When patients present with complex symptoms and hard-to-identify hormone imbalances, comprehensive testing can be crucial to making a proper diagnosis and building an effective treatment plan. In this podcast, Dr. Fitzgerald talks with the medical director of Precision Analytical, Dr. Carrie Jones, about new additions to DUTCH testing, including cortisol awakening response testing and six new organic acid tests. In this podcast, you’ll hear:
In this podcast you will hear:
- Why DUTCH has added the cortisol awakening response
- What organic acids have been added to the DUTCH complete (for free)
- How these six new organic acid markers relate to hormones
- Why glutathione is important to the cancer pathway
- Why diet and lifestyle are so important to hormone and organic acid markers
- About some of the genetic SNP’s involved in the hormone pathways
- An interesting case study and Dr. Jones interventions
Dr. Carrie Jones graduated from the National University of Natural Medicine, School of Naturopathic Medicine located in Portland, Oregon where she was adjunct faculty for many years teaching gynecology and advanced endocrinology.
She completed a 2-year residency in advanced women’s health, gynecology, and hormones and later went on to complete her Master of Public Health at Grand Canyon University in Arizona. She has been the Medical Director for 2 large integrative clinics in Portland, Oregon and is currently the Medical Director at Precision Analytical, Inc.
She often writes for women’s health websites and takes part in podcasts and interviews that promote hormone education to both the public and practitioners. She frequently lectures both nationally and internationally on the topics of adrenal and hormone health.
Podcast Sponsors
Precision Analytical exists to make it easier for patients and their healthcare providers to find answers to complex clinical questions that affect their lives every day. Our unique hormone testing and reporting methods create better tools for healthcare providers to explore hormone issues with their patients. We are fully committed to the mission of improving the lives of those who trust us for their laboratory testing needs.
Dr. Kara Fitzgerald: Hi everybody, welcome to New Frontiers in Functional Medicine where we are interviewing the best minds in functional medicine and today is no exception. I’m your host Dr. Kara Fitzgerald, and I’m delighted to be talking to Dr. Carrie Jones. She’s the medical director at Precision Analytical and we both graduated together at the same time, the same class, from National University of Natural Medicine School of Naturopathic Medicine in Portland, Oregon, where, she informs me, it’s snowing vigorously today.
Dr. Jones was also adjunct faculty for many years, teaching gynecology and advance endocrinology. She completed a two-year residency in advanced women’s health, gynecology, and hormones, and later went on to complete her masters of public health at Grand Canyon University in Arizona. She’s been the medical director for two large integrative clinics in Portland, Oregon, and is currently the medical director at Precision Analytical.
She often writes for women’s health websites and takes part in loads of podcasts, actually, and interviews that promote hormone education to both the public and practitioners. She frequently lectures both nationally and internationally on the topics of adrenal and hormone health.
Dr. Jones, it’s always fabulous to talk to you. Welcome to New Frontiers.
Dr. Carrie Jones: Thank you. I’m so excited to be back and talk to you today.
Dr. Kara Fitzgerald: Absolutely, you know your podcast, actually your podcast and the training you did for the clinical development program, both of them, are some of the most popular content we have.
Dr. Carrie Jones: Oh, I love to hear that. I get a ton of feedback, like, “I heard you were on Dr. Kara’s podcast and it was just amazing. I love listening to you two together.”
Dr. Kara Fitzgerald: Well, you know, I think the reason is that you bring a remarkably practical, Monday morning, kind of take home, applicability to everything you say. I mean, you really have doable interventions and ideas and thoughts on cases for really everything you talk about. You’re just … We just got fabulous feedback from just the practice changing stuff you discussed.
Dr. Carrie Jones: Well, I’ll keep that up then.
Dr. Kara Fitzgerald: Yeah, keep that up.
Dr. Carrie Jones: That’s perfect.
Dr. Kara Fitzgerald: Yeah, keep it up, indeed. Well I can tell you’ve been teaching for many years, it comes through. Alright, so we’re talking about your flagship test today, the DUTCH, and we’re going to jump in to some new additions on the DUTCH which I’m pretty excited about because I order the test all the time. But, first of all give me an overview on what the Dutch Test is.
Dr. Carrie Jones: Absolutely, so first and foremost, I always tell people, we are not testing for Dutch heritage. It is an acronym. It stands for Dried Urine Test for Comprehensive Hormones. So basically, it is strips of filter paper that you would urinate on first thing in the morning, two hours later, around dinner, and before bed. Let it dry, send it in, and because it is a urine test, we get all your main hormones, estrogen, progesterone, testosterone, what have you. But we then get the pathways and the metabolites that you can pick up because it is a urine test. So you just get that much more clinically helpful information.
Dr. Kara Fitzgerald: Versus saliva?
Dr. Carrie Jones: Like serum. Right, or saliva, exactly. You run a blood test or a saliva test and you get, let’s pretend, estrogen. You just get an estradiol and that’s it and if it’s normal or even low or high. You think, “Oh, it’s just estradiol that I’m addressing.” But when you do urine testing like the DUTCH test, you get the phase one and the phase two detox markers. So not only do you get to understand what’s going on with estrogen, is it high or low, but you also then get to see how is your body processing it.
Dr. Kara Fitzgerald: Mm-hmm (affirmative). Which I think is extremely important additional content and guides me in how I’m addressing my patients all the time.
