welcome everyone I'm Noah Reed vice president of sales and marketing for precision analytical creators of the Dutch test thank you all for joining us in this March webinar with our very own clinical educator Dr Hillary Miller this webinar focuses on estrogen metabolism an often misunderstood aspect of hormonal health most people know that estrogen can be the culprit and hormon related symptoms and that several women's health concerns are impacted by estrogen directly such as endometriosis and breast cancer estrogen symptoms and risk can be impacted by how it's metabolized in the body this is a practical guide through phase one and Phase 2 Pathways where key players like p450 and methylation enzymes will be explored if you're ready to start using Dutch testing in your practice sign up today as a registered provider click the link we've posted in the chat and complete the provider application form a member of our onboarding team will walk you through the steps to set up an account so that you can begin taking advantage of the education and resources Dutch has to offer plus as a registered provider you gain access to the mastering functional hormone testing course the Dutch interpretive guide and one-on-one consults with Dutch clinical Educators like Dr Miller this dedicated support and education is designed to help help you become the hormone expert now let me introduce today's speaker Hillary Miller indd is a clinical educator at Precision analytical with 9 years of clinical experience in women's health and fertility Dr Miller got her Bachelor of Science in biology from Portland State University she completed her medical training at the National College of natural medicine or nunm in Portland Oregon in 2014 at nunm she focused on advanced gynecology and Women's Health and spent one year shadowing midwives her clinical experience focuses on women's health including fertility Mental Health weight management menopause and anti-aging Dr Miller has been a clinical educator at Precision analytical since 2016 and now without further Ado let's get today's webinar started all right thank you Noah um I'm super excited to get started talking about estrogen metabolism today so let's just go through an outline of what we're going to talk about what is estrogen what are the metabolites how do we read them on a DCH test and what is the research and what does it say about these ratios now I just I wanted to give a warning in the beginning of this webinar in the first maybe 20 minutes we're going to go through some information that that is very quick okay we're going to go high level through estrogen metabolism research as well and hopefully if you're really interested in these metabolites and you're really interested in these studies you'll have them there in the references to dive into later but I'm really going to try to skip through that so that we can slow down once we get to looking at Dutch tests and Dutch examples and then we can bring in that information that we had before um apply it to what we're seeing and if you have further questions I definitely suggest looking in the research so what does estrogen do or what is estrogen it's a female reproductive hormone although everyone has estrogen at all stages of life it has significant impacts on many body symptoms systems sorry um I'm going to show this diagram because it really demonstrates well how estrogen impacts all aspects of our body sort of head to toe we have the brain the eyes um cognition skin cardiovascular health bone density then breast and reproductive tissues the colon it has impacts on and uh liver function estrogen also has negative impacts on the courses of some diseases so breast cancer breast tumors and endometriosis endometrial hyperplasia endometrial cancer and uterine fibroids these are the top things that we see in medical literature when it comes to the negative impacts of estrogen and if you'll notice my point here is that these are in the breast and the endometrium or the uterus those are where estrogen receptors are concentrated and so estrogen has a really big impact on these tissues I want to be transparent about estrogen metabolism and breast cancer um most of estrogen metabolism research looks at breast cancer and I want to make sure I'm transparent in saying that we don't know the full role of estrogen metabolism in breast cancer although we do see associations and when we look at risk factors for breast cancer we're going to see a lot of overlap in estrogen metabolism so in the US breast cancer accounts for 30% of diagnosed female cancers so it's a really big deal about one in8 average W average risk women will face a breast cancer diagnosis and there are a lot of non-modifiable breast cancer risk factors this means there's many things we can't change that will increase our risk like age and being a woman family history and genetics and ethnicity also account for this but you can see family history accounts for 15% of diagnoses that means 85% of women who get breast cancer will not have a family history um same with genetics 5 to 10% but that means 90 to 95% of women will not have these genetics modifiable risk factors for breast cancer are smoking alcohol BMI um certain types of HRT exposure to environmental chemicals low V low vitamin D exercise healthy weight Etc and breastfeeding before the age of 35 now modifiable is stuff that we can influence which is stuff that we're typically interested in with prevention and once we get to estrogen metabolism we're going to see these pop up again highlighted in green on both of these lists actually uh impact estrogen metabolism and this next list is risk factors for endometrial cancer uterine fibroids and heavy Menses so I wanted to hit um these lifestyle factors that affect both the breast and endometrial tissue like I'm focusing on here for estrogen a little bit different uh adequate progesterone here in the endometrium can prevent a lot of um or can prevent fibroids endometrial cancer and Menses in some cases heavy Menses uh we're not going to talk about progesterone and looking at the progesterone to estrogen ratio and that is really important but this webinar is really going to focus on estrogen and estrogen metabolism so how do we assess estrogen levels well we test estrone and estradi usually estradi is the target since that's the most potent estrogen knowing about the timing of estrogen Cycles um and their appropriate reference ranges is really important and