysfunction and coronary artery calcium and a periodic plaque score, that's corrado plaque burden, really, of how much plaque theories were statistically significantly associated with subsequent. And you can just look here, the number of vascular abnormalities.


This is the frequency of among patients with different vascular abnormalities of the presence of erectile dysfunction, and as vascular abnormalities increase.


So, does erectile dysfunction the same here?


And so they concluded that subclinical vascular disease is common in men who later develop Edye someone or males with erectile dysfunction, proceed with cardiovascular risk stratification, regardless of symptoms and all men with subclinical vascular disease. Assess them for ED, as well as low testosterone. Speaking of low testosterone, this is a small study, five year prospective study done in Italy, assessing cardiovascular disease in men with erectile dysfunction, and testosterone deficiency.


All of these men were at intermediate. Risk is defined by the Framingham 10 Year.


Event rate in intermediate risk is 10 to 20 percent.


802 men, 40 to 80, and here, they all had endothelial function, and they all had The erectile dysfunction questionnaire, and the bottom line is, men whose teched up total testosterone was less than 300, had a higher prevalence of low risk back.


In addition, they more frequently had acute myocardial infarctions debt, post, MI, major stroke, and the composite of all major adverse cardiovascular outcomes. And you can see testosterone less than 300 testosterone greater than 300, And you see that independent predictors of future events were dyslipidemia, not surprising, catching inflammatory markers. Lipids are part of the innate immune system.


Obesity, inflammation, total testosterone less than 300, and direct dial dysfunction. So, man with cardiovascular disease risk factors in ED should have total testosterone levels obtained, and total touched on, and testosterone therapy may prevent future events. Sewing males with DB, Chevron levels to assess the presence, or absence of testosterone deficiency, and improving total testosterone levels may decrease major adverse cardiovascular events.


And so a complete history provides insight and the need for additional risk stratification.


In females, visual motor symptoms are important and not just an annoyance in males, Erectile dysfunction is a marker of vascular disease. And we're going to skip ahead now. So we can get to what everybody really wants to see. The physical exam, the laboratory data, are pretty straight forward.

15:50 – Physical Exam and Treatments

I'm going to start with uncommon treatments that many of you may not be, I'm aware of.


And that I use.


And that you should consider including in your armamentarium are terrorists?


Has recently been patented ... plaque and stay, vulnerable plaque stabilization and regression, it strengthens and heals the glycol calix.


Thus ameliorating vascular dysfunction. Its main component is running sulfate which is, which is this green algae that I can't pronounce and known functions of this green algae oriente viral. Now, coagulant anti tumor, you could see all the things it does. It decreases blood sugar. And, as we talked about last week, blood sugar or elevated fasting blood sugar, even for 15 or 20 minutes causes damage to the endothelial black, OK looks.


It's a powerful regenerating compound.


in the setting of LPs induced endothelial cell inflammation, it will decrease tissue factor, Inbound will a branch factor, Thus, decreasing pro coagulation, and let me just show you. This is very interesting, you know, not as, you know, an absolute, but this was a proof of concept study done with our tour sale.


Looking at its effect using fancy MRI scanning on vulnerable plaque, the lipid rich inner product poor, which is kind of soft and that's the stuff that's prone two rupture.


And what they found was that it reduced this lipid rich product poor by 47% males and 64% in females, and you say, Wow. But let's compare it to what statements do.


And when they look at staff meetings in this, using the same parameters, MRI, corrado plaque regression, looking at the lipid rich in a product, or they found that statins only reduce the ...


by 25% and 38% in females. And so, what you're still in the short-term led to a greater percent reduction in the lipid ... product, Corda Vulnerable Plants than statins. Thus better stabilizing, vulnerable plaque. That doesn't mean you shouldn't you stanton's in the appropriate population. I'm just trying to show you the power of this nutraceutical.


You all know about magnesium. H garlic is another nutraceutical that has over 750 clinical studies. It lowers blood pressure by about 16%.


There are a number of studies, one done by Matt, but off, uh, on plaque regression and it did cause plaque regression in the aorta when it was given for two years. It supports blood vessel integrity.


It prevents glycation, uh, of which is how, that hot, elevated blood sugars by creating advanced glycation end products increases inflammation and oxidative stress, worked on the microbiome and immune support.


And this is something that I use a lot.