Now, one of the recent analytes that you’ve started to report is the cortisol awakening response. Talk about what that is.
Dr. Carrie Jones: Absolutely. It’s a hyper-focus on the first hour of the morning. So this is where we took the greatness of the dried urine test and we actually added in saliva with it. So people are like, “Whoa, I thought you were a urine company.” Like, I know, but the cortisol awakening response is a response that happens right as you’re about to open your eyes in the morning, right? You’re asleep, you’re asleep, so your brain is talking to your adrenals, going, “Okay, let’s do this. Okay, let’s do this.” And when you open your eyes, then all bets are off and your cortisol is supposed to go up. It’s supposed to go up for about the first 30 to 60 minutes and then come down again. That’s the spike that you see.
Now, traditional testing looks at first thing in the morning at about two hours later to give you a general idea. It’s kind of a general overview. But if you have that patient that really wakes up with symptoms. They wake up with anxiety, panic, pain, autoimmune symptoms. They can’t wake up and they hit their alarm 16 times and they need four cups of coffee. When we look, we focus right in on that first 60 minutes, we get a lot of specific answers as opposed to general answers. What do you generally do two hours in the morning, which is compared to what do you do in the first 60 minutes of your day. And because most people can’t urinate on command, well I might be able to, but we need in the moment, we need like waking, and then we need 30 minutes later, and then we need 60 minutes later. So it had to be saliva because nobody wants their blood drawn. And we do it with cotton swabs.
They just put the cotton swab in their mouth, get it wet, take it out, 30 minutes later do it again, 30 minutes later do it again.
Dr. Kara Fitzgerald: I so appreciate that you guys jumped on this. I think there’s some cool research on the cortisol awakening response and I just … That you were so responsive and added this, no pun intended. You’ve got good cortisol awakening response, I’ve been there as a lab.
Dr. Carrie Jones: Right, exactly, well they say, I’ve read in a couple of places that if you can’t get your cortisol awakening response right … they call it the mini stress test of your HPA access, so if you can’t get that right, you’re probably not going to get much else right with your HPA access. So when you know what your first hour of your day is and can correct that, usually it corrects the rest of your 23 hours.
Dr. Kara Fitzgerald: So this is an actual add on. It’s the DUTCH Plus test where you get the cortisol awakening response, correct?
Dr. Carrie Jones: Yes, it’s a separate test. So it’s all the urine markers plus we add in these extra saliva cotton swabs.
Dr. Kara Fitzgerald: And we’re doing that routinely now. I’ve actually gone from using the standard DUTCH to adding the CAR for everybody. I think it’s really that fundamental. And, okay, so now you’ve expanded.
Dr. Carrie Jones: Again.
Dr. Kara Fitzgerald: Yep, you’ve expanded again. I was actually in dialogue with Mark Newman, your chief bottle washer over there and I love talking to him because he’s such an analytical scientist, he’s such a geek and he’s just been falling in love with organic acid testing for a long time and thinking about adding analytes to the DUTCH and you’ve finally done that. So talk to me about what you’re doing and why.
Dr. Carrie Jones: Right, so we have what’s called now the DUTCH Extras. Which we had added before, melatonin and the oxidative stress marker 8OHDG and then Mark expanded on that. So we have added three nutritional, organic acid markers. We’ve added the MMA for B12, and xanthurenate for B6, and pyroglutamate for glutathione, and then we added three neurotransmitter metabolites. So we have HVA which is, I mean, it’s a dopamine metabolite but of course it represents a lot more, and then VMA which is norepinephrine, epinephrine metabolite in five HIAA, which is a serotonin metabolite, and the reason we added them is because they directly relate to the DUTCH results, to hormone results, and it just gives you that much more information.
Dr. Kara Fitzgerald: Well let me walk through each of the sections of the new organic acids and how they relate to hormones. So the nutritional markers, the xanthurenate, the MMA, what’s going on, why do we want to know these when we’re looking at somebody’s hormones?
Dr. Carrie Jones: Definitely. So MMA, methylmalonate, for B12, we obviously … if somebody is low B12 they’re going to have the typical symptoms like fatigue or tremors. But we also need methyl, especially methyl B12, for phase two estrogen detox. So if you do a DUTCH test and you see, oh my patient cannot get from phase one to phase two, they can’t clear their estrogen out, they can’t methylate very well, you can look at the methyl B12, the MMA, and see maybe I need to add more B12 into their mix to help and to see if that’s a big cause.
Dr. Kara Fitzgerald: Well, I see that routinely. I mean, I see poor methylation evidence on the DUTCH test in my patients all of the time. So having a handy MMA there is useful, you know, that evaluation.
Dr. Carrie Jones: Yeah, absolutely.
Dr. Kara Fitzgerald: Yeah.
Dr. Carrie Jones: And I remind people cause they forget. I say, “You know, B12 is absorbed right in the stomach and the small intestine, so if your B12 is low you’re either not eating it or you’re not absorbing it, right? You’re not getting it in, so maybe you should back up and look at intestinal stuff. Look at stomach stuff and see what’s going on.”
So it even can point you in other directions. Like, yes, you need B12, but maybe you should address why the B12 was low in the first place and that’ll set you off on a whole other rabbit hole.
Dr. Kara Fitzgerald: Yeah, that’s right.
Dr. Carrie Jones: It’ll help.
