Patient Case Study – Perimenopause, Chronic Fatigue And More

We are pleased to share with you a case study* which demonstrates an example patient journey for an individual who came to us with symptoms of chronic fatigue, perimenopause, and adrenal fatigue. We hope it will provide you with insight into what a typical patient with these symptoms can expect from a comprehensive consultation.

Patient introduction

We’d like to introduce you to a 50 year old female patient, who we first met in January 2024. She came to us after a very stressful period in her life, self-reporting burnout, poor sleep, as well as chronic pain issues. She was also experiencing a flare-up of chronic fatigue syndrome. At her first hour long consultation, we explored various aspects of her life and health, and discovered she was also suffering with moderate PMS symptoms. She was also describing brain fog, difficulty with word capture, weight gain, hair loss, and poor memory.

Patient information

Age: 49 at presentation
Gender: Female
Ethnicity: White caucasian
Relevant medical history: Recurrent chronic fatigue, psoriasis
Family history: Parent with vascular dementia
Lifestyle factors: Could only manage 4000 steps per day, drank very little alcohol and was a non-smoker. The patient was gluten-free as she had noted that eliminating gluten improved her fatigue and joint pains
Goal(s): To be able to exercise again and to develop more resilience towards stress

Differential diagnosis

Dr Sandhu’s initial impression was that the patient had HPA axis dysfunction leading to adrenal fatigue. She was also describing symptoms related to perimenopause, as well as chronic fatigue which was linked to previously having glandular fever.

The inflammation triggered by her HPA dysfunction was also affecting her brain gut axis, likely leading to neuroinflammation and a dysfunctional immune system.

Investigations

Dr Sandhu recommended the following tests for this patient, based on the information provided in the initial consultation:

A comprehensive blood test which included a hormone panel. This looked at the reproductive, thyroid, and adrenal hormones
A DUTCH test (Dried Urine Test For Comprehensive Hormones) to look at hormonal metabolites on day 21 of her menstrual cycle.

Results

The test results provided a wealth of information that allowed a carefully structured treatment plan to be created. Results showed:

Cholesterol levels were high, with an elevation in LDL, the cholesterol associated with clogging of the arteries (atherosclerosis) – in functional medicine we regard this an indicator of inflammation
DHEA-S adrenal marker was very low, indicating adrenal fatigue/ HPA dysfunction on both her blood test and DUTCH test
Follicle Stimulating Hormone (FSH) level was indicative of perimenopause
Thyroid function was suboptimal
Progesterone and testosterone levels were low
The patient had oestrogen dominance and this was confirmed by her DUTCH test. As the name suggests, oestrogen dominance is when the ratio of oestrogen to progesterone is skewed towards having more oestrogen. This gives rise to a set of symptoms known as the 5Bs (bleeding, bloating, breakouts, breast tenderness and bad/low moods)
DUTCH testing also showed she had low free and low metabolised cortisol Metabolised cortisol is like the fuel tank, and free cortisol is like the engine! Overall, both her production and utilisation were very low. Unfortunately, the years of chronic stress had taken a toll. This meant her ability to handle stress was poor.
Her DUTCH test also showed she was not able to detox oestrogen well, which which would contribute to her oestrogen dominance

Diagnosis

After careful consideration of test results and analysis of the information provided in the consultation, Dr Sandhu diagnosed the patient with:

HPA dysfunction leading to inflammation
Perimenopause
Oestrogen dominance and poor capacity to detox oestrogen

Treatment

Agreed treatment goals:

Optimise and balance reproductive hormone and adrenal health
Reduce inflammation
Improve detoxification of oestrogen
Boost the immune system
Improve background nutritional status

Initial management:
Prescriptions

LDN (Low dose naltrexone): This aims to help support the patient’s immune system and help it fight back against inflammation which in turn should help her energy levels and chronic fatigue
Pregnenolone: Bioidentical compounded pregnenolone capsules to focus on adrenal support and brain fog
IV vitamin therapy: Basic Myers + glutathione, 3 drips every 2 weeks. Dr Sandhu wanted to build up the nutrients which would have been depleted from the period of burnout. In our experience, this can buy us weeks to months of time compared to taking the same nutrient supplements orally
DHEA: Bioidentical compounded DHEA daily to support adrenal function and indirectly boost testosterone
Melatonin: Taken at night to support with sleep
Progesterone: Daily bioidentical compounded progesterone at night, to address perimenopause symptoms and PMS symptoms

Supplements

Magnesium glycinate at night for sleep support
Omega-3 daily with food to reduce oxidative stress
D3+K2 IM shot Vitamin D plays a vital role in all hormonal pathways and generally speaking, we like our patients to have a level between 100-150
A methyl B-complex to improve the capacity to detox oestrogen
Curcumin to reduce inflammation
A set of 3 targeted adrenal supplements to support the adrenal gland

Outcome and follow-up

Our patient came back for her first three month follow-up.

Even though we are still very early in her patient journey, she is already reporting significant improvements. She was managing to exercise without crashing which she attributed to LDN, had recently returned from an adventure trip where she had managed to walk 24,000 steps per day with steep climbs! The patient was more motivated to change her life. Her brain clarity was improving. Sleep was still disrupted but this could have been mainly due to her not having started one of her hormone prescriptions.

On her repeat blood tests, we saw that her adrenal marker and reproductive hormone levels had improved. She will continue with all her recommended prescriptions and supplements until her next follow-up appointment.
In addition, we added a protocol for histamine intolerance as she developed severe allergic reactions to insect bites following her travels.

We will next be following up with this patient in a further six months.

*Some of the details in this case study have been changed to protect patient identity.