WOMENThe most important labs for

A Functional MedicineApproach to lab tests for Women’s Health

By ReNee Greenberg, RN, MS, LAc, IFMCP

THAT YOUR DOCTOR WON'T ORDER

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Hormone imbalance is often an APPROPRIATE response by the body to imbalances happening throughout the body, which is why treating those imbalances- thyroid, adrenals, infections of the gut - often will put your body back in hormonal harmony.

Functional Labs and blood tests are a way to look at the true func-tion of the body and how it interacts with each each body system biochemically - not only looking for full blown disease. Functional lab testing assesses optimal functioning of the body and can detect a pre-disease condition before it is irreversible or chronic. This type of interpretation of blood work is grounded in the most current lab-oratory research and has been practiced by natural medicine practi-tioners and medical doctors for the last 25 years.

Functional Medicine, along with functional lab testing, usescurrent researchof physiology and biochemistry as a way to improve health and chronic conditions. It is a holistic, science-based movement of medicine, that is trying to replace the disease-drug model that has-been accepted as mainstream but is no longer serving us in our cur-rent health care crisis.

INTRODUCTION

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Typically, routine labs are run as a reaction to insurance reimbursement and doctors often feel like their hands are tied. Sometimes routine or screening labs are just that, routine. If they are normal, no need to look deeper, right? You know when there is something wrong and you need help to figure it out.Sometimes Functional Lab testing is more expensive, but in the long run, it is much less expensive than dealing with chronic conditions that can be treated or cured in the initial phases. This is a preventative approach to health by find-ing big shifts in lab work before the patient has a full blown disease or an irre-versible conditions.

Blood chemistry is the most cost-effective way to look at the overall health of women over 40. Essential markers for Thyroid health, Digestive health, Blood sugar regulation, anemia, Immune health, cardi-ac health and hormonal health are listed below

DETECTIVE WORK TO FIND THE SOURCE OF

A WHOLE BODY APPROACH

HORMONE IMBALANCEHave you ever went to your doctor because you didn’t feel right and you were certain that something was wrong? Or you knew you had some type of hormonal imbalance? You had some labs drawn and you waited for the results - only to hear from your doctor’s office that your labs are normal?

Blood Chemistry

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It is common to get tested for hypothyroid/hyperthyroid, but often conven-tional physicians will only order TSH (thyroid stimulating hormone). If it is high, your doctor will prescribe thyroid hormone replacement, but it is also important to address the intricate thyroid-pituitary feed-back loop, thyroid resistance, or a possible autoimmune thyroiditis causing the hypothyroid con-dition of each individual.

There are several scenarios of thyroid dysfunction that doesn’t require thy-roid hormone replacement. That is why we need to look at the entire panel.

I recommend that women have a complete thyroid panel, with antibodies, annually - and more often if taking thyroid medication or have symptomatic Hashimoto’s thyroiditis (auto-immune thyroid disease).

THE THYROID

Thyroid Panel (TSH, TT3, T3 uptake, ree T3/T4, Reverse T3, Thyroid antibodies)

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Thyroid antibodies should be tested even if the TSH is a normal level. Often with autoimmune thyroid disease, the TSH levels can fluctuate wildly as the antibodies attack the tissue causing hypothyroid and hyperthyroid symptoms.

An Autoimmune hypothyroid condition, also known as Hashimoto’s thy-roiditis, is the most common cause of hypothyroidism in the United States and cannot be treated with thyroid medication alone.

It is valuable to diagnose this condition and treat with lifestyle changes, diet and essential nutrients before it advances and interferes with daily life. When you develop an autoimmune thyroid condition, you are at high risk for devel-oping a second autoimmune condition. An autoimmune condition is a red flag for you to look deeper into the source of your thyroid imbalance and your life-style choices.

What causes Hashimoto’s?Some common triggers for thyroid autoimmune condition are high estrogen levels, insulin resistance, leaky gut/infections, gluten intolerance, too much iodine, pregnancy, Vit D deficiency, and heavy metal toxicity.