It's some fiber, It's a soluble fiber, it's got prebiotic so we produce short chain fatty acids, it supports the got the immune, the cardiovascular system, and estrogen metabolism. A 2017 review documented significantly reduce CVD and CVD. Mortality rates reduces in the incidence of coronary disease and stroke. It's tasteless. You know, you can put it on in oatmeal. You can put her in a smoothie and patient seen to tolerate it really well.


And here are two things that I tend to use for the HPA axis. Again, I use a lot of the metabolic products, and I use the metabolic questionnaire.


And we calm is if somebody has, you know, dopamine and, you know, does a lot of stressful eating and adapt CNAS I tend to use in people who I think have lots of oxidative stress. It's got partnerships, you know, you can give it, it's a weak p.d.i.


five inhibitor, and both of them support HPA axis bass.


And if you are not able to prescribe, I don't want to prescribe, You can try T time. You can try your him be. Centrally works better than orginally at increasing nitric oxide.


But, again, none of these have been studied to, in cardiovascular outcome studies, so again, it or bone mineral density study, so it is, again, you can use it, but you have to take the entire patient into context and, or estrogen progesterone balance. Professional health product makes this its similarity to, but doesn't bind to the estrogen receptor. It may help support bone mineral density in a couple of studies.


It has been found to be breast protective and like anything else, it acts like a hormone, so you need to monitor hormones regularly, you all heard of Chase Tree. It works by raising progesterone lowering lead to a blocks FSH and increases. So, if somebody as low dopamine and they do all that stressful heating or they have 15 this may be helpful if you don't want to use progesterone.


But its effect on bone mineral density where Progesterones, really important, hasn't been studied.

21:57 – Case Studies - Peter

All right, everybody, take a deep breath, and we're here to where we want to be, Peter.


These are actually real patients, Peterson, 50, Euro lawyer, who has an app been working, who has been working from home since the pandemic.


I changed his name, and actually, I was going to call him Fritz, and I was going to call the female patient.


Brenda Lead, which people who know me know that I'm like obsessed with the closure and.


major crimes, and but I thought, I would be chuckling too much and I gotta be serious anyway, He states that it can't concentrate. His work performance has decreased, said he has a Foggy Brain all the time.


He's here because his spouse insisted. He has had 6 to 9 months a decrease Libidos, erectile dysfunction, reduced spontaneous and sexual related erections, and decreased Orgasmic function. So, this guy, regardless of anything else, needs cardiovascular risk stratification, in addition to assessing always hormone stuff.


Prior to nine months, he noticed, decreased morning erections, which he thought was normal, but was without any other sexual symptoms.


He sleeps 6 to 7 hours each night, such that he can wake up at 400 to exercise. But two hours a day.


He does Iron man every day with no days off.


So he over exercises. Think about what his HPA axis is gonna look like. He survives on coffee all day, otherwise he could not keep up.


His diet is on and off lately, mostly all went on each, a Mediterranean style diet, that is gluten and dairy free.


His diet lately consist of 1 to 2 meals a day, processed foods, lots of carbs, few vegetables, and a lot of animal protein.


His cardiovascular risk factors are down.


It takes nomads. He has no allergies, he had a vasectomy at 45. His dad had first MI at 45 and is equal V three for his older brother, had a first MI at 50 and is also April E 3 4. So not much lucky with the genetics.


He's happily married for 25 years, Yes, Regrowing healthy children. He drinks red wine with dinner on weekends. He never smoked.


Review of systems is remarkable, but you're a bow and he's noted testicular shrinkage over the past six months. You need to ask about these things.


His blood pressure is high, and he says it's similar to what it gets at home. His heart rate was 19. He says normally as heart rate's about 60 or 50. So this may just because he's nervous. He's six foot tall, £190. His BMI is 25.8, barely overweigh. His waist to hip ratio was 1.3 to 1 you want it could be less than zero point nine around, or one is GDP is normal. The cardiovascular exam has an S four, which is a billing sound indicative of a step ventricle.


His pulses were all symmetrical his testicular rectal exam, where normal is 48 on the atom that should have been on the I V E F, not the atom, and he was low on the atom score.


He's, so he's a 50 year old male asymptomatic. With cardiovascular risk factor and sexual symptoms, There's him summarized. He probably has HPA axis dysfunction. He probably has testosterone deficiency, and he has ... with metabolic ....


I know that you'll see when he's labs come. Here's what I do on just about everybody who comes to me for preventive cardiology, and basically for hormones and I do some of this depending on the history.


And everybody gets a Dutch test.