this point ties into estrogen metabolism later so I just wanted to make it here so that we remember how important this is later you can definitely use serum and of course you can use Dutch urine testing and we also have cycle Maps so that you can see the levels of estrogen over an entire cycle which is great one day test is also great now we get to our destination estrogen production affects estrogen related symptoms and diseases but also how we excrete it can affect our levels of estrogen and that's what we're talking about today the magnifying glass is our window into the body so we can look at parent estrogens Phase 1 metabolites and Phase 2 metabolites along with our patients history and their symptoms and we can make an inference to how we can help them on this slide I wanted to have an overview of the entire estrogen life cycle with starting at the top estrogen can move passively into the cells and estrogen's actions occur within those Target tissues phase one is a tool that the body uses to deactivate the estrogens in most cases and therefore control its action phase one can be problematic and it seems as though lots of substances can't be fully neutralized in one step so we see phase one being populated with or sorry we see phase one being problematic with a lot of different substances the body tries to detox and so it's not surprising that we can have some issues with Phase 1 metabolism in estrogen as well for estrogen detox Phase 1 metabolites have significant oxidative potential although this varies between the metabolites Phase 2 takes care of that so they use methylation and conjugation to neutralize the oxidative Phase 1 metabolites and it also makes them more water soluble for removal through the stool and urine so here's just a diagram of what we've been talking about but you can see what we're then measuring in their urine the methoxy the hydroxy and the parent estrogens now let's dive into phase one so I really love this quote and this study that I have cited here is a great review especially if you're new to estrogen metabolism I suggest you read it because it's really well written and it explains not only how the estrogens and their metabolites work but where they work and why they're important and this beginning quote that I've have up here encapsulates everything that they're trying to say and that trying to say here so the cytochrome p450 enzymes this is Phase One metabolize estrogens that are expressed in the Target tissues so these are the tissues where we have estrogen symptoms and they form these hydroxylated estrogens and these hydroxy estrogens are right at or near the estrogen receptors and they can have important biological effects therefore profoundly influencing estrogen action and this is how they might impact our patients symptoms they're in the tissues right there with the receptors acting on their own so what is Phase One metabolism well this is an example on the Dutch test of phase one and we have the parent estrogens right there we're following out of estrone the green pathway is the two hydroxy pathway and this is the happy pathway the Red Arrow coming out of estrone shows for hydroxy with which is the bad pathway and we also have a red arrow coming down out of for hydroxy that shows why it's bad it can form reactive Quinones it can become oxidative it can bind to DNA and cause DNA damage the blue arrow up top coming out of estone points to the 16 hydroxy and this one is estrogenic so you imagine your you know you have a tissue and it wants to control the action of estrogens and then it detoxifies them and it's still estrogenic right so that can be problematic the 16 hydroxy hydroxy metabolites are sulfated for removal so Downstream is also important for phase one the two and four are going to be methylated and the two and four are known as catacol estrogens and this will come up word catacol several times and it might help you to understand um something about the pathways these catacol estrogens can be oxidized by any oxidative enzymes and metal ions and the oxidation creates Quinones and semiquinones and reactive oxygen species they'll need to be methylated to be neutralized but once they're methylated they are neutralized and for methylation we use the catac o methyl transferase so you can see where knowing that their Catal estrogens helped you understand why they use the compt enzyme in the presence of antioxidants as well the oxidative potential is minimized so that's going to come up again too phase one occurs both in the liver which is probably a lot of what we're seeing in the urine but it also occurs in the estrogen metabolizing cells and this leaves estrogen sensitive tissues vulnerable to the damaging effects of Ross we'll just review where those are that includes the liver but also uterus breast cardiovascular tissue lungs brain Etc now let's look at each of these pathways on their own the two hydroxy estrogens are formed from the c 1 A1 and 1 A2 enzymes we show the 1 A1 on the test but both of those are involved they're also they're formed in the liver and the target tissues the two hydroxy metabolites are anti-carcinogenic and inhibitory and although they are oxidative they're much more stable on their own as well as being methylated faster so as you can see I'm sort of demonstrating that the two hydroxy pathway is the happy pathway we have uh several articles here which looked at serum and urine samples from women with and without breast cancer that found found that greater two hydroxy estrogens were associated with reduced breast cancer risk and again we don't have time to go into all of the details but I wanted these to be here for your review later if you're interested here's another study this one is a really interesting read because not all of the studies are consistent about what the metabolites might mean and Zigler here gives the history of measuring estrom metabolites and demonstrates that immunoassays which were what were used in the beginning of measurement are not as accurate especially when we're dealing with very low metabolite levels as in postmenopausal women and so the lcmsms which is also what the Dutch test uses is more accurate and they demonstrate that these studies get more consistent results and they also found that higher to hydroxy metabolites were associated with reduced breast cancer risk this study um used urinary estrogens and they measured urinary estrogens and metabolites they reviewed them in