Dr. Kara Fitzgerald: Yep, absolutely. It’s essential, that’s a really good call, why B6?
Dr. Carrie Jones: Because again, with P5P, the methylated form of B6, it can really go with that phase one, phase two detox for estrogen. And of course, B6 is used in what, like over 100 enzymatic reactions in the body? It helps make neurotransmitters, so like brain health stuff. It helps with something called the transsulfuration pathway which makes cysteine, which is part of glutathione, so we’re testing pyroglutamate for glutathione. So it really has it’s fingers in so many pots from estrogen to neurotransmitters to detox and we added it so you can just say, “Let’s look at B6 markers.”
Now, the other big thing, xanthurenate itself, if it’s elevated, it can actually increase the risk for diabetes and it can cause insulin problems. And we know that diabetes and insulin problems greatly contribute to hormone problems and adrenal problems. So if you have high xanthurenate then I might say, “Hey, let’s get you also worked out for blood sugar and insulin. Let’s assess your diet and see what’s going on, and maybe that’s why your hormones and adrenals are a mess because your blood sugar and your insulin is a mess because your xanthurenate is high and we can address this with B6 and diet.”
Dr. Kara Fitzgerald: That’s great. Good, good. That’s a really nice synopsis of xanthurenate. Also the evidence on xanthurenate, I should throw out there, is really pretty solid, as a functional marker of B6 status. It’s definitely more useful than getting a serum B6.
Dr. Carrie Jones: Right, right.
Dr. Kara Fitzgerald: Okay, so, glutathione, talk to me about that molecule and pyroglutamate and it’s relationship to hormones.
Dr. Carrie Jones: Definitely. Glutathione is, I think it’s definitely the most important antioxidant in the body, and so with pyroglutamate or pyroglutamic acid, believe it or not if the level is high or low, is a problem. And it means you’re either not able to make glutathione or you can’t recycle it or something in your body, like an infection, is causing you to use it all up. And these absolutely correlate with your hormones and, of course, your cortisol because with hormones we’re looking at again, estrogen detox, let’s start there.
So let’s pretend in your estrogen detox, you’re headed more towards the cancer pathway, the glutathione, there’s a sort of I call it a stop gap, the GST gene and enzyme can help redirect that cancer pathway back to the beginning so you don’t continue along. Well if you don’t have enough glutathione then your chance of continuing down the cancer pathway goes up and nobody wants that, no man or woman. And that’s just for estrogen.
We have another marker call 8OHDG which is for DNA damage and oxidative stress. So let’s pretend you’ve got some sort of environmental exposure like herbicides or pesticides or heavy metals and it’s causing you some DNA damage which is showing up on our test and it’s glutathione that’s trying to help combat that. Well now that’s getting used up because you’ve got all this exposure. You can see it right on the DUTCH test like, oh my gosh, this is affecting me way more than I thought it was or even realized. Just as an example. Or even people who were exposed to moldy buildings. You know we’ve … micro-toxin is a huge thing everywhere and it uses up a lot of glutathione in the body to try to help you get back to stability. And so I can look at the test and be like, “Wow, this is actually a lot more significant than we thought. You’re either using it all up or you can’t even make it in the first place, so we have to help you.”
And those are just like, what, three examples? I mean it’s just super important.
Dr. Kara Fitzgerald: And how do you address that clinically? What are you doing?
Dr. Carrie Jones: Well there’s a couple options, right? You can do … You can go bigger. People will say, “Well can I test the transsulfuration pathway? Can I test cysteine? Can I test some of these other markers?” Yeah, absolutely you can try to really pinpoint where the glutathione problem is. Other people choose to give the precursors NAC, N-acetyl cysteine, to help make glutathione. They’ll give glycine to help make glutathione or they’ll just straight up give liposomal glutathione to replenish what’s missing.
Dr. Kara Fitzgerald: Okay.
Dr. Carrie Jones: There’s also some co-factors that make glutathione so that’s another area where I might say, “Hey, you know it actually does require B6 so look at xanthurenate.” It does require vitamin C and selenium, zinc, and what’s the other one? Oh, B2. B2 to help recycle it and make it. So I’m like, “Maybe we should do some broader vitamin testing or …”
Dr. Kara Fitzgerald: Yeah.
Dr. Carrie Jones: Yeah, look at absorption again or like talk to them about their dietary intake and see what’s going on.
Dr. Kara Fitzgerald: And B12 is a big player too because if you can’t recycle … If you can’t keep methylation happening, you’re not going to have homocysteine to shuttle into transsulfuration and make glutathione so homocysteine is an essential actor supplying that cysteine.
Dr. Carrie Jones: Totally, yep.
Dr. Kara Fitzgerald: I just wanna back up, you mentioned the cancer pathway. Can you just articulate what that is and how we might analyze it on the DUTCH test.
Dr. Carrie Jones: Yeah, for sure. So, when, male or female, you make an estrogen, you make estradiol and then the body has to get rid of it so it pushes it into phase one detoxification. And it has three pathways it can choose from. It can choose the two pathway, the four pathway, or the 16 pathway. So the two pathway is generally considered the healthier pathway. The four pathway, if not methylated, if it doesn’t go through phase two, it turns tail and it goes down what I call the naughty pathway’ which is also called the quinone pathway, with a q. And when it goes down the quinone pathway, it’s headed towards the potential to make cancer, to get mutations that happen in DNA.