And I have to tell you that previously I may have you serum and occasionally saliva cortisol.


but knowing what I know now and what I've learned from, you know, Marc Newman and the clinical team over the past two plus years and my own research, I cannot take care of a patient without doing the Dutch test.


It tells me about metabolomics. It tells me what the tissues are seen.


It gives me insights into not just the free cortisol pattern, but total cortisol production, and how it's being activated, and in the day.


And, you know, in some guys and a guy like this, I will get a testicular.


And very interesting, his fasting blood sugar was 100 ish fasting insulin, was 10, 5 to 7.


And hemoglobin A 1 6 is 5.9, so he's insulin resistance, is vitamin D was 30.


Is TSH was one of his T 4 was 1.5 is T 3 was 3.2, not terrible, is reverse T three, which 12.


But he's got thyroid antibodies and that's why I know he has, despite aosis with metabolic ..., is C reactive protein is 2.5 is homocysteine is 10 HTML is eight is a DMA is 125 which is an independent predictor. So he's got a bunch of moderate and high risk markers. Is triglycerides 180 little too high for me.


I like them social one for a huge LDL particle number 1300, which is modest, moderate risk, and LDL. Particle number is 5000. You want at a much higher than that. So he and I will tell you those HBO's 35. It is April B is moderate risk. He is lucky.


He's an April 3 3, he got the three from his dad and the three from his mom.


And he's got an abnormal, CMT, carotid interim or medium thickness. So he's got subclinical vascular disease and here are his hormone levels is total testosterone and was 225. His free T was 55.


... using ... equilibrium dialysis, and I also calculated, it is E 2 was 18, which is lower than you want. So he's sorry, he may be at increased risk for osteopenia, you need a really an extra dial in a man they, say, above 10 to 15, to maintain bone mineral density. I like it, above 20 and list, and that's where I keep my guy somewhere in the 30 35 ranging must use LC MS MS similar to what you must use for testosterone in all women. And for post-menopausal women when you're measuring ... hormone, binding, globulin ish 13, why is that while he's insulin resistant?


Normally, when individuals are insulin resistant, serum hormone, binding globulin goes down, he's LH is five, and he had a particular role for sound, which was eight mills squared, and the range is 12 to 19, so it's decreased.


His testicular volume is, so, do we need additional cardiovascular testing? We know, yes, subclinical vascular disease but do we need anything more?


Well, this is a decision tree that I adapted, Romm, Martin Minor, and, again, again, the glia, and it has to do with erectile dysfunction in males so that he has confirmed E D.


He doesn't have cardiovascular symptoms, and what is his cardiovascular risk?


And depending on his risk, you're going to do a coronary artery calcium scan, and you want a tested exercise capacity, if it's appropriate.


And so, let's see, he or she is, you can just go online, This is free the ACC AAJ CVD risk calculator. And as you see, his risk is 25.4%, whereas the 10 year risk for someone at the same age without the risk factors is 2.1. So here's where it gets hot.


So, he was referred to a cardiologist, which is me, and I did a coronary artery calcium scan.


And he has a coronary artery calcium score of 80.


And we did a Bruce Protocol, treadmill stress test for a exercise, 12 minutes. You choose the 100% of the match heart rate. You know, EKG changes, his resting heart rate, that time was 50, and he had excellent heart rate recovery time and his HRP for a 50 year old was excellent.


And so he is going to need aggressive risk factor modification stat and he's got that he's got subclinical vascular disease. Our tour. So, aspirin and we did all that, You're also gonna get a garlic. Now, let's look at his hormones.


Well, this is a Dutch plush, and let me orient you, the stars in between the two stores are the reference range.


And so, as you see in him, not only is his testosterone low, but as extra dial is really low which suggests that this is a true number.


Because all of a male's extra denial all come comes from testosterone and appears to extradite always it here.


You'd have to question this.


Now we look at his salivary cortisol and his morning when he woke up cortisol, if he did detached right, is a little on the high side. And his car is on, a little, on the low side, 1.81. It's right, it's just above the bottom limits of normal, but it's certainly not optimum. And then he's orange or dropped.


But when we come over here, he's making adequate cortisol.


Is free cortisol's OK, his total V G S, which is all of this looks OK, and if we stop here, we'd be missing a lot.


All right. Let's look at his HPA axis.


And the first thing I do when I look at this is I glance around at everything and then I look at metabolites. Quote this is me. Everybody has a different way of doing things.


I look at both curves and a good friend of mine and Colliery who's very smart doctor Wright who's the Clinic and Education Director. And I were chatting and she and I agree that in order for you to get high Cortisone it must have been cortisol at some point.