Peri-menopausal women can have low thyroid function causing hot flashes, night sweats with cold hands and feet. It can mimic low estrogen symptoms as well as low adrenal func-tion so it is important to assess the thyroid, adrenals and sex hormones together.

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Most women I test have low Vitamin D levels - even here in Southern Califor-nia! Vit D is considered more a hormone than a vitamin. The darker your skin or the farther north you live, the more you may need to supplement with Vit D3. Ten to 15 minutes of sunshine 3 times weekly (without sunscreen) is enough to produce the body's requirement of vitamin D- depending on where you live. Important for strong bones and teeth, Vitamin Dhelps your body absorb the amount of calcium it needs. It also has other roles in the body, including modulation of cell growth, neuromuscular and immune function, and reduction of inflammation. There are associations between low Vitamin D levels and peripheral vascular disease, certain cancers, multiple sclerosis, rheumatoid arthritis, juvenile diabetes, Parkinson's, and Alzheimer's disease.

Vitamin D level - 25 (OH) Vit D (50-80)

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BLOOD SUGAR

Maintaining a stable blood sugar is extremely important to support healthy adrenal and hormone levels. High levels of insulin and insulin resis-tance cause higher amounts of estrogen, estrogen dominance and no ovula-tion. Women diagnosed with PCOS (polycystic ovarian syndrome) must keep their blood sugars stable to keep their testosterone levels balanced and within normal limits.

Glucose (70-85)If your fasting glucose level is high, it is good to follow up with a fasting insulin and Hbg A1C test.

Insulin Insulin is a hormone that is produced and stored in the beta cells of the pan-creas. Insulin helps transport glucose , the body's main source of energy, from

Blood Sugar (Fasting)

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/IRON/CHEMISTRY/LIPID PANEL

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Ferritin (50-90 mcg/l)

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the blood to within cells. If a person makes too little insulin or is resistant to its effects, cells starve and the body cannot function properly.We are concerned with insulin resistance, type 2 diabetes and metabolic syndrome in relation to midlife and lifestyle awareness. If the blood sugar is chronically high, the insu-lin receptors on the cells get less sensitive and do not let the glucose into the cell. The goal is prevent this from happening by monitoring fasting blood sugars annually and eliminating refined carbohydrates from our diets (sugar, white flour, processed foods).

Hgb A1c (4-5.6%) Hemoglobin A1c measures your blood sugar average over the last 2-3 months.Hemoglobin A1c levels between 5.7% and 6.4% indicate increased risk of diabetes, and levels of 6.5% or higher indicate dia-betes.

Ferritin is a marker for acute iron deficiency- within the last few months.

Chronically low iron reserves can explain chronic fatigue in some patients but can also have similar symptoms as adrenal fatigue or hypothyroid: hair loss, cold, fatigue, palpitations. Lower levels can contribute to restless leg syn-drome, infertility, hair loss, fatigue, and immune dysfunction.

If your levels are low, you have iron deficiency anemia and it is important to find the cause: is it low absorption of iron, heavy menstrual flow, poor iron intake or poor nutrient intake?

Homocysteine (<7 µmol/L)

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This is an extremely important inflammatory marker that can tell us how the liver is functioning.Healthy detoxification pathways are essential to metabo-lize environmental toxins and hormones in your liver. If high, there may be a methylation issue and we may want to follow up with genetic testing specifi-cally for the MTHFR mutation. High levels have been linked to neurodegen-eration, increased risk for stroke, dementia and Alzhiemer’s disease which is why this is an extremely important marker for men and women alike. Proper methylation is also important for the production of neurotransmitters like serotonin (mood/depression) and melatonin (sleep).