So the body and all of its wisdom has two stop gaps on the way. One is through an enzyme called quinone reductase and the other is through glutathione sulfur transferase. And basically those two stop gaps are to help your body not continue you down the naughty pathway but to turn you around and get you back on the path of enlightenment for your estrogens so that you can methylate them out properly and get rid of them.
If you’re missing glutathione then it just swoops right through the tollbooth like nothing and heads right down towards potential cancer creation.
Dr. Kara Fitzgerald: And you’ll see that because you’ll see the four hydroxy estrogen …
Dr. Carrie Jones: Will be elevated. And we’ll see the methylation will be low.
Dr. Kara Fitzgerald: Okay, so it’s actually … if you haven’t used the DUTCH test yet, listeners, we’ll have links on the site and you can … They’ve got a lot of great videos and they’ve got some sample reports and interpreting the DUTCH test is really pretty straightforward. And you guys offer a lot of support in it. In fact, your tech team is helpful …
Dr. Carrie Jones: Yes.
Dr. Kara Fitzgerald: And provides guidance. Actually, even un-requested, you’ll give some reviews to folks which I appreciated when I first started using it and you can continue to access your tech team as needed, right?
Dr. Carrie Jones: Yeah, absolutely. There’s six of us doctors on staff and so we do, we call them clinical consults and so practitioners can schedule appointments to go over their patients results and everybody gets 30 minutes and they’re free and we do them Monday through Friday so we are here for you.
Dr. Kara Fitzgerald: Yep, you are. Alright, and so let’s talk about the neurotransmitter metabolites that you mentioned, you know in relation to common hormone-associated issues like fatigue or mood swings. So give me the low down on the neurotransmitter markers, how they’re related to hormones and just what we might do about it or think about it with a handful of patterns.
Dr. Carrie Jones: Absolutely. Now, with HVA, which is homovanillate and VMA, which is vanilmandelate , I tend to think of them together. I tend to think of them … because they can go up together, they can go down together, and one or the other one can be high. So with HVA, it’s the dopamine metabolite and of course VMA is the norepinephrine metabolite so if they’re both really elevated, both of them, then we tend to think of high anxiety and high stress and that fight-or-flight mindset and so we can look at the adrenals and see what the cortisol is doing as well. But it also can maybe give us some insight into genetics because there are two genetic SNP that help break them down. One is COMT, which we inadvertently look at when we’re looking at phase two detox and the other is MAO so if they have COMT or MAO issues then there HVA and their VMA might be high.
Now, on the flip side, if the HVA and VMA are quite low, right, fatigue is a big one, addiction, addictive personality, depression. And so now again, we’re looking back at the HPA axis, saying, why can the adrenals not maybe put out, especially norepinephrine and epinephrine and even a little bit of dopamine to figure out, are they so tired because it’s an HPA problem. Or maybe it is a genetic problem. Maybe, once again, it’s a COMT/MAO issue causing a lot of these symptoms. And in the creation of HVA and VMA there’s a number of coenzymes that help move them forward. So it can also point you in that direction too. To get from one to the other one requires certain nutrients and so if one’s high or low, we can go, “Oh, look at these nutrients and see.”
Dr. Kara Fitzgerald: And you actually have a pretty nice discussion on the report walking people through the various patterns, correct?
Dr. Carrie Jones: Yes.
Dr. Kara Fitzgerald: They can access the tech team.
Dr. Carrie Jones: Yes.
Dr. Kara Fitzgerald: Okay. Now you’ve looked at I’m sure thousands of DUTCH assays over your time there. What kind of cortisol patterns might you expect to see? I mean, that’s probably really not a straight answer, but I’m just curious given the time that you’ve looked at them. When you see abnormal HVA/VMA, either high or low, what might you see that’s going on with cortisol?
Dr. Carrie Jones: Yeah, usually it sort of correlates across the board. So if HVA and VMA are high, they’re in an upregulated state, I tend to, now not always, but I tend to see higher cortisol levels. And when everything’s low, I tend to see lower cortisol levels as well. Not always. So for example, maybe their cortisol is fine or the opposite. They have really high levels of VMA but really low levels of cortisol and the person says, “Well, I’m tired with a lot of anxiety.” And I’m like, “Yes.” Because your cortisol production and free cortisol is low but your VMA is high so you are in fight-or-flight emotionally but tired because you don’t have cortisol.
Dr. Kara Fitzgerald: Right, I’ve seen that pattern, running on adrenaline. Give me a handful of interventions that you’re thinking about with some of these patterns.
Dr. Carrie Jones: Absolutely, so the big one, to get from HVA to VMA requires copper and vitamin C. And so if you see that the HVA is normal or high, usually and the VMA is low, then you may have to assess them for copper and you may have to assess them for vitamin C. And I remind people, hey vitamin C is required by the adrenals. So if you see this pattern, I mean you can test them, sure, but if they also have adrenal problems, HVA problems, just put them on Vitamin C. And as we all know it’s like the nastiest cold and flu season ever, so just put them on Vitamin C and then go do a serum copper on them and see if them need copper support as well.
Dr. Kara Fitzgerald: Incidentally Vitamin C is a pretty fabulous recycler of glutathione. It’s a major player there, so there’s that.
Dr. Carrie Jones: Yes, good point.