Right because cortisol, get, Inactivating, took Cortisone.


That's the only way this is going to happen and you see is Cortisone is much higher than his total cortisol. So he's favoring 11 beta H S D two metabolism to de activate that.


And why would he be trying to de activate cortisol, is inflamed.


He's insulin resistant.


He's got a lot of oxidized stretched And though he's making a lot of cortisol, his body says, uh, I stop. I can't use this court is all I need. I'm already inflamed, I probably have some degree of neuro inflammation and to keep up with my needs, I need to deactivate this.


And when we look, the melatonin each low and melatonin is one of the body's most potent intracellular and each the body's most potent extracellular anti-oxidant ...


is the body's most potent intercellular anti-oxidant.


Let's look at, before we get to organic acids, let, we've already looked at Total. DHEA Production, let's look at metabolized, cortisol, and you see metabolized.


cortisol, is favoring cortisol.


So he's metabolizing, cortisol predominantly in the liver and it's being more of cortisol, is being metabolized.


Alright, and now let's look at the Buddha Thymine markers.


It's on the lowing, not surprising.


Melatonin is low and he has a significant amount of oxidative stress.


And if you just took this at face value and didn't see this, my guess is this guy cortisol is actually at one point was higher than this and the body is trying to de activate.


And when we look at his androgens, what we see is his testosterone is low, let's come here, is DHT is low, is phi Beta, and brushed her own, sorry.


..., is low, SES's five Alpha, he does not have an engine SNP, and so, in essence.


Here's testosterone R&D, all low.


When you look at DHEA and ..., remember, D H S, is adrenal, cortex is meeting the adrenal cortex. So similarly, it's not putting out a lot. And so he is further along on the HPA axis spectrum that you, then you may actually get from here is just looking at a shallow reportage, Wouldn't think it was so bad. and his resilience is not optimum.


And then, when we look at his metabolite, you see that he, he's making DHEA, he's just an act sulfate DHEA, again, adrenal cortex.


And, this all happens as a result of the brain sending the signal to the adrenal cortex to make cortisol and D a G. And V G S.


All right?


Now, let's look at, is estrogen metabolism. Now, if I didn't have labs that told me as H SERP was abnormal and slippage were abnormal and his homocysteine was abnormal.


If I looked at this, I would say, this guy's in Flint, even though his hormones are low you know that based on his HPA axis, but here's more evidence.


I'm guessing that aromatase upper regulation, would suggest inflammation.


And, you know, I don't know, if there's extra dial, may actually be higher but wasn't being metabolized and is a strong, wasn't being metabolized with up regulation of all the C Y P one enzymes.


But, inflammation is associated with aromatase of regulation, as it is five alpha and phi Beta, five alpha reductive. But look at here. Look at all he's given how low is hormones are. You would've expected his metabolites to be really low, but they're not.


They are actually fairly balanced.


And he's methylated fairly well. But this tells me, he is very inflamed.


And so if you're going to talk about treatments, you know, this is just a general guideline for adapt engines but remember, a treat them, not like, you know, candy, your supplements over the counter, Treat them as medicine, Start low, go slow.


And when you are going to assess what you should treat a guy who's got low testosterone like, he does. The first thing you have to ask is, what is his elledge Now, his LH was five.


It wasn't high, which would suggest primary hypo bone age And he said kids. Typically this diagnosis is made at a young younger age.


And so we have some degree of secondary or mixed hypo gonad agent.


And so you want to do restful sleep, you want a higher protein, Mediterranean eating, you can try all these. This, you know, teatime, or certainly may need zinc.


He's 50 years old. So, you may want to go right to testosterone. He may not want testosterone. And so, all of these are options.


You also want to assess his prolactin, because if it's greater than 18, that may, in and of itself, that will suppress testosterone.


And so, he would need a workup and don't forget that, especially in young women, check for heavy metals and biotoxins.


And when you're talking about testosterone options and invite, you can use a patch. You can use a gel, nobody uses patches anymore, but skin irritation.


You can use Andrew Joe, 50 milligrams is typically the starting dose. If you use compound that stuff, you may need a higher dose, and you'll want to rotate it and you'll want to check labs on a regular basis, and those labs typically include a direct rectal exam. Some people do it at one month and six months, one month, three months, six months in a year.


Some people just do it at one month at three months and six months and then a year. But you will at least should do it by annually and yearly or yearly on people on testosterone.


Injectables. Let me tell you a little secret about appropriating a man.