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Lipid Panel (cholesterol, HDL/LDL, triglycerides)

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Metabolic syndrome is a set of risk factors that increases a women’s chance of developing serious conditions such as cardiovascular disease (CVD), type 2 diabetes, and stroke. These risk factors include:

• Excess fat around the waist (abdominal obesity)

• Decreased ability to process glucose (increased blood glucose and/or insulin resistance)

• high triglycerides (>150) and low level of high-density lipoprotein (HDL) (<50)

• High blood pressure ( >130/85) or on blood pressure medication

methylation is also important for the production of neurotransmitters like serotonin (mood/depression) and melatonin (sleep).

Methylmalonic acid (MMA) (0-4.7 mol/L) levels are commonly used to eval-uate for vitamin B-12 deficiency when homocysteine levels are high.It is more specific than homocysteine and is the confirmatory test of choice if you sus-pect B12 deficiency. Women over 40 yrs old can be at risk for low levels of B12 from vegan or vegetarian diets, low hydrochloric acid (digestive enzyme), digestive problems or chronic stress.

Symptoms of B12 deficiency:

• Mental fogginess

• Problems with your memory

• Depression

• Lack of motivation

• Fatigue

• Muscle weakness

• Tingling or numbness in your extremities

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High cholesterol levels should never be driven too low with the use of statin drugs as cholesterol is vital as a pre-curser for the production of your hormones: progesterone, estrogen, testosterone, DHEA and corti-sol.

Cholesterol is found in your brain, liver, kidneys and nerve fibers. It is more important to increase HDL and to decrease LDL than to look at overall Cho-lesterol numbers. With the newer functional lipid panels, we can assess the particle numbers and size of LDL - this can give us an even better understand-ing of cardiac risk with women who have a family history of high cholesterol.

Triglycerides - elevated levels seen with insulin resistance, obesity, high carb diet, hypothyroid and alcohol abuse. The body will shift high blood sugars into triglycerides to try to maintain normal blood sugar levels.

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Serum Lab tests (estradiol, free and total testoster-one, Progesterone, DHEAS, Sex hormone binging

globulin (SHBG)

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Serum labsare ideal for testing most hormones but notfor all the sex hor-mones.There are reasons to choose between saliva testing and serum testing. Most conventional labs report Estradiol, estrone, and progesterone as total (bound) hormone levelwith free hormone levels not commonly available. In serum hormone testing this may lead to misleading results in which hormone levels appear to be normal or even high normal because of an abundance of bound hormone. However, if the free hormone level is low, the patient can be functionally low and symptomatic even with a normal total hormone level.The exception is serum testosterone which is commonly available as both total and free, and therefore,is a more accurate picture.

Another limitation of serum hormones testing is the nature of our hormones and how they fluctuate day to day and within the day. A single blood test is not a complete picture of what is going on during the 28-day cycle.

If you are still having periods, then add:

SEX HORMONES

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Lutenizing hormone (LH) (values vary depending on time in cycle)- Signals from the pituitary are sent to release the egg from the ovary for ovulation. High levels can indicate PCOS with high testosterone and low levels cause infertility by stopping ovulation.

Follicle Stimulating Hormone (FSH)- A level <10 is used to check fertility in pre-menopausal women. This hormone is controlled by the hypothalamus and pituitary gland in the brain that controls ovulation. LH and FSH go up and down together and indicate level of fertility. These hormones are not neces-sary to check when in menopause and beyond.

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SALIVARY TESTS

There are specific reasons to use saliva vs. blood test. The 28-day saliva test for women who are still menstruating reveals a comprehensive, base-line

In the past 15 years, saliva testing has gained in popularity among practi-tioners of functional medicine for many reasons. Saliva has the advantage of being noninvasive and easy for patients to use at home with test kits. Saliva collection also allows for multiple collections over a period of a day or month, which can help find abnormal hormonal patterns in cases of stress, insomnia, infertility, peri-menopause and menopause which is a more comprehensive way to look at each individual’s hormonal rhythm. Another valuable reason to test saliva is that it can test the bioavailable hormones (usable form) in the tissue as opposed to serum collection that only can test the bound hormone level in the blood.

