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Understanding hormone profiles: Functional pathology

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Understanding Hormone Profiles: Functional Pathology

Beth Bundy is a Melbourne based naturopath with a strong focus on the interplay of the thyroid, adrenals and sex organs.

In this interview, she reveals the benefits of functional pathology as an objective measurement to show patient benefits of treatment over time. Beth takes our listeners through the differences in functional testing as opposed to standard pathology testing, and shows the practitioner some of the commonly useful tests to determine or confirm clinical suspicions of what's going on inside the patient's body.

Covered in this episode

[01:20] Welcoming back Beth Bundy
[02:44] How Beth uses functional medicine testing in her clinic
[04:40] The differences between functional pathology vs standard pathology
[09:39] The three-legged stool: thyroid, adrenal and sex hormones
[10:59] Adrenal profiles
[14:17] Sex hormone profiles
[15:42] Choosing the right test
[18:26] Additional hormone testing options
[20:48] The importance of symptom based testing
[24:39] Are there differences in testing results between laboratories?
[29:03] Determining which test is most relevant
[32:02] Why doctors are limited in ordering functional testing
[35:39] Thanking Beth and final remarks

Andrew: This is FX Medicine, and I'm Andrew Whitfield-Cook. With me on the line today is Beth Bundy, who's a qualified naturopath of over 16 years, specialising in integrative and functional medicine. Beth's been practising using a combination of nutrition, herbal medicine, and homeopathic medicine with a strong emphasis on health issues such as detoxification, weight management, adrenal fatigue, hormone balance, and general anti-aging therapies. 

She's worked previously as technical and practitioner consultant with Path Lab, one of Australia's original functional pathology companies, and is currently training health practitioners nationally as Clinical Consultant at NutriPATH Integrative Pathology Services. She's also Practitioner Consultant for smartDNA Genomic Testing

Beth works as a functional medicine practitioner in a busy and highly successful integrative medicine practice and worked with Allied Health Professionals in a multi-modality clinic and in a cosmetic clinic, as well. Beth was also lecturer in Nutrition and Food As Medicine for several years at the Australian College of Natural Medicine, which is now called Endeavour College in Melbourne. Welcome, Beth. That's a decent bio.

Beth: Yeah, that sounded like quite a mouthful, didn't it? Hello. Hello. Hello, I can actually say from sunny Melbourne today. The sun is actually out.

Andrew: Well, that's this hour. So Beth, first tell me about your practice because you actually walk your talk, you know? You've used functional medicine testing for many years. Tell me how it started in your clinic.

Beth: Well, it actually started like most things do. I went to a talk by an integrated pathology company. Really liked the sound of what it was. I saw that it could add to my practice already. 

So, of course, always after something shiny and new, I thought I'd guinea pig on myself as practitioners are wont to do. 

Andrew: Yes.

Beth: And so, I did a saliva test on myself for my adrenals and my hormones. Got the results, it brought tears to my eyes. I decided to start working on myself, and I’m in a much better place, so it was great. And I've really been a converted zealot about the testing since because I think it offers so much more to us as practitioners to get a bit deeper into the patient. 

And, of course, now working for NutriPATH and in an integrated medical clinic for nearly 10 years now, we use it all the time alongside standard pathology, of course. But we use quite a lot of functional testing and because what we find is that standard pathology is really just that, it is pathology tests. 

So often, when people get these tests, the doctor or the practitioner is looking for pathology. So the practitioner can prescribe, usually, a pill for an ill. So, you know, they might say, "Oh, yes, Mrs. Smith, you've got diabetes. We have a tablet for that. Here is some Metformin." But I believe that we could really prevent these from even getting there if we could look at suboptimal and functional status of the patient before they get to disease status.

Andrew: And I think we need to define that, because with regards to functional pathology, there's some scepticism around it versus standard pathology. And one of the examples I talk about is a functional test called N-telopeptide, which looks at bone turnover. And years ago, this was pooh-poohed by orthodoxy and yet now it's becoming accepted as a marker for bone turnover in osteoporosis. So it's almost like it’s finding its place, isn't it?