They you want to use an an phaeton over me.


You get less fluid retention.


You want to break up the don't, so you don't get the highs and lows shipping for younger guys. And I'm talking about, you know, this guidance 50 could probably take shipping, and I'm talking about 60, 65. You may want to consider an a viable option, cost considerations.


And, uh, patients want a lot, but they typically don't need as much as you think. And don't forget to check a PSA greater than zero point seventy five nanograms per mil. Is worrisome for prostate cancer? But, remember, testosterone does not cause prostate cancer.


It's like extra dial does not cause breast cancer.


And here is what I gave him, because I think he has a lot of oxidative stress, ..., with its weak P D P D E five inhibitor, Collated, magnesium, I asked him to get IV therapy. I started a melatonin trucking. It's a great anti-inflammatory anti-oxidant and it will help him with sleep and this will be traded up.


And there's all this stuff for cardiovascular system. It's all the stuff we talked about.


Hormones I started testosterone, gel 50 milligrams a day, I will convert him to pellet once. I see how he does and remember that.


For every 75 milligram pellet you're going to increase the guy's testosterone to 70 by 75 nanograms per deciliter.


And you're shooting for, rather than 500 less, than a thousand in that, you know, random 500 to 800.


He's gonna get vitamin D He's got thyroid antibodies so he's gonna get an hour trek shown. He's Blaine.


We need immune modulators and ... and probiotics and a Mediterranean diet.

42:11 – Case Studies - Maggie

Now, let's talk about Maggie.


She's a 48 year old peri menopausal, female Who seeks advice or menopausal hormone therapy.


Our last cycle was about 8 to 9 months ago and she's miserable. She's had brain Fog, Hot Flashes, night sweats, and vaginal dryness, for 9 to 10 months.


No energy bills, ame Church. Her mind can stop racing. She has trouble sleeping waking multiple times. In addition she feels her heart racing all the time.


She's happily married. Has grown children. She's a physician, very busy practice, normal body weight and BMI. That doesn't mean she doesn't have visceral adiposity she ought to, was an over exerciser, she recently had a diagnosis of osteopenia.


So, we have a couple of things increasing her cardiovascular risk, but this is very concerning, that a 48 year old has Osteopenia.


She's a paleo diet with organic grass fed beef, wild caught fish, organic, free-range tricking. She drinks no Apple. She doesn't smoke sheets. Lots of vegetables, doesn't need any carbohydrate.


She's on life center portal, a multivitamin Vitamin D methylated B vitamins, and she gets IV therapy monthly, Which grams alluded fine.


Her past medical history. She has hypertension, insulin resistance, borderline Hyperloop edema, actually, That should be osteopenia she had a recent mammogram and GYN exam including a pap smear. That was normal. She had gestational diabetes and putting a lamp seal with both children. So she has lots of high risk indicators.


She has a positive family history. Her mom had an MI 45 for dad had an MI 40 and her brother had an MI and 44 on mom and dad are both April three for her brother was able or for mom and sister, are breast cancer survivors.


Some family history night sweats occur multiple times a day, every day. She as Ero Bilbao with constipation.


Her blood pressure on ... was 1.62 for heart rate is 95. She's five shift. Weight is 120, BMI is 19.4.


She has, uh, pretty optimum waist hip ratio. The rest of her exam was normal, except she too had an S for. She had an ECG with prominent voltage. She had an exercise echo that came to me, which was normal. if she's MTH FR positive.


She's heterozygous for the C 6 77 T A wheel, which again, can increase your risk of vascular disease. She's in April 3 4, and she's BRCA negative.


So we have a 50 year old symptomatic. Peri, menopausal, females. You see all version stems here. She probably has a BA access, an autonomic dysfunction.


Somebody who runs that much shouldn't be Field Taqwacore article.


She is peri menopausal, she's late peri menopausal.


She has, Despite OCI, with metabolic ....


There's her EKG just to show you. she has voltage criteria that Olivier Drip or AVL. If this R wave was 11, she would definitely have BCG criteria for LTCH. This is just voltage, which a lot of people have.


Her glycaemic parameter, she's insulin resistance.


Her vitamin D is 70 while she's on vitamin D and look at her 5.9 point 9 2.7 18. And her ... antibodies are 100 when you see this thyroid pad.


And unfortunately, I don't have time to talk about thyroid at it.


Adaptation with HPA axis dysfunction.


This is HPA axis dysfunction.


This is down regulation.


What happens is the thyroid is an organ that requires energy latch it.