Dr. Kara Fitzgerald: Right, right. You’re going to be nourishing that area as well.
Dr. Carrie Jones: Which is great. And the other thing is that they’re made from amino acids, the HVA and VMA and even 5HIAA. So they’re made from tyrosine and tryptophan, respectively. So I find that a lot of patients don’t eat enough protein or they have a lot of digestive issues that they don’t digest their protein very well and so their levels are maybe low because they just don’t even have the initial starting precursor to make it. And so we just go all the way back to diet. Like, do you even eat enough protein and what is going on with your stomach and intestines to get it in you in the first place. And then you may have to just make some adjustments starting from right in the beginning.
Dr. Kara Fitzgerald: Right, very smart. So again, just going back to rest, digest, adequate nutrition, good gut function, perfect.
Dr. Carrie Jones: Right.
Dr. Kara Fitzgerald: It all sources back there so much of the time. What if HVA and VMA are really high? What are you thinking about as far as interventions?
Dr. Carrie Jones: Usually, I’m … Well first and foremost, I always ask them, “Are you taking stimulatory stuff? Are you on ADD medication? Do you do a lot of caffeine? Did you do caffeine at the time of this test? Are you taking the appetite suppressants like phentermine? Are you on Sudafed, because it’s cold and flu season?” So first I ask those questions.
Then I ask, “Are you actually taking the precursors? Are you taking tyrosine? Are you taking L-DOPA? Are you taking Mucuna which has dopamine in it?” And then if they’re like, “No, no, no, no, I don’t take any of that.” So then, it’s calming. Then I’m doing like, “Hey, look, this primarily is probably HPA fight-or-flight related, let’s do either mindful calming interventions, get to bed on time, meditation, journaling, acupuncture, what have you.” And then calming adrenal support, holy basil. I do use vitamin C even though it’s not quite calming, it’s supportive. Ashwagandha, magnolia, skullcap, passionflower, or L-theanine. Love L-theanine. Just these calming, nurturing, supplements to help while you’re addressing the cause.
Dr. Kara Fitzgerald: Oh, that’s perfect.
Dr. Carrie Jones: Thank you.
Dr. Kara Fitzgerald: Alright, so 5HIAA. 5-Hydroxyindoleacetate is a serotonin marker that you’re offering now. Why don’t you just give me an overview on that, your thinking about it, and then if we’re going to see any … If somebody’s taking an SSRI, what kind of patterns might we see?
Dr. Carrie Jones: Right, absolutely, well the one thing with 5HIAA, well serotonin, let me just start with serotonin. People forget, 90 percent of your serotonin is made in your gut, it helps with motility, which is good. And it helps with smooth muscle activity, so to get things moved forward. And only roughly about one percent is made in the brain and the rest is out there in your peripheral tissue.
So I know people say, “Oh, you can’t test serotonin, it’s not a direct measurement of the brain.” We’re like, “We know.” It’s usually because the gut and the brain talk all day long through the vagus nerve. If it’s going on in the gut, it’s probably going on the brain and vice versa. And so the 5HIAA is really nice because it gives us an indication of maybe what’s happening with serotonin system wide. It does require the SNP MAO to break it down. So if you have an MAO issue on your genetic test, you may have a hard time getting from serotonin to 5HIAA. And there’s a number of things that get in the way of making serotonin that I don’t think people even realize. Like estrogen is a great one as it relates to the DUTCH test.
Estrogen is required to get from tryptophan, tryptophan is the amino acid that kicks everything off. So, tryptophan to 5HTP, so if you don’t have enough estrogen, let’s pretend your menopausal or you have irregular cycles or your amenorrheic. Then you don’t have a lot of estrogen floating around and these women tend to come in and say, “I feel more depressed lately.” And they’re missing out on that ability to jump forward to make 5HTP.
Now on the flip side, estrogen dominance which we can see on the DUTCH test, estrogen dominance will divert the creation of serotonin away from serotonin and down a different pathway, it’s called the kynurenine pathway. And so you can’t really win. If you have too little estrogen or too much estrogen, you’re going to lose out on serotonin and depression which we know this. Women come in and go, “I feel more depressed, I have more anxiety.” Whether your too low or too high estrogen, this is a big reason. You know what happens, right? They get put on an SSRI. Here, take Prozac.
Dr. Kara Fitzgerald: Okay, and then what are you seeing on labs when people are on an SSRI?
Dr. Carrie Jones: If they have healthy levels of tryptophan then it … making serotonin then we should see high levels of 5HIAA. That means that the medication, the anti-depressant medication is working. So don’t freak out, don’t think they’re on too much. If you have high levels of 5HIAA and they are on and SSRI or SNRI like Wellbutrin, they will have high levels of 5HIAA.
And the same if they’re on 5HTP, you know if they’re taking the supplements that will drive it up as well.
Dr. Kara Fitzgerald: Yeah, in fact, I see 5HTP, since it’s metabolized peripherally, drive it up more than SSRIs.
Dr. Carrie Jones: We see that all the time.
Dr. Kara Fitzgerald: Right, and it isn’t cause for concern. It’s just confirmation they’re taking it and they’re metabolizing it.
Dr. Carrie Jones: Right.
Dr. Kara Fitzgerald: And serotonin is also converted to melatonin and you have melatonin on the panel as well so I think that’s a nice little piece that could be useful.