Beth: Yes. And there's things that do come and we are behind the eight ball sometimes this, what's accepted as standard. I mean, especially in the medical arena, and this is due to a lot of the “gold standard testing” that can be seen as the only way to have things done. Whereas actually learning more about what the functional testing can give us, information on the patients, I think can help us a lot. 

As I said before, you know, the standard pathology, which is your standard… like TSH. So if you want a thyroid function test all we'll really get is a TSH. And it is either “You have a problem because you're over five,” or “You're fine because you're under five.” And we know that it's far more about optimal levels of health of that particular individual, you know? 

So saliva is another classic one. It's been much maligned by various medical bodies, but salivary cortisol has actually proven on numerous studies to be on par with serum cortisol measurements.

And, of course, salivary cortisol is a lot easier to perform for our clients and they can produce their samples in the privacy of their own home and they don't have to be stressed out and get elevated cortisol by going and getting a blood test. And now, even some endocrinologists are using salivary cortisol and melatonin more too, for their patients. 

And also the LDL subfractions and that oxidised LDL are being taken up by cardiologists more and more as they realise it's a more finite measure of cholesterol measurements. And, of course, we have urinary methylmalonic acid which is highly regarded as a measurement of B12 status. And these are not standard, as we would see it.

Andrew: But I think one of the beauties of...and it's not always the case, but often the case is that functional pathology isn't as invasive as standard pathology tests.

Beth: Oh, absolutely. Absolutely. I mean, as I say, the patient can do a saliva in the privacy of their home, they can do a urinary test, they can give us a stool sample quietly at home and then send it into the lab. So I find that many patients much prefer that. Plus, the other thing is patients are asking for these tests. 

Andrew: Yeah.

Beth: They’re more savvy than they used to be. They spend a lot of time with Dr Google and they want more information about themselves. Especially when they go to a standard practitioner who does the standard test, the patient's told they're “fine” and that's in quote marks. And, of course, the patient says, "Well, I don't feel that way. I still feel really horrible." And they're not getting the answers they want. 

And so, at least with functional medicine, we can see just what things are a little bit off-kilter, as opposed to, as I said, diseased state. LFT or liver function test is a prime example as well. Once you have problems between the functions, then there's a pathology opposed to just a functional liver issue that can be dealt with, with health practitioners quite easily.

Andrew: You know what I just realised is regarding, call it functional testing and you talk about patients doing it in the privacy of their own home. And I guess the first thing that pricked my ears up was, well, okay, what about user interface issues? What about patients contaminating the test or not doing the test properly? And then I thought further, I thought, "Hang on. Patients very, very commonly do these tests in the privacy of their own home all the time. It's called a pregnancy test."

Beth: Yes. Exactly, exactly. And look, there is a margins of error and patients sometimes decide not to read instructions until after they performed the test. But, generally, generally, we find that there's not too much problems with contamination if people follow the instructions. And I find the best thing is actually the practitioner advising the patient as the professional authority, telling them how to do things.

Andrew: And we'll talk about that a little bit later about the practicalities of what happens with testing. 

But today, we're going to be talking about some of the more commonly used tests by integrated practitioners. 

Tell me about what we're going to be talking about today, which is thyroid, adrenal, and sex hormones. Tell me about their relevance in everyday clinical life.

Beth: My three-legged stool, as in the chair, not the body waste. Yeah. Well, really, I find the tip is to keep it simple. When we're talking about functional testing, people get a little bit overwhelmed. Keep it simple, start with the basics, and build from there. 

Of course, it's always relevant to the sort of clients you have in the clinic and what your clinical focus is, and the conditions you're going to treat. But I would say making a major a generalisation, generally, complementary health practitioners are seeing fat, frumpy, fatigued and frazzled people because I think most people are stressed in our world and most of their health conditions are due in part to this. 
So generally, I start with most of my new clients with what I call my three-legged stool of adrenals, thyroid, and hormones because they're all highly interactive with each other. They're all sex hormones. And you know, if one's not working, then the other one's upset and what have you. 

So I usually start with a salivary adrenal profile so I can check out their cortisol levels, exactly how flat or flowing are they. Because many people are handed antidepressants when they complain of feeling flat and fatigued and often they're not necessarily depressed, they're just really tired. 

Andrew: Yeah.