And if it sees, it doesn't have enough reserve, it will down regulate, and you'll see these kinds of numbers. Doesn't mean you shouldn't treat it but don't keep bumping up.


Your thyroid dosage crucial dropped TSH to almost zero with no effect Karen here unless you address the HPA axis.


And again, her risk markers were elevated.


Her advanced lipid profile was a little worse in some parts and a little better than Peter. She's in April eighth 3 3.


And she does not have carotid minimal, medium, thick.


So, do we need additional tests on her?


Well, again, there's our same thing. And I just put, confirm, frequent, persist in visual motor symptoms with no symptoms.


Calculate the 10 year risk, she low risk, borderline risk, intermediate risk, or hirers, and then go from there, So that's what I did.


And I just put her in the ... risk calculator. And as you see, her 10 year risk of apple sclerosis is really low.


It's higher than her peers, but lower. And then there are risk enhancing factors. Because this doesn't take into beta or motor symptoms and ... function, it doesn't take care. Take into account premature menopause or adverse pregnancy outcomes, or any of the risk markers that we've identified.


So she has a family history.


She has a history of pregnancy associated conditions.


She has abnormal lipid markers.


She's got elevated, C reactive protein.


And all of the rest of this were normal. So they say three determinations, 1, 2, 3, 4. How much this is increased? Somebody's risk, nobody knows.


And I typically, if she would have had an abnormal COMT, I would have put her in this intermediate.


But, you know, this is me guessing. It's, it's definitely, you know, somewhere in between here and here, so wide fault, or a borderline. And so, as far as I was concerned, she needs a coronary artery calcium scan.


And it was zero.


She had an exercise echo that she came to me with. She exercise 10 minute teaching, greater than 100% match heart rate, and the EPO stone cold normal, no left ventricular hypertrophy. Our heart rate recovery time was 110 beach permitted it needed to be less than 163.


But our heart rate variability, as opposed to Peter's, which was 75 Hertz, is 25, and that's because she has increased heart rate a lot of the time, and doesn't sleep well.


And so with a coronary artery calcium score of zero, but a borderline risk lifestyle, if indicated red, yeast rice, co-q. 10 or terror cell, and a garlic and we're going to look at how hormones now she's perimenopausal.


Do you need to do a Dutch plus on people who are women who are Perimenopause, especially Lake Perimenopausal.


The answer is, I don't know.


She hasn't had a cyclone, about nine months.


But Or eight months. I've read it anyway because I like to see what's going on.


No. I can. I can better take care of patients when I have the entire picture. A one day test doesn't give me an entire picture.


A one day test if it was done on Day 19, wouldn't have show me these things.


The these little estrogen peaks, which we'll talk about in a second. And it would have told me that her progesterone is basically flat line. So she's, in Essence. And I've been with Tory.


What I would have wondered if that was just, You know, if I missed or it was going to happen much later.


So, I always do this these estrogen surges in the follicular phase off call Moodle, out of phase, estrogen bumps, and they're thought to be due to persistently elevated FSH and LH.


And as you can see here, if she didn't have, um, just a flat progesterone mine, if she wasn't ambulatory, this is called change of life babies. This is how older women, or peri menopausal women get pregnant.


is they have these estrogen peaks. Then they have, you know, progesterone peaks and FSH and LH are high in women, get pregnant.


Here are her serum labs which we've done around the same time for sure. Hormone binding globulin is low for two reasons.


She's not making hormones, right?


You need hormones to make sure on hormone binding globulin and And she's insulin resistant.


No, 70 above 70. You start to see with the menopause but these are this is unreliable. It could be up and down until she's actually menopausal. Same thing with our late.


Her E two, using l.c.m. SMS was 12.


That's pretty low, and this was probably done in the around the follicular phase because we were looking at testosterone which we want to measure early in the liquid phase.


If you're using Sharon and her total testosterone which 12 again using LC MS MS, and her progesterone was zero point one using ..., Cartland.


Now, let's look at her Dutch complete, because you can't stop with the cyclamen. You need to look at metabolomics, and you say, what the heck why is your ... high here?


Because these were done around the same time and they typically take the peak of extra dayal progesterone.


And in her case, it was that ..., and as you see, her testosterone low, progesterone really low, and if you blanch, this is your So, you're not going to get a car. This works pretty well.


Right, This is on the low ish side. This is definitely low. This is low. This is low, and this is flat.


And as I told you last week, a flattened cortisol curve is associated with increased adverse cardiovascular events, and a low awaking cortisol, is associated with, now, this is everything in her bladder.


