Dr. Carrie Jones Q&A

Participants of Dr. Jones’ 2018 events (Finding Balance with Hormones full day workshop in Sydney, and Hormonal Dysregulation seminar in Perth) had the opportunity to ask Carrie some follow up questions following these events. These questions and her responses are below.

Click on the question to view Dr. Jones’ response

 

If a patient only bleeds for 2 days, do you still count forward 19 days from the first day of bleed, or would you choose to test closer to the 21 days? OR just use your luteinizing hormone strips?
Consider utilising LH strips to be absolutely sure, then counting forward 5-7 days from a positive LH test, do the DUTCH test.
What is the relevance of an elevated RT3 with regards to a male patient? How this would influence the DUTCH results?
An elevated RT3 means that the body is diverting T3 over to inert RT3. Therefore the practitioner would have to figure out why the body is diverting T3 to RT3. One of the many reasons is high cortisol, so you can look to see if the cortisol (or VMA) is high on the DUTCH.
How the test might benefit a perimenopausal patient, and when to test if cycle is irregular?

The DUTCH test provides information on Oestrogens, Progesterones, Androgens and Cortisol within the one test. This test not only reveals the levels of basic hormones, but also their upstream and downstream metabolites which provides information on the root causation of imbalances and therefore helps to target treatment protocols. Although the levels of the various hormones and their metabolites are highly changeable during peri-menopause, as well as different for each individual, the DUTCH test can reveal critical information which can be utilised to specify treatment and manage symptoms.

Testing for the DUTCH test will depend on the regularity and irregularity of the patients cycle. If the patient is somewhat irregular, it is ideal to utilise LH strips to detect ovulation. Once positive, count forward 5-7 days and perform the DUTCH test.

If the patient is highly irregular e.g. menses every 2 weeks, followed by several months without menses etc., further instructions are indicated. Please contact the RN Labs’ technical team to further specify the instructions for such a patient.

I have a patient who completed a DUTCH Complete test last year. It helped to address some issues, but she presented again recently, not coping with cyclical migraines in 2 weeks leading to her period and during period. She experiences irregular long cycles - 30 to 40 days. Will Cycle Mapping help?
Yes, Cycle Mapping is an excellent tool to utilise for menstrual migraines as you can observe the rise and fall (or not) of oestrogen and progesterone.
My patient has a Mirena, but is about to have it removed. Is it best to test while still in, or wait a few months after removal? Or shall we test both before and after?
It is ideal to wait 2-3 periods after Mirena removal to perform the DUTCH test.
My patient has Endometriosis (or fibroids - oestrogen that has built up in the tissue) and suffering with chronic pain. Is the DUTCH still relevant in these cases? Does it show whether the oestrogen is built up in the tissue?
Yes, the DUTCH test is relevant. Further information regarding “oestrogen build up in the tissue” is required to answer your question in more detail.
How would endocrine disruptors impact the DUTCH result?
Certain endocrine disruptors such as BPA, can increase E2 levels in men and women. Others can bind to the Oestrogen Receptor and cause oestrogen type symptoms but do not raise levels of oestrogen itself.
Is the DUTCH test relevant for a menopausal woman (post 10 years)?
The DUTCH should only be done on a post menopausal women if relevant. If the indvidual is 10 years post-menopausal and is feeling fine and does not have any symptoms, then there is no need to do the test.
Why would you need the salivary Cortisol Awakening Response in the DUTCH Plus, when the DUTCH Complete still gives you the same information via urine?

The CAR is useful due to its ability to offer a more precise reading of free cortisol. The CAR records waking cortisol, 30 mins post waking cortisol and 60 mins post waking cortisol, to record the overall cortisol patterns in the first hour.

When we open our eyes upon waking, cortisol levels naturally begin to rise by an average of 50%. 30 minutes after waking, cortisol levels will still show this sharp increase. By 60 minutes after waking, cortisol levels have peaked and begin to decline. Measuring this rise and fall of cortisol levels at waking can be used as a “mini stress test”. Research shows that the size of this increase correlates with HPA-axis function, even if the sample measurements are all within range.