Salivary Hormone Panel

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This is a the Expanded female hormone saliva panel from Diagnos-techs that shows estrogen dominance in the luteal phase and low progesterone in both the follicular and luteal phases in a pre-menopausal women. 11 samples were taken over 28 days to produce this women’s individual rhythm.

evaluation of her entire cycle specifically for infertility or in peri-menopause to find any imbalance. A saliva sample is done every 3 days (11 samples total for a cycle), refrigerated, and then sent to the lab when the cycle is complete.

For a women in menopause, a one day saliva test or urine metabolite test (below) is usually adequate to assess hormone balance since there is no hor-mone cycling any longer.

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THE ADRENALS

Stress induced hormone imbalances can be fixed by supporting the adrenals first. A popular and simple test if chronic stress is suspected is the saliva test kit to measure the circadian rhythm of cortisol. We can see if a patient is chronically stressed and has a high cortisol - which leads to high insulin and abdominal weight gain, and probably sleep disturbances or insomnia. We can also see if cortisol is extremely low, which usually means my patient has had chronic stress for a long time causing fatigue, sleep disturbances and achy joints/muscles.

Adrenal Stress Profile

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The graph shows an example of a patient with very low cortisol during the day (fatigue) and rising at night. This is a common picture for women who complain of insomnia and fatigue “wired and tired”

Treatment is aimed primarily at restoring the normal feedback loop between the Hypothalamus-Pituitary-Adrenal axis (HPA axis) with nutrients that sup-port each pattern. Balancing hormones is targeted and more efficient when based on each individual’s circadian rhythm of cortisol and it’s relationship to DHEA levels.

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URINE TESTS

To evaluate women taking synthetic or bio-identical hormones or women at risk or breast cancer, the 24-hour urine test is a convenient, easy way to test estrogen metabolites. The main estrogen metabolite markers are, the pro-breast cancer,16-OHE1, and the anti-breast cancer, 2-OHE1, can be evaluated by a convenient and accurate home urine test kit.

The ratio of these estrogen metabolites, 2:16, are measured in pre and post-menopausal patients for a comprehensive look at detoxification of estrogen in the liver.

Nutritional supplement and diet intervention is a logical and inexpensive way to support liver detoxification. Flax seed lignans, isoflavones (kudzu, non-gmo soy), cruciferous vegetables (broccoli, cabbage, kale) are examples of foods that can be used to support these hormone detoxification pathways.

Urinary Estrogen Metabolites

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Dutch test (Dried urine test for comprehensive hormones)- This is a truly comprehensive urine test that shows not only the estrogen metabolite ratio but also a complete picture of the hormones themselves (estradiol, proges-terone, testosterone, etc) as well as the cortisol circadian rhythm (for stress and fatigue) and melatonin level (for sleep). It is useful for women who are considering bio-identical hormones because it can tell us not only how much estrogen, testosterone, progesterone she is making but how it is being detoxi-fied and broken down in a healthy or not so healthy way. This test is also a more accurate way to measure free cortisol to monitor the health of the hypo-thalamic-pituitary-adrenal axis (HPA axis). Since we know that our hormone balance is closely connected to our HPA axis, it is valuable to test them at the same time to get the big picture.

Find the causes of:

This test provides a comprehensive view of organic acids, which are com-pounds that are used in the body’s cellular metabolic processes and break-down. Organic acids tests look

at energy production, detoxification, neurotransmitter breakdown and intes-tinal bacteria or yeast. This test can usually answer the questions of nutrient deficiencies, GI infections, unexplained fatigue, or toxins present. These find-ings can usually be treated nutritionally and preventatively.