So I'm not sure that we can apply the Mesa study, which looked at inflammatory markers, but everything in her blatter overnight.


So she should have slept.


And you see she's not making a lot of cortisol, a total DHEA is in very hot pie, And when you add this up, it's not very hot.


So she is definitely further along on the HPA axis continuum.


Now let's look at this, as opposed to Peter who had really high Cortisone here.


This cortisol, cortisol import, is on pattern, look similarly, which they should, this is what you want to see. this nice balance.


When we look over at total DHEA, we already saw what it looked like before and her metabolized. Cortisol is low, not surprisingly, and in the liver.


Uh, she is metabolizing too.


Down cortisol is metabolizing by Phi Beta, Reductive Tablet.


And when we look, the only abnormal D was the low end of the range of blue design. Which is not surprising, how melatonin looks OK, but it's probably not OK enough.


So we know she's a flanged, just looking at this anxious further along on that spectrum.


You know, so, her HPA axis, you know, she can tolerate a lot.


And so now let's look at our formal 10.


Remember, when you're looking at progesterone and and metabolites, you're not looking at tissue metabolism.


You're looking at pathway predominance.


And here, because they are both so low and you look here Alpha and beta. They're both low, but it looks like she has five beta pregnant dial preference if we gave her oral progesterone would be interesting to see whether that change because in the gut the intestinal microbiome has five beta or a duct Asian. Cultural wall has five hour for a destination, whichever one predominant may shift what you see in metabolites here.


But one thing is clear no pedestrians.


All right, now let's come over here.


Her DHEA yet, again, which is from the adrenal cortex, is low similar health board, is also, she is further along that.


That continues, her testosterone is low on the low side, how much of the video wrongly ties And I don't know but aromatase is up, regulated in inflammation. And she is inflamed.


Now, when we look at her five alpha and everything below five alpha and beta with update, five, you know, ED or colon alone is a little better than so, she's she's going down this five beta pathway, and trash drone is also with testosterone metabolite, as well as a DHEA metabolite. But any way you slice the bread, it's it's on the lower side.


Now, let's look at her astringent metabolism.


Her E one is high. Her E two is high. E three is on the lower side and remember, adipose tissue of visceral adipose tissue has lots of aromatase. It shouldn't be converting, Cortisone, cortisol.


You know, stores cortisol, it has high amount of 11 Beta H S D one activity, but one of the reasons why it's not doing that is probably because this isn't you know, everything is down regulate and her body is meeting.


The cortisol is meeting the demands of her body.


But when we look down here once again, we see upper regulation of all these enzymes and decreased detoxification.


Similarly, Peters Detoxification was balance, but he added up regulation of all these hormones.


If we don't detoxified each one and get rid of these hormones, remember, she had irritable bowel with constipation.


These are all going to be toxic intermediaries.


two Hydroxy will be we know about four hydroxy as well 16 Hydroxy, so we know she is in plane.


She does have high methylation activity, but it may not be enough. This may outpace this. So, we need to watch this carefully.


And she does not have a ... women can get as well as men testosterone five Alpha is within their all at the lower end. five Beta is within range testosterone is low, typically, if you had a UV teach. And if this would be higher, as would be five alpha. ... Dayal, which they save above range here a little bit. But in our data, it looks like that Epi testosterone comes a lot from the overreach. And so this is not surprising.


So interesting to know and she's metabolizing her, um, androgens. five Alpha, at least, which is up regulated in inflammation testosterone to DHT to five alpha ... is all up regulated duty nation.


And again, you can look at treatments And then if you are not really comfortable giving menopausal hormone therapy, you can use in pursuit of goals and herbs and botanicals.


But again, these do not improve bone mineral density. And I'm not really sure of the, I don't think there's a whole lot of evidence using these in cardiovascular risk.


And for those of us who prescribe Ashford, I all, the typical starting dose is zero point zero two five milligrams in a patch.


Those, the point 0 1 4, milligram patches are no longer available.


You want to place the patch on a fatty area of the abdomen, or the, but it just note that it increases absorption on the, but you'll want to get labs in 12 weeks to a set.


and you want to get the body time to acclimate.


Creams must be compounded.


And remember, you may need a higher dose of a compounded cream to effectively reduce symptoms and come within the study.


Granger's: you know, Menopausal, Hormone Therapy, folkestone dosage in men.


When they were giving hormone therapy.


They, they focused on therapeutic range is regardless of the looper.