A low or blunted Cortisol Awakening Response can be a result of an underactive HPA axis, excessive psychological burnout, seasonal affective disorder (SAD), sleep apnea or poor sleep in general, PTSD, chronic fatigue and/or chronic pain. A decreased CAR has also been associated with systemic hypertension, functional GI diseases, postpartum depression, and autoimmune diseases.

An elevated Cortisol Awakening Response can be a result of an over-reactive HPA axis, ongoing job-related stress (anticipatory stress for the day), glycemic dysregulation, pain (i.e. waking with painful joints or a migraine), and general depression (not SAD).

A recent study showed that neither the waking nor post-waking cortisol results correlated to Major Depressive Disorder, but the CAR calculation (the change between the first two samples) did. This measurement of the response to waking has independent clinical value showing dysfunction that may be hidden by current testing options.

Overall, the Complete test is not the same as the Plus as far as free cortisol is concerned. The Complete test offers a more comprehensive insight into free cortisol and therefore further insights into the HPA Axis.

You mentioned using the dials more, but I would like some clarification on this. For interpreting oestrogen, do you go by more the dials lining up, or the % ratio between the oestrogen metabolites? (Is it more important to ensure visually the arrows are lined up on dial, or whether the pie chart is correct).

It is ideal to use both forms of information. The pie chart represents the ratios of the different oestrogens that are approaching detoxification. Therefore if a patient has a high level of oestrogen in their system (E1 and E2 are in the red) coming into Phase 1, then it’s possible for all the phase 1 dials to be in the red range while the pie chart showcases normal percentages due to ideal distribution.

While this means the distribution of 2, 4 and 16-OH is acceptable, the absolute number of 2, 4 and 16-OH may still be too high/low. It is not ideal to see the absolute number of 4 or 16-OH in the high range regardless of the distribution.
Specifically if 4-OH is not methylated, it has a high chance of becoming a Quinone (which is a reactive oxygen species) and then a depurinating adduct (increased cancer risk).

Therefore it is useful to take both the pie chart and the absolute numbers into account. Overall, the pie chart represents the ratio of 2, 4 and 16OH and is a useful indicator to evaluate whether the ratios are in the ideal ranges. However, the absolute numbers offer the actual levels of hormones, which ideally should be within range, regardless of what the ratio may be.

Furthermore, optimum methylation is ideal in either case otherwise there is an increased Cancer risk.

When a patient's methylation index is low, and they already eat well, exercise, are on magnesium and B vitamins and have a COMT SNP – what do you do? Do you do a plasma methylation profile from Doctor’s Data?
Yes, it is an excellent idea to further investigate the various aspects of methylation to enhance methylation. Further information on methylation to homocysteine cycle is important, but also consider other supplements such as glutathione/NAC to bind up the semi-quinones and quinones and properly excrete them.
How do you safely act on the low methylation?
Further details on what is meant by acting safely on low methylation are required.
Why would my patient's DUTCH result show low methylation activity, however when tested further, their methylation profile has come back normal?
To analogise this example imagine a bathtub. Although the patient has an open drain, she also has high level of 2-OH pouring into her bathtub and her drain is not wide enough to eliminate the 2-OH at the same rate that it is entering the system. Therefore her methylation activity is leaning towards low. Her methylation is functioning, however it is not at a high level as given the amount of 2-OH (and 4-OH) substrate that is present.
I would like some more insight around when a patient has COMT Mutation (I have found this hard to treat, especially when methylation profile is normal, however DUTCH result indicates low methylation activity (both low 2 hydroxy and 2 methoxy).
Please refer to previous question and answer for further insight.
What do you do in clinical practice if methylation indicates low, when already treating patient with optimal lifestyle – and other results are normal, and don’t want to increase too much eg. for cell proliferation.

Ideal supplements for supporting methylation would include: choline, methionine, magnesium, liposomal glutathione, sulforaphane. Furthermore, low doses of B vitamins are also useful. Do not use folate initially. There is also a chart by Ben Lynch which further showcases what other factors may be influencing the situation such as infections, inflammations, heavy metals, gut issues, stress…etc.

Furthermore, oestrogen dominance slows down COMT, therefore increasing fibre, supplementing calcium-d-glucarate and other gut supportive nutrients to support oestrogen clearance via various pathways is also useful.