Beth: And we can measure that across the day. So usually with the adrenal profile, we measure them first thing in the morning, around about lunchtime, in the mid-afternoon. And then I like to measure them just before they're going to bed and trying to wind down for the day. 

Andrew: Yes.

Beth: And with that information, we can really see are they flying really high in the morning and then collapsing in a heap or are they never really getting started in the morning? 

So I found with using this therapy, rather than just throwing adrenal herbs at somebody or nutrients, I can actually be more targeted throughout the day to help better support that person. And they just feel better, they get through the day, or whatever their world is involved in. 

And so, this whole "depression" in quote marks is not quite the problem that it is. And it's easy. People just have to spit in a little tube.

Andrew: Yeah. And I think this is also one of the important things about the multi-sample adrenal profile, is that because hormones fluctuate during the day. If you're going to have a blood test, it's one snapshot at one point in one time in one day. So it doesn't give you the flux of the hormones over the day. The dial of the reaction. Yeah.

Beth: No. That's what I found too. And if they don't like getting their blood taken, they're already stressed out and worried about that, you know, did they eat beforehand? Did they not? Did they have a coffee beforehand? All those sorts of things are confounding factors. 

So definitely, I find… I will say in practice we still to do blood cortisol, and DHEA, but I will also always do the salivary cortisol, so I get a picture of a rhythm of what, as a general rhythm, of what this person is doing. 

I don't necessarily retest it too soon after some therapy because often people have been suffering for quite some time, so it's very hard to turn around 20 years or 40 years of lifestyle in three weeks or four weeks on therapy. And I explain that to the client.

Andrew: So when would you retest? When would you retest though?

Beth: Often, as a minimum, 6 to 12 months.

Andrew: Right. And does that…

Beth: Because, again, as I say, a lot of these people are really quite exhausted in the adrenals and it takes a while for it to fill the bucket up, so to speak, for that to be reflected adequately in the testing. 

And the other thing with the testing is when you get a grasp that you can show somebody, I find my patients love to see themselves in colour on a piece of paper and it's fabulous for compliance. 

And then, of course, not just the adrenals, I'll also look at sex hormones. So we see ladies and gentlemen in our clinic, but a lot of ladies we'll see are overwhelmed and stressed out from being a superwoman, wife, worker and mother and their hormones are usually left behind in the lunchbox they made for the kids. 

And, again, they are not necessarily depressed, they're just tired because, as we've mentioned in previous podcasts, they're being chased by the tiger constantly. And that's really tiring. And I find too, that women who suffer various premenstrual symptoms have usually got a hormonal imbalance rather than an SSRI imbalance. 

And often, these women see these symptoms as normal, or I usually say to them, "Just because it's common amongst your girlfriends, doesn't mean it's normal." 

Andrew: Yes.

Beth: And I think some of that is, you know, educating our patients about what is normal, you know? And I would say there's a great percentage of girls we see in clinic that are oestrogen-dominant relative to their progesterone levels. And this will make any lady lose her mind a little bit sometimes.

Andrew: So, you know, when there's so many tests to choose from, how does a practitioner choose the relevant test or tests? And how do you balance that to the cost that's incurred by the patient?

Beth: Yeah. Well, again, I keep it relatively simple. If we can get an adrenal profile, some sex hormones… So I like, I would, again, for a woman, I would start as a very basic, it applies to the major issue, I would be looking at E1, E2, E3, and progesterone in the saliva. In a man, I would look at his E1, E2, and testosterone. 

I would try and get bloods. If people have a friendly doctor who will do bloods or otherwise they can be requested. Testosterone, sex hormone-binding globulin, free testosterone and DHEA in the blood, because these can be Medicare’d. 

Thyroid hormones, again, TSH can be Medicare’d, but ultimately, we need a bigger picture with thyroid. Again, it's been spoken about before. We need T4, we need T3. Reverse T3 is usually beneficial now, in stressed-out people. And thyroid antibodies, plus or minus. 

So I usually don't hit everyone with this. I will depend on what I'm going to do because obviously then there's stool testing that we might need. We're seeing a lot of parasites in people, blastocystis hominis is certainly a beasty that we see a lot. 