And I would tell you to do the same thing. In a young in a peri menopausal, or early post-menopausal less than five years, You'll want to keep her ... die all.


40, 60, and her Dutch, which, as I showed you, has been validated with serum about 1.8 to 2, and that'll give you that, you know, 40 to 60 range as women progress through menopause, They don't need as much extra dial and you want to keep their extra die all levels less than 40, probably closer to 30. So, just look at a ***** dial levels, were drawn a Dutch test, is zero point seven, to about one.


And remember that: gels which are FDA approved or not approved for osteoporosis and I would not pellet women to start off, I don't pellet women with a uterus.


I do Pelt women without a uterus after I see how they handle transdermal extra dial and I optimized there, detoxification, pathways, et cetera, et cetera.


And don't forget, or ... progesterone balances.


Each two effects or vaginal progesterone, not trench dermal.


Testosterone, the typical dose range of zero point five to five. And in perimenopausal women, you want to start 1 to 3 milligrams, menopause 1 to 2 milligrams.


Some people think you can start, you should start testosterone prior to E two and give it with progesterone. If you're worried about a woman's endometrial, may want to prime meaning Demetrius so that it has progesterone, or TO get bleeding or spotting, And you want to monitor vaginal need low doses. And so the most communist point 5 to 1 and pellets are excellent option. You need to understand metabolism and detoxification. and the most common doses are 75 to 125. Patients typically require, again, less than you think.


And if you want to increase a woman's testosterone level, the same thing doesn't go for women and men because if you say that a decrease it by 75, and it starts off at point, a network, typically happens with the pellet 150.


And so then, here's her treatment plan, what I want you to notice.


I didn't give her a statin.


We did red yeast rice, which has that property, plus a whole lot of other good stuff in it, biochemicals, And that's because she has no coronary artery calcium At all.


Are terrorist shell, age garlic, co-q. 10, sun, fiber, fish, oil, and curcumin for the inflammation. She got melatonin. She got a melatonin trophy. Why did I give her that? She got a family history of breast cancer.


She's in plane.


Inflammation drives breast cancer as well as it drives cardiovascular disease, and what they abandon hormonally grouping cancers. Melatonin prevents certainly recurrence in women with breast cancer and be cauchy some length. I really need to get her anti-oxidants.


Potential up, she's gonna get three grams every other week. She goes once a month, she's going to start going every other weekend.


I started hirano Patch, or micro nice, progesterone testosterone cream.


She's going to maintain her Vitamin D and then, I started Ryan just a little bit of thyroid, or you could give her something for viral Complex, which supports the thyroid production.




Synthesis of hormones, I'm going to start Orion Naltrexone, ... care, probiotics in a Mediterranean diet.


And so the real question becomes, you give people the shipments probably not.


I start with the HPA Act I start with. They want to store most people one. So that's a no-brainer.


And then I kind of march through it, and I tell them, for 3 to 6 months, this is what it's going to be, and then we'll re-assess.

1:04:51 – Final Thoughts

And remember, some of these are chronic inflammatory disease, HPA axis dysfunction, autonomic dysregulation and hormone dysregulation increase, cardiovascular events.


Optimal hormone levels are necessary for cardiovascular health, learn and understand for a moment, abolition.


Metabolomics, it's essential for optimum health.


Whether you're talking about hormone health, cardiovascular, health, God, help, all of it.


Ask yourself, are your decisions, evidence based, and are questioning the absolute and asking? Show me the data.


And remember that women and men may spend a third of their lives hormone, insufficient, deficient. So it's really important that we get this right.


And once again, there's our little Monitoring BH or tea. And red, yellow and green is go, pause.


Not the best test, there are my chiclets, And don't forget that, and I ask you, again. But why aren't you will provide, become, or provide new providers receive 50% off? And I get no kickbacks from any of this, just so you know, I'm just telling you how I changed my practice with the use of deduction.


And you get up at five testing kits. And here are all your additional benefits.


And the link is in the chatbox, and I think that's we are, that's it. We actually made it.


We made it. Thank you all again for joining us today. Don't forget to follow us on Instagram. Just search for the Dutch test. You'll find us, we will be announcing when the Q&A will be, so if you do have any additional questions that you would like doctor ... to answer, please send those to marketing at dutch test dot com, again, marketing at dutch test dot com. Check your inboxes tomorrow for a link to the recording and to download the slides. Hope you guys have a great day and we look forward to seeing you on next month's webinar, information, to come out soon about that. Have a great day.