Dr. Kara Fitzgerald: So in estrogen, in low estrogen states, you’re going to see low serotonin and low melatonin for the estrogen conversion need. And then in inflammatory estrogen states all your tryptophan is being commandeered and shuttled down the Kynurenine pathway as you mentioned, so you’re going to see actually a really similar picture in both cases and both cases are going to present with some really pretty lousy symptoms.
Dr. Carrie Jones: Right, and practitioners know this. When I explain this, when I’m like, “Think of your perimenopausal woman who’s heading into menopause and she comes to your office and says, ‘I used to be in a good mood and could sleep, and now I can’t, now I’m depressed and I can’t sleep, what’s going on?'” And low estrogen causing low serotonin causing low melatonin is one big reason.
Dr. Kara Fitzgerald: Yeah, that’s really logical, you know, in truth when Mark first started pinging me cause I did my background in laboratory science and did a lot of focus on organic acids over the years …
Dr. Carrie Jones: I know, I was nervous to talk to you. He was like, ” Alright, you’re going to talk with Kara.” I’m like, “No, this is what she does. She’s the expert, no way.”
Dr. Kara Fitzgerald: You’re actually doing a rockin’ job, you really are, Carrie. And the fact that you’re actually marrying it to the hormones is out of my wheelhouse and I just really, really appreciate it. And so what I was going to say was that when Mark first started pinging me with these organic acid questions and he was batting around, thinking about which ones he would do and I was like, “Y’know, really, are you going to do …” And I supported him and I thought he made some good and interesting choices but, honestly, you’re marrying the relevance together for me in a really, really nice way.
Dr. Carrie Jones: Good. And it’s on our results if you are on six different pages. So I tell people, you will flip a lot, cause you’ll flip forward and flip backwards and, like, oh that’s B6. And you’ll flip back and oh, B12, okay, and you’ll be flipping back to the estrogen page and then you’re flipping to the cortisol page, but it’s all in one test so you just get one test and you get all these answers and can really just help your patient that much deeper.
Dr. Kara Fitzgerald: And you guys … I don’t think you actually raised the price on it.
Dr. Carrie Jones: We did not, no. We added it for no extra charge just to give more information.
Dr. Kara Fitzgerald: Yeah, that’s pretty neat. Okay, so can you … Well, I have a couple of questions now. Well first of all, are there any single nucleotide polymorphisms that you want to cover in more detail? I know we talked about COMT, we talked about glutathione transferase and MAO or any other relevant players come to mind in this whole journey?
Dr. Carrie Jones: No, I mean, definitely I know it gets … And this is your wheelhouse 100 percent and everyone is on the MTHFR train and I just want people to realize having a mutation with MTHFR and when I talk about estrogen methylation, it’s not one to one, it’s not apples and apples, it’s not the same thing. Of course MTHFR plays a big role in all of this but I just remind people, well actually it’s COMT, it’s COMT, with estrogen is kind of helping convert one to the other but you need the whole methylation cycle to work in which MTHFR is a part of.
Dr. Kara Fitzgerald: And I think that I’m in my practice, people come to me having measured, having tested for their SNPs and I need to talk them off the ledge, often these days. That it’s not … Having any of these mutations, hetero or homozygous isn’t a death sentence. If we see evidence that they’re in balance or that we’re suspecting imbalance coming from the SNPs it’s imminently correctable and sometimes we really don’t see evidence of imbalance. Would you agree?
Dr. Carrie Jones: Yeah, absolutely. I have people that tell me, “I have the COMPT SNP, hetero or homo.” And I’m like, “Well, but you’re estrogens look fine and you’re VMA and HVA are totally within normal range. I don’t think it’s manifesting.” I mean you have it, but ignore it.
Dr. Kara Fitzgerald: That’s right, I mean, and you know it’s not always about loading up on a really intense supplement protocol, which again, people will come to me taking many, many things. I mean what you pointed out immediately, which I thought was brilliant, in your discussion of interventions was lifestyle modification.
Dr. Carrie Jones: Always. Right, isn’t it everything? Don’t you find the more research you read, you get more of the why but the treatment’s always the same. It always comes right back to lifestyle.
Dr. Kara Fitzgerald: It does, lifestyle and diet.
Dr. Carrie Jones: Mm-hmm (affirmative).
Dr. Kara Fitzgerald: Those are our two biggest leverage areas. And most folks that I’ve talked to, most clinicians will bring in the lifestyle piece, recognizing that it’s important. And I’m guilty of doing this too as the last intervention. And you brought it first, front, and center, so you go, Dr. Jones.
Alright, any cases that you can think of off the top of your head where you went in and did some correcting, I know I’m putting you on the spot here with this question, and no pressure.
Dr. Carrie Jones: No pressure. I actually just presented a case of a perimenopausal woman presenting with depression and anxiety and it just sort of ties into what I’ve said with estrogen. But she was alternating between some months she had a period and she had really bad PMS and other months, of course, she’s perimenopausal, she had no period. And then she said, “my depression and anxiety is worse.” And she said, “I don’t understand why, with the skipping of periods or the missing of periods, my hormone symptoms change so dramatically.” And so we happened to test her on a PMS month like we knew her period was coming. And so she was estrogen dominant and she had low progesterone and she had low 5HIAA and she had high VMA. And so she was in a job, she was actually a school teacher, which I wouldn’t wish on anyone unfortunately right now.