Find the cause of:

Urine Organic Acids test

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• Fatigue

• Weight gain

• Mood swings

• Depression

• Low sex drive

• Weight gain

• Poor sleep

• Depression

• Chemical sensitivities

• Fatigue

• Digestive problems

• Migraines

• Hot flashes/night sweats

• Poor sleep

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STOOL TESTS

GI-MAPThis newer stool test utilizes cutting edge, quantitative PCR technology to provide a true DNA/PCR based stool test. This technology has high sensitivi-ty, specificity and a rapid turnaround. The GI pathogens include bacteria, par-asites and viruses, measures opportunistic organisms, normal flora, fungi/-yeast, parasites and antibiotic resistance genes. This test also looks at immu-nologic markers for GI health and function including SIgA (immune response), Elastase (pancreas), beta-glucuronidase (affects estrogen break down), blood, Calprotectin (inflammation) and Anti-gliadin (reaction to gluten) test-ing.

Comprehensive stool analysis

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GENETIC PROFILES

23 and me - The Human Genome Project was completed in 2003 and it was discovered that an important gene for optimal health, called the methy-lenetetrahydrofolate reductase gene, MTHFR, was defective in an estimated 60% of the population. When this gene is healthy, it helps break down excess metals and toxins to be removed from your body. When there is a problem, there may be a family history of heart disease or cancer, and other disease states, because those heavy metals and toxins aren’t being eliminated from the body.

This is a genetic testing service for public consumers that you can order the test online and have it shipped to you. When the results are ready in 6-8 weeks, 23andme will provide you with a plethora of genetic data that will be interesting regarding your ancestry but more importantly for your health, you

DNA testing

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will receive data regarding your detoxification and methylation SNPs (Sin-gle-Nucleotide Polymorphisms) which are very important for your overall health - especially for women.

Although you may have a genetic SNP, we now know that genes can be turned on or turned off, call epigentics. We can’t change our DNA, but we know that lifestyle and diet can change your family history in many cases.

This test is good for women who:

• have high homocysteine levels

• have a family history of cardiac disease

• have a family history of cancer

• have recurrent miscarriages

• have poor detoxification of drugs or alcohol

• have altered hormone detoxification

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FUNCTIONAL DIAGNOSTIC LABS

Some of the labs below have been around for more than 40 years providing cutting-edge laboratory testing that assists the practitioner in their systems assessment of each individual patient. Others are newer and innovative in creating lab tests that challenge outdated ways of thinking about laboratory testing for our individual biochemistry. This is why I use these labs and trust that they are ever-evolving to benefit the health care practitioners that use them and ultimately, the patients we serve.

Some of these labs will need a licensed health care provider to assist you with ordering and interpretation. I am happy to help you find the source of your imbalance!

Genova Diagnostics: www.GDX.net

GI-Map:diagnositcsolutionslab.com

Great Plains Laboratory:https://www.greatplainslaboratory.com

Doctors Data:https://www.doctorsdata.com

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This report contains general information about medical conditions and treatments. The information is not advice, and should not be treated as such.The medical informa-tion on this website is provided “as is” without any representations or warranties, express or implied. Women’s Hormone Health makes no representations or warranties in relation to the medical information on this website. You must not rely on the infor-mation on this website as an alternative to medical advice from your doctor or other professional healthcare provider. If you have any specific questions about any medical matter you should consult your doctor or other professional healthcare provider.If you think you may be suffering from any emergency medical condition, you should seek immediate medical attention. You should never delay seeking medical advice, disre-gard medical advice, or discontinue medical treatment because of information on this website. This template drafted by Contractology.

FIT (Food inflammation Test): https://www.KBMO.com

Dutch Test:https://dutchtest.com

Direct labs: https://www.directlabs.com

23 and me: https://www.23andme.com

If you want to find the source of your symptoms, not just symp-tom management, let’s work together to find your hormonal

bliss!

I offer a 15 minute complementary phone consultation so I can hear your story and health concerns

Get an Appointment

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REFERENCES

Anderson, S. et al, Narrow individual variations in serum values T4 and T3 in normal subjects: a clue to the understanding of subclinical thyroid disease. J Clin Endocrinol Metab, 2002. 87 (3): 1068-72

Wartofsky, L. and R. A. Dickey. The evidence for a narrower thyrotropin refer-ence range is compelling. J Clin Endocrine Metab, 2005. 90 (9): 5483-8.