We have neurotransmitter testing, which we can look at our serotonin, GABA, dopamine, noradrenaline, adrenaline, and glutamate, which again, has effects interdependent with our thyroid and our adrenals and our sex hormones. 

So I won’t do all of those in one go with a patient. I will get my base ones done, which is usually adrenal and some hormones and then work on it more as a treatment program where we say, "Well, let's look at what the results brought us in on this" and start working on these. 

Because as I said before, because people are so stressed, we can always usually generally start working on their adrenals cause they take a while to fill up again. And in the meantime, we can table other tests that we do that add more pieces to our jigsaw puzzle of our client.

Andrew: So, Beth, what other parts of this three-legged stool do you assess? What other tests do you do?

Beth: Well, again, if we're looking at our ladies and their hormones, some of our ladies have very irregular periods or they're no longer menstruating, in menopause. So it may be difficult to pinpoint exactly where in a cycle we are looking for hormone levels in saliva. 

So with those ladies, I would do what we call a 28-day female hormone profile, which will give 11 samples across a 28-day timeframe so we can actually see, again, some sort of rhythmic pattern to oestrogen and progesterone levels. So at least we can see whether these girls are flat-lining entirely the whole time or are really high at the beginning instead of the end of the cycle or what have you. So that can be really informative, especially with say a polycystic girl. 

Also, there's also the oestrogen metabolites. So we do urinary oestrogen metabolites so we can look at our 2, 4, and 16 hydroxy oestrones and our 2 and 4-methoxy oestrones which, again, will give us some idea about methylation and oestrogen metabolism capabilities. And this can be very helpful for ladies who have a personal history or a family history of gynaecological cancer. So they may be…

Andrew: And that's one of the tests that you should be repeating at a like a three-month into treatment. Is that right? So you do a baseline and then a three-month?

Beth: Oh, most certainly. Most certainly. Most tests, I would definitely test within three months because part of that is too...you want to say that your therapy is having some effect. 

I know I said previously the adrenal one is a slower process and that's why I don't rush into retesting that. But certainly your thyroids and your hormones, absolutely. I want to know that my therapy is having some benefit to the client. 

Obviously, I go on their symptomatology, so we'd go on clinical as well as just lab results. We don't just go on the lab results. We must always put it in the context of how the patient is presenting. That's for sure.

Andrew: I think that's a really interesting point that you make there, because like, for instance, blastocystis hominis is sort of a...what do they call it? A facultative pathogen, in that in many people it just resides as a commensal, but it's when it's causing issues and duh, that's the reason you're testing.

Beth: Yeah, absolutely. Yeah, it's kind of… you know, we're doing the screening testing that Medicare doesn't allow GPs to do with the functional testing. And the blasto, again, I'm seeing that people may not necessarily have gastro symptoms or gastrointestinal symptoms, but we've had people with bizarre skin things that they can't find the answer to, or mood issues or some other kind of, interesting aspects that we find blasto, we treat that and people's symptoms are resolved. So it's good to look at. 

It's not always, if someone's suffering from anxiety, are we going to jump down the neurotransmitter route? I would always look at adrenals and hormones and the thyroid first because sometimes, as I said before, hormones can affect our moods. Absolutely. 

Andrew: Absolutely. 

Beth: And as can bugs in the gut, and dysbiosis can have numerous symptoms that are not just gut symptoms. The same as when we do food sensitivity testing on people. People go, "Oh, but the food doesn't affect me." Yeah, but you've got joint pain and you get these headaches every time you eat something. Patients don't necessarily correlate a symptom with perhaps a reasoning behind it. You know, Dr. Google can only tell them so much, and then that's where we come in.

Andrew: Yeah. Well, I think that's the ethical part of doing any sort of testing. And indeed, consulting is… you know, testing really only should confirm your existing suspicions. It shouldn't be used as a crutch for poor diagnostic competence.

Beth: I totally agree and I take issue if I'm speaking to pracys and they're saying, "I heard about this test, I thought I'd do it on a patient." I will always say, "For what purpose? What are you hoping, what information you're hoping to get from that? And then what are you going to do with that information then?" Because we can do tests on people and spend their money and then not know what to do with the results when they come through.

Andrew: That's exactly right.

