Inflammation – A Patient Case Study

General Wellness

In an effort to pull together all of the information I’ve shared with you so far about inflammation and provide you a bit more practical insight, I’m doing something different on the blog this week – sharing a case study.

The case study that will be shared here is about a former patient who was struggling with chronic inflammation.

Her name is Susan.

Susan, a school teacher, was a 52-year-old female who was experiencing heavy bleeding and painful periods. She had previously been diagnosed with endometriosis and in addition to the heavy bleeding and painful periods exhibited the following symptoms and concerns:

  • Hot flashes
  • Weight gain of 30lbs in 2 years
  • Brain fog
  • Skin rashes and acne
  • Joint pain
  • Hair loss
  • Frequent yeast infections
  • Depression and irritability
  • Dry skin
  • Insomnia
  • Constipation
  • Frequent illness
  • Hypercystic breasts
  • High cholesterol
  • Maternal family history of breast cancer

Susan came into my clinic and said “I’m a hot mess. Help me!

One of the first things I did was run lab work for Susan. What I discovered when her lab results came back was that many of her hormone levels were low, with the exception of estrogen.

Her estrogen levels, which should have been between 60 and 100, were 500 – indicating estrogen dominance.

In running the estrogen metabolism test to find out what the ratio of good vs bad estrogens was, I discovered that most of the estrogen in her body was bad. Her elevated estrogen and the presence of so much toxic estrogen was what was contributing to the heavy bleeding, painful periods, and endometriosis.

Not only did we discover that she was estrogen dominant we also found through lab work that she had hyperthyroidism and Hashimoto’s, an autoimmune disease affecting the thyroid. Her TSH levels were 4.5 and thyroid antibodies were more than 600, which was contributing to the weight gain, lethargy, brain fog, hair loss, dry skin, constipation, and of course, lots of inflammation!

I know this because, in addition to hormone testing, we also tested her c-reactive protein (CRP) and Erythrocyte Sedimentation Rate (ESR). Her CRP level, which should be less than 1, was 26. Her ESR was 40 and should be less than 10.

Another test I ordered was a saliva test to assess cortisol levels and adrenal gland function. Her cortisol level was 90 and elevated throughout the day, but the ideal is 40.

More in-depth testing determined that Susan also had several food allergies – gluten, dairy, and yeast.

Susan was under a lot of stress in her day to life, had lost her sister to breast cancer, and she was in the early phases of menopause, which explained why hormones like DHEA, progesterone, testosterone were low. Additionally, Susan was eating poorly – lots of fast food and several cups of coffee each day.

Her chronic stress and poor diet were most likely what triggered the cascade of illnesses and autoimmune concerns.

Armed with all of this information, I created a treatment plan.
  1. Natural hormone therapy with testosterone and DHEA to balance her hormones and also reduce inflammation.
  2. Enzymes to help her body clear out the bad estrogens.
  3. An anti-inflammatory diet, beginning with a 10-day cleanse of green juices and powders to help restore the ph balance of her body.
  4. Stress management, which included lots of rest and gentle movement, like yoga and nature walks.
  5. Cooling baths and acupuncture to help reduce the heat her body was producing.
  6. IV Hydration therapy to ensure that she was well hydrated during the cleansing process.

After several weeks, Susan began to notice improvement – weight loss, increased energy, decreased brain fog and improved brain function.

The improvements she noted were confirmed by her lab work as her inflammation markers were lower on her next lab order.

Susan came to see me in the clinic once a month and each time her lab work came back, the levels of inflammation decreased by 2 or more points.

After 6 months of treatment, we saw the following improvements:
  • CRP was down to 2; her ESR down to 5
  • Hormones were balanced
  • Weight loss of 35lbs
  • Hair growth
  • Increased energy levels
  • Clear skin
  • Less painful periods
  • No more hot flashes

She literally looked and felt 10 years younger!

To maintain the progress, Susan decided to retire early. She realized that her job was causing quite a bit of stress and felt it was best to eliminate this as a factor in her life. This freed up time for her to practice yoga regularly and play with her grandchildren – a much less stressful life, and one that felt more fulfilling and in line with what Susan believed to be her purpose.

True healing came on all levels with Susan – physical, mental, emotional, and spiritual.

She was able to grieve and process the loss of her sister, connect more with nature, and she made her health a priority by incorporating the natural therapies that I recommended into her daily wellness routine.

As you can see in addition to lifestyle changes, balancing Susan’s hormones was key in reducing the level of inflammation in her body and helping her to heal.

Balance and good health are possible for all of us when we can get to the root cause of illness and find a medical practitioner that can support us holistically – using medical interventions when necessary as well as lifestyle interventions, like diet, stress management, spirituality, and sleep.


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