Clarke R Smith AD, Jobst KA, Refsum H, Sutton L, UelandPM. Folate, vitamin B12, and serum total homocysteine levels in confirmed Alzheimer’s disease. Arch Neurol 1998 Nov; 55 (11) 1449-1455.

Seshadri S Beiser A Selbub J, et al. Plasma Homocysteine as a risk factor for dementia and Alxheimer’s disease. N Engl J Med 2002 Feb 14; 346 (7):476-483

Bischoff-Ferrari HA. Optimal serum 25-hydroxyvitamin D levels for multiple health outcomes. Adv Exp Med Biol. 2008;624:55-71. doi: 10.1007/978-0-387-77574-6_5.

Bischoff-Ferrari H. Health effects of vitamin D.Dermatol Ther. 2010 Jan-Feb; 23(1):23-30. doi: 10.1111/j.1529-8019.2009.01288.x.

Vitamin D as an Early Predictor of Multiple Sclerosis Activity and Progres-sion. Ascherio A, Munger KL, White R, Köchert K, Simon KC, Polman CH, Freedman MS, Hartung HP, Miller DH, Montalbán X, Edan G, Barkhof F, Pleimes D, Radü EW, Sandbrink R, Kappos L, Pohl C. JAMA Neurol. 2014 Jan 20. doi: 10.1001/jamaneurol.2013.5993

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Iron supplementation for unexplained fatigue in non-anaemic women: double blind randomised placebo controlled trial. F Verdon, B Burnand, C-L Fallab Stubi, C Bonard, M Graff, A Michaud, T Bischoff, M de Vevey, J-P Studer, L Herzig, C Chapuis, J Tissot, A Pécoud, B Favrat. BMJVolume 326 24 May 2003. 1124-8

Clinical Nutrition: A Functional Approach (second addition) 2004 IFM Publi-cation

Textbook of Natural Medicine, Second Edition. Pizzorno, Joseph, E. and Murray, Michael T., 1999

Laboratory Evaluations for Integrative and Functional Medicine, second edi-tion. Lord, Richard and Brally, J. Alexander. 2008

Hormone Testing: When to Use Serum, Saliva, and Urine, Pushpa Larsen, ND; Michael Kaplan, ND; Leah Alvarado, ND; and Mi-Jung Lee, ND, LAc, Townsend Letter, January 2014

O'Leary P et al. Salivary, but not serum or urinary levels of progesterone are elevated after topical application of progesterone cream to pre- and post-menopausal women. Clin Endocrinol. 2000;53(5):615–620.

Falk RT et al. Relationship of serum estrogens and estrogen metabolites to postmenopausal breast cancer: a nested case-control study. Breast Cancer Res. 2013 Apr 22;15(2):R34.

Ruan X1, Seeger H, Wallwiener D, Huober J, Mueck AO. The ratio of the estradiol metabolites 2-hydroxyestrone (2-OHE1) and 16α-hydroxyestrone (16-OHE1) may predict breast cancer risk in postmenopausal but not in pre-menopausal women: two case-control studies.Arch Gynecol Obstet. 2015 May;291(5):1141-6. doi: 10.1007/s00404-014-3512-1. Epub 2014 Oct 16.

Estrogen metabolism and risk of breast cancer in postmenopausal women. Fuhrman BJ, Schairer C, Gail MH, et al. J Natl Cancer Inst. 2012 Feb 22;104(4):326-39. doi: 10.1093/jnci/djr531. Epub 2012 Jan 9. PMID: 22232133

Relationship of serum estrogens and estrogen metabolites to postmenopaus-al breast cancer risk: a nested case-control study. Falk RT, Brinton LA, Dorgan JF, et al.Breast Cancer Res. 2013 Apr 22;15(2):R34. [Epub ahead of print] PMID: 23607871

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