Beth: And that's not helpful. So this is, again, why I say to some people who are new to the functional pathology, is start with some basic testing first, get comfortable with that. Then you can move to other areas. 

I mean, at NutriPATH we have, I think, over 200 tests. I can tell you there's no way I use them all and there's many that I have not used. Because it hasn't been relevant to the patient, my patient profile. 

Andrew: Yeah, that’s right.

Beth: And there are certainly ones that we do a lot of because the information that I get from them definitely guides me to the treatment of that patient to good effect.

Andrew: Well, what about inter-laboratory discrepancies though? I can still remember an example when I was nursing in ICU and the specialist came in, ordered some blood gasses off the hospital pathology lab. And when they returned in very quick time, he took one glance at them and said, "Rubbish. Get it done by the outside pathology lab and get them to put it on an urgent basis." 

So he knew, by looking at that patient and their clinical picture, he knew that that pathology result was absolute rubbish and he got them retested and sure enough, they were different. Now, that's in standard orthodox pathology.

Beth: Oh, absolutely. Well, you've also got to remember that as much as they have machines that do a lot of things, they still have people that do a lot of things. People also type in figures. 

Andrew: Yes.

Beth: And so typos can and do happen in all of these places. So, again, that's also knowing a little bit like, your specialist there, he knew exactly what he was expecting and looking for. So he knew when the figure was strange. Whereas just saying, "Oh, well that's what it says. That must be what it is." I'll recognise a figure that's really out of kilter and will always confirm with the pathology lab that that is the raw data figure because it can be...

Andrew: Oh, I see.

Beth: Yeah, yeah, yeah. So they'll have the raw data and then that has to be entered into the system that then can spit out the results.

Andrew: So any practitioner can request to confirm the raw data, not just the test result that was conferred to them?

Beth: Yeah. Yeah. Because there is… I mean, I have had people that go, "Oh, it must be wrong." Kryptopyrrols is a classic. They do a test and they presume either the patient has said, "I have done the Dr Google questions. I know I'm pyrrole. Do a test." And the tests come back negative. 

So then they say, "Oh, well, the test is wrong." Now, that's not necessarily the case. You can't expect a result and then be disappointed when you don't get that. You know, it's like, "Oh, damn, I really wanted to be diabetic." Oh, really? You know, it's not like that. 

So you can't presume that you're going to see... I mean, there can be some presumption, especially when you see a lot of them. Like, you know, I can tell when someone walks in and tell me their story, where their adrenals are going to be, but that's over numerous years of seeing that.

Andrew: Well, that's clinical competence. That's right.

Beth: That's it. That's it. And the other thing you've got to remember about labs is different labs will have different machines and different instrumentation for running tests, even if they're measuring the same analyte. 

So even if they're both measuring TSH, they may use a different instrumentation. And those different machines will use different reagent kits from different suppliers. And then they will have different reference ranges.

Andrew: That’s right.

Beth: And this is due to the statistical data of the results that go through that particular lab. 

Andrew: Yes.

Beth: So this is why there will be differentiation. So you will say... I mean, vitamin D is a classic example. Some labs that I get back, will say, 50 to 150 nanomoles is the reference range and another one says 75 to 250. 

So this is where we have to know what our optimal ranges are and what we, as practitioners are wanting to say the patient to be at. Yeah? And things like D, and iron, and ferritin, and B12 are good examples for that. They are standard pathology, but when you as practitioners can determine whether, "Yeah, but this patient could do better if they had a bit more of this or a bit less of that." So this is why we may see differences in figures.

Andrew: Yeah. Beth, let's say a patient walks into your clinic and she's a female, obviously, 40-something female, tired all the time, overworked, overstressed, looking after a young to growing family. There’s so many things that could be wrong with her. How do you pick out of your three-legged stool of thyroid, adrenal and sex hormones? How do you pick which test is the relevant test?

Beth: Well, depending on, of course, her story, her history, her family history will determine how I go. But generally, if she came in as one of these frumpy, frazzled, fatigued girls, I would generally look at the entire three-legged stool. 