So her stress was very high and it was the perfect lab results to say, “This is why you feel this way. Obviously, a lot of it’s situational, your stress is very high, your job is very demanding, but you’re also perimenopausal. So, on the months you’re going to get your period, you’re going be estrogen dominant, you’re going be low progesterone and you’re going have serotonin problems cause the high estrogen is diverting you. And on the months you skip your period, you’re going feel more depressed and anxious because your estrogen plummets and your progesterone has already plummeted, it just stayed plummeted. And you’re going miss out on serotonin creation.”
And so the treatment plan was a little bit of on the months you feel like this, do this, right? Like on the months you feel more depressed and anxious, we’re going to try to support estrogen and do 5HTP. And then on the months you’re feeling more PMS-y, we’re going focus a little bit more on estrogen detox and still supporting 5HTP and serotonin and so it was just really neat to sort of walk her through how she could switch from one month to the next and it was important to know in her testing, is this a period month or is this a skip month? Because then I knew what I was looking at.
Obviously, we addressed a lot of diet and lifestyle, as you can imagine, teachers often don’t eat, they eat on the fly, they don’t hydrate because they can’t go to the bathroom, they have no time for that. And dehydration is a massive stress to the body. So we were working on all of that while explaining, when you flip, perimenopausal’s a time of chaos and it absolutely shows up in your labs like that. But we can be very individualized about it and work through that.
Dr. Kara Fitzgerald: Well what’s interesting, too, is I remember learning this a long time ago, actually, before I went to med school even, was that perimenopause, menopause journey is absolutely asymptomatic in other countries. You know the so-called ‘developing countries’.
Dr. Carrie Jones: Right.
Dr. Kara Fitzgerald: And so, why is that? What’s the major deal breaker, here?
Dr. Carrie Jones: I think it’s everything we’ve just said. I think it’s environmental toxins, lifestyle, and diet, and stress, which falls under lifestyle. It just … Our bodies in these first world countries are just overwhelmed and we cannot just slide from perimenopause into menopause gracefully. Some women do it. I had this one amazing patient who had hot flashes one time and she said, “I did menopause, that was it.” I was like, “What?”
Dr. Kara Fitzgerald: Wow, yes.
Dr. Carrie Jones: Can I bottle up what you have? I could be a billionaire if I could sell that. But most women struggle with insomnia, anxiety, hot flashes, night sweats, weight gain, fatigue, and I said, “You know, it’s just, there’s so much wear and tear on the body.” It’s like a trampoline. You jump on your trampoline all through your teens and twenties and thirties and you hit the trampoline and you rebound, right? And the more you add from dietary choices, lifestyle, environmental exposure, stress, your trampoline gets threadbare and then all of a sudden you go to bounce one day and you form a hole and you hit the bottom and it’s hard to recover. And I think our society and the way, and I’m 100 percent guilty of it and I’m a medical director for DUTCH test. I think just this society nowadays, we don’t take care ourself and we add more on our plate and we’re always on our phones and our computers and it’s unfortunate.
Dr. Kara Fitzgerald: Yeah, it is. It is. You know, we went to school together and I rode my bike all of the time.
Dr. Carrie Jones: Yes, you did.
Dr. Kara Fitzgerald: I was permanently in bike clothes and sort of mildly sweaty.
Dr. Carrie Jones: That’s how I remember you.
Dr. Kara Fitzgerald: Well, of course, why wouldn’t you? That’s so funny. But you know and we thought we were so busy and overwhelmed and unhealthy and adrenal depleted and you know little do those students know.
Dr. Carrie Jones: I know. I actually did a interview with a woman asking me about my naturopathic background and all this stuff and she said, “What advice do you have?” And my first advice was, cause the point of the article was for physicians, I said, “It’s physician heal thyself. I’ve seen thousands and thousands and thousands of labs now and I can tell you the burnout rate is way higher in my practitioners I consult with than the patients themselves.” And in the article I said, “And if you’re reading this, and you’re in school, I don’t care if it’s naturopathic, allopathic, chiropractic, acupuncture, I don’t care, take care of yourself now. Get your self care habits ready now, cause it doesn’t get any better, let me tell you.”
Dr. Kara Fitzgerald: No, it gets harder. I mean, I’m on my butt, I guess I was going to juxtapose that with my writing habits. I mean, back then I was commuting everywhere and now I really live on my butt in my office. And I have this little mini bike pedal under my desk but it’s not comparable, it’s not. I mean, it’s better than nothing. I can get my legs moving a little bit here and there. But you know, I look back on those days with kind of relish now that they’re so far gone.
Okay, so I just wanted to circle back, we’ve got a few more minutes before we end, and I just want to ping you on, because I know people are wondering, for this perimenopausal person, cycling through these two monthly phases, what were your interventions? Can you give me kind of an overview of how you worked with her?
Dr. Carrie Jones: Yeah, absolutely. So I had her … Baseline everything right? We worked on diet primarily cause she wasn’t eating so we focused on at least having something to eat, trying to eat, or having snacks that were appropriate. And we focused on hydration because the more dehydrated she was, the more her HPA access kicked in and that raised cortisol and that raised VMA. So I was like, “Look, just the very basic, let’s try to control this stuff.” And then sleep. She was on her computer late at night cause she was a teacher and she was grading papers and stuff. So I said … We had to work on screen time, apps to get the blue light down, and then those every so sexy blue light blocking glasses.