Reducing overall chemical impact is also a necessary aspect of such treatment. Reducing the presence of endocrine disrupting chemicals though avenues such as skincare, household cleaning chemicals, lawn care/gardening, how the patient cooks, the food the patient buys, water filtration, the presence of plastic lids with coffee/tea etc., is also an a major focal point for such patients.

Thyroid and 24 hour cortisol levels are closely linked – if someone has subclinical hypothyroid condition, where they are not on thyroid hormone replacement, but doing all nutritional actions. T3 and T4 in range, but not optimal – would you then expect that that will keep affecting the cortisol levels?
Yes, it is a possibility and is dependent on the person.
What if my patient has a downregulated hypothalamic pituitary axis which is not optimally supporting the thyroid?
If it is suspected that the HPA axis is downregulated then consider addressing it, as well as consider further tests such as ACTH testing.
What if their thyroid doesn’t improve into optimal range after treatment?
Further information is required to fully answer this query.
And how can you tell whether the cortisol is affecting thyroid, or thyroid affecting cortisol?
If there is low metabolised cortisol and high free cortisol and there is also a known presence of thyroid problems, then it can be strongly suspected that the thyroid is affecting the HPA axis. Other patterns with low thyroid function can also be indicative of detrimental impacts by the HPA on the Thyroid. However, it is ideal to address both at the same time as there can be overlap and the conditions for these physiological systems are usually multi-factorial.
If there is an adaptive response to downregulate free cortisol to protect the brain, isn’t this a good thing? How do you translate that to the patient if there is an optimal response? Is there a guide on how long this could take to correct this?

As there are no set guidelines on how to rectify such mechanisms, treating the patient and changing treatment as required is the ideal form of action. This is the same for treating with a blood work or salivary testing.

For example in a patient who had high cortisol during a rheumatoid arthritis flare up, treatment for lowering cortisol levels resulted in worsening of symptoms – clearly the high cortisol was helpful at that time.

How long would it take to bring cortisol pattern into optimal range, given that flat curve is linked to breast cancer etc.
Assuming the patient is compliant with lifestyle and diet changes along with supplement intake, cortisol has been known to correct itself in as little as a few weeks. In some instances it may take months.
Would subclinical hypothyroid be causing the adrenals to be low? And should a patient like this be treated with T4/T3 to bring their thyroid back to optimal levels (even though within range?)
Subclinical hypothyroidism is not usually the cause for low levels of metabolised and free cortisol. Further thyroid lab tests are required to indicate appropriate treatment.
What about Addison’s disease?
Addison’s disease may be identified on the DUTCH test as extremely low metabolised cortisol, extremely low free cortisol and cortisone. Furthermore, the pattern is often very low and flatlined. In such cases, additional testing for Addison’s is indicated.
Would thyroid extract be an option? Would it have an effect on the cortisol?

Thyroid extract may be an option depending on the individual at hand. If the thyroid extract corrects the thyroid imbalance then it may correct imbalanced cortisol levels as well; if thyroid issues were the only reason for the cortisol imbalance.

However, a patient may shift into another pattern of hormonal imbalance, as the thyroid may start functioning appropriately but other aspects of the HPA that may not be functioning well may come to the forefront.

If someone has deficient cortisol/24 hour cortisol, but have normal DHEA and DHEAS levels are normal, what could that be indicating?
The layer of the adrenal gland that creates cortisol is not receiving the message to create cortisol or is not responding, but the layer that creates DHEA is responding.
If someone is on the oral contraceptive pill and you do a Dutch Plus, which tests are valid. I gather oestrogen and progesterones are invalid but will oestrogen metabolites, androgen metabolites and cortisol/cortisone readings be valid? What is valid if they have a mirena IUD?
Oestrogen and Progesterone will display as very low for a patient on the pill, indicating that the pill is functioning. All the other markers will be valid for a patient on the pill. Often testosterone will display as low due to higher levels of SHBG. The cortisol is not often observed to be affected by the pill.
If the Mirena is inhibiting ovulation, then the progesterone will be low. Please refer to slides for further information.