I would look at adrenals, thyroid, and sex hormones because I don't want to miss one thing or the other. Because just treating adrenal is not going to help if there's a thyroid or oestrogen dominance, just doing the thyroid. And I've seen this, I've seen practitioners do this. They just treat one leg of the stool. You won't get as a good response if we're not doing all of them because they interrelate so strongly. 

So I would definitely do a full thyroid panel if there's thyroid history in the family. Absolutely. And as I said, most of the girls that I see do have hormonal issues, even if they're thinking that their symptoms are "normal." 

We usually find, and especially with the toxic world we live in, there's a lot of oestrogen dominance. I think there's a lot of liver and gut issues people have, so we're not metabolising our hormones as well we should. And as I said, everyone is very stressed with what's being asked of us to get through life.

So I would more than likely, if that's my general clientele, which it is, I would do the three tests. Then from there, I would move on at another time to go deeper into that. I mean, we also - because I work with the integrative doctor - we also have the facility that standard bloods are looked at. 

So we'll do standard full blood counts and cholesterol sugars. We do some basic general pathology as well to see if anything's really standing out there. Not often that that happens, but more than likely in our functional testing, there's definitely things we can start working on.

Andrew: I would perhaps caution our listeners out there who are practitioners that it's not always easy, and certainly not professionally comfortable for you to simply send a patient and request tests to be done. 

A doctor has a professional responsibility to actually consult with that patient to determine what relevant treatment needs to happen. So if you want tests to be done, certainly if you're going to be doing a battery of tests, just do them yourself. Don't put a doctor in a professionally uncomfortable place unless they're willing to do that.

Beth: I agree. And the other thing that some practitioners need to be aware of is that… A classic example that I often hear, "Oh, the doctor only did TSH." Well, the doctor only did TSH because there's a strict Medicare ruling about that. 

Andrew: Yes.

Beth: So the doctor is hamstrung to a degree of what he can actually order and stay under the radar of Medicare not coming to knock on his door. So they're not to do screening testing. So this is when often I will do the test private. And there's many doctors that work in the integrative medical space that will do them as a private test. They will not go through Medicare. 

Andrew: Yes, that’s right.

Beth: So in that instance, yes, practitioners who can't request Medicare tests are sometimes better off just discussing with the patient. And all of this is positioning to your patient and saying, "This is why I would like you to do these." 

I'm very, you know, very certain that I’m educating my patients about why they're doing these tests and what information I'm going to get from those so they truly understand why I'm asking them to spend a couple of 100 dollars on themselves. And if I explain that well, they're often very keen to do that because they haven't been getting these results or the answers from standard testing.

Andrew: Yeah. And that's the perfect place I think of functional medicine testing rather than pathology testing.

Beth: Oh, absolutely. I might not get excited about it, because there's so many to do and there's so many to look at. And I think the trick is not getting overwhelmed, sticking to the basics as I've mentioned, and they can always get me on the phone. "Help, help. Which one do I do now?" And I'm good at that.

Andrew: And this is one of your fortes, Beth. I've got to say, I love it when you present in seminars because there's so much animation and it's teemed with relevant practice. And that to me is the beauty of what you do.

Beth: Well, we need to make it practical. All the knowledge and information in the world is not very helpful if we can't then bring it to our patients and use it practically. It was just a really interesting seminar we went to.

Andrew: Yeah, that's right.

Beth: So I like to make it useful so my clients then do well and get better and tell their friends and bring more. 

Andrew: That’s right. And that's kept me in it. And I love what I do and I like being animated. That's, you know, people have told me I'm a bit of a Muppet. I'm not too sure whether it's Animal or Miss Piggy, but I'll take that.

Beth, there's so much more to go into, even with the three-legged stool. We could tease apart that and dive into each of those tests much more comprehensively. So would you, perhaps, join us on another FX Medicine podcast at a later stage?

Beth: I'd love to.

Andrew: Thanks, Beth. We'll do that.

Beth: Fantastic.

Andrew: And thank you so much, again, for taking us through, A, the three-legged stool, the thyroid, adrenal, and sex hormones, but also their relevance with testing and how to benefit your patients. I really appreciate that.

Beth: Oh, my pleasure. Thank you for having me on. And as long as we can share this information out to the practitioners in the world, I think that's the best for our patients, ultimately.

Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook.

Other podcasts with Beth include


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