Dr. Kara Fitzgerald: Yes.
Dr. Carrie Jones: She invested in so that she could … I mean she had to be at her computer, it was her job. But tried to at least minimize the blue light exposure.
So we started there first and foremost. So the months she was skipping cycles, I actually did add in 5HTP because she didn’t have the estrogen to get from tryptophan to 5HTP so I just went ahead and gave her 5HTP. I said, “In fact, you probably need this every month, not just the months that you don’t cycle.” And then I gave her adaptogens in the morning and I gave her calming adrenal support at night. So I think it was a blend of like ashwagandha, theanine, and some other nice stuff that just sort of brought the cortisol down. So I was basically trying to train her like down at night, up in the morning, down at night, up in the morning.
Dr. Kara Fitzgerald: And what was the up protocol?
Dr. Carrie Jones: Actually it was just adaptogens. So I think was more ashwagandha, it was rhodiola, and I think it actually had vitamin C, some B vitamins, I’m trying to think. I don’t know if I’m allowed to mention companies on here.
Dr. Kara Fitzgerald: Yeah, yeah, you are, absolutely.
Dr. Carrie Jones: Oh good, it was the morning one was Biotics.
Dr. Kara Fitzgerald: I can just have them look for the adaptogen blend that’s a little more stimulating.
Dr. Carrie Jones: ADB5. Oh my gosh. It’s Biotics ADB5 Plus that’s what I used. And then I did ITI’s cortisol manager at night.
Dr. Kara Fitzgerald: Okay, integrative therapeutics, cortisol manager. Perfect.
Yeah, go ahead.
Dr. Carrie Jones: 5HTP I did 100 milligrams so …
Dr. Kara Fitzgerald: Okay, good.
Dr. Carrie Jones: Pretty standard.
Dr. Kara Fitzgerald: Good.
Dr. Carrie Jones: And then the months where she was feeling PMS-y where she could tell. She’s like, “My boobs would start hurting, I’d get moodier.” I actually had her add in DIM. Diindolymethane. And said, on those months, use DIM when you’re feeling those symptoms. I had her do 200 milligrams because I was trying to … She was estrogen dominant those months, like really literally high estrogen. So I said, “Do DIM until you get your period and then stop it because if you use DIM, it will lower estrogen.” But on the months she was skipping, she already had low estrogen, she didn’t need it. It would make her hot flashes worse. So I did DIM and then I actually … her progesterone was low the whole time and we actually decided to do progesterone. I actually added in oral progesterone for her.
Now some people would argue, why didn’t you use something like chasteberry or what have you. And I just find, and you may agree or disagree, I find that the herbs to encourage ovulation, once their perimenopausal, she was 48. Once you’re perimenopausal, like her ovaries are not going to listen to chaste tree, that well. Right? Like they’re like, “Oh, I don’t wanna get stimulated anymore, I’m pretty much over this. I don’t wanna get pregnant.”
So we actually did add in progesterone to help, for two reasons. One, on the months she was estrogen dominant and two, because she was having anxiety and she was having insomnia. And so while I did cortisol manager at night, the oral progesterone, when it goes to deliver, it goes through first pass and it creates a whole lotta metabolites of which some of them turn into the alpha metabolites and they become what’s called ALLO, A-L-L-O. Not the plant but A-L-L-O. And ALLO crosses the blood-brain barrier and supports GABA. So, another big reason perimenopausal women will say, “I’m having more anxiety is because she’s not making the progesterone to make ALLO to cross the blood brain barrier to support the GABA A receptors and so it was a twofer for me.
Dr. Kara Fitzgerald: Smart, smart. And this is why you skipped topical progesterone. Is that correct?
Dr. Carrie Jones: Yep. Cause if she was not having sleep or anxiety issues, then like six to one, half dozen or another, I probably would have used topical instead.
Dr. Kara Fitzgerald: Okay. Great case. That’s a great, great case.
Dr. Carrie Jones: Yeah, and it was very and follow-up, once I explained it to her, which happens to a lot of our patients and she went away and came back for follow up. She knew. She knew on the day she skipped lunch and she didn’t drink enough water and she was on her computer too late. She said, “Oh yeah, all my symptoms, I felt hot flashy, my anxiety went up.” Then, she could totally correlate it and she knew how to self-correct herself. I was like, “Great!”
Dr. Kara Fitzgerald: That’s great. Doctor as teacher.
Dr. Carrie Jones: Right.
Dr. Kara Fitzgerald: Well, we’re at the end of another fabulous, very user-friendly podcast with Dr. Jones. I just want to thank you again for being apart of our world, here.
Dr. Carrie Jones: Thank you! Thank you so much! I love talking to you.
Dr. Kara Fitzgerald: And I’m sure we’re going to do this again, hopefully, in the new year sometime. And maybe we’re even doing it again this year, I don’t know. But I can’t remember our schedule. I think either you or Mark may be back.
Dr. Carrie Jones: I think it’s Mark next. I think we’re alternating, yeah.
Dr. Kara Fitzgerald: Okay.
Dr. Carrie Jones: So you’ll get all geeked out with him.
Dr. Kara Fitzgerald: Good, good, it’ll be fun. Alright, Dr. Jones, thanks so much for joining me today.
Dr. Carrie Jones: Oh, thank you, Kara. I appreciate it.