Chinese and American women women with breast cancer were compared to controls but they also compared Asian women to American women includ including Asian-American women and white Americans one finding was that higher two hydroxy metabolites were found in the controls compared to breast cancer patients and another was that American women had higher estrogens than Chinese women and higher parent estrogens were also found in women with breast cancer versus controls so risks are determined by the action of estrogen and how estrogenic the cells are and though estrogen is good for our cells our cells need to be able to turn it off is something that's what I read out of these studies now let's look at the 16 hydroxy pathway this is the second most used pathway the 16 hydroxy estrogens are formed from the cyp3a4 in the liver and in the extra hypa tissues these are the target tissues for estrogen it binds and activates estrogen receptors and some studies show that it has a pretty high binding affinity and some show that it might be more like E1 so this might depend on the tissue that it's in its defining characteristic though is that it's more estrogenic but it's also pro-inflammatory mitogenic which would mean proliferative and angiogenic and the inflammatory mitogenic angiogenic characteristics are all the characteristics of an abnormal cell growth terrain so the 16 hydroxy is estrogenic and we know that certain actions of estrogen are really good for the body we can see that postmenopausal women were found to have better bone mineral density when they had higher 16 hydroxy so I would not suggest that we support this pathway in postmenopausal women even though we are always concerned about bone mineral density in this group um I would probably suggest that if your patient was at risk you would use estradiol because we still do see that the 16 hydroxy pathway is a little more pro-inflammatory and so what we're thinking is not pushing this pathway for bone mineral density we're looking at estrad and trying to get her to metabolize it through the two hydroxy the 16 hydroxy pathway is also pretty high although I don't know if it's relatively high in pregnancy and we don't see increased like breast cancer risk in pregnant women so we want to definitely be transparent that there's some Nuance to to interpreting the 16 hydroxy so back again to the more study that I talked to about uh Chinese versus American women they also found that higher 16 hydroxy metabolites were associated with increased breast cancer risk I mentioned before certain types of HRT might increase breast cancer risk and this study looked at serum samples from the women's health initiative and they found a reduced risk of risk of breast cancer in their group of patients who only took estrogens or the conjugated equin estrogens but they also found a higher incidence of breast cancer in the group that was taking both the estrogens and the progestins and when they looked at the serum samples they found that there were higher 16 hydroxy metabolites in the patients who took both the estrogens and the progestins and so they came to the conclusion that the oral progestin might actually upregulate the 16 hydroxy pathway and that might be part of the increased incidence of breast cancer that they saw in those groups so interestingly uh this condition idiopathic pulmonary arterial hypertension is also associated with increased 16 hydroxy metabolites so in this condition high estradi is known to increase the risk and severity of idiopathic pulmonary arterial hypertension and I'm going to just call it pah from now on because it's a lot to say um men with higher estrogen and uh postmenopausal women with higher estrogen tend to be at higher risk however they have found that estradiol is protective to the cardiovascular system including in these patients with ph um the women would have have women do have higher survival rates than men and estrad inhibits the inflammation in the cardiovascular tissues but the serum 16 hydroxy metabolites appear to increase inflammatory cyto and again be angiogenic and mitogenic and this incre increases this sort of abnormal cell growth which might um contribute to negative or poor outcomes with arterial Health rheumatoid arthritis and systemic lupus emosis are two autoimmune diseases 16 hydroxy metabolites are significantly increased in the urine of patients with these diseases and it was found that the SL Auto antibody binds to the 16 hydroxy E1 metabolite so that metabolite might actually be stimulating this autoimmune process um SLE and ra have also both been associated with ph from the previous slide so there's probably a tie in there with 16 hydroxy now in endometriosis which is a a case that we get a lot of questions on for 16 hydroxy metabolites we don't have any direct outcome studies or Association studies with measuring 16 hydroxy metabolites in these patients but this study shows that the cyp3a4 enzyme is significantly higher in endometriotic lesions and that can increase the estrogenic activity of these tissues or maybe it's the pro pro-inflammatory and proliferative effects so now let's look at ratios and I just want to explain the math behind a ratio for a second just so all on the same page the ratio helps us understand what metabolite is dominating even when estrogen levels are changing so estrogen levels change throughout a cycle and they change throughout a woman's life so which one is most prevalent in the woman at all times with the two hydroxy on top at of the ratio that means that a higher ratio equals more two hydroxy or less hydroxy therefore we're going to say that a higher ratio is probably better because two hydroxy is associated with fewer risks than 16 hydroxy so this study looked at the 2 to6 ratio and they found that it was higher in controls compared to breast cancer patients or high risk um women so women who had a high risk of breast cancer and here is another study where you can see that the control group had a higher ratio of 2 to 16 compared to breast cancer patients finally uh this study looked at urine samples collected after breast cancer diagnosis and compared to control patients um urinary estrogens and th metabolites were measured and they found a lower 2 to6 ratio was associated with higher all cause mortality especially in breast cancer patients and a higher 2 to6 ratio had a lower risk of mortality especially from breast cancer or cardiovascular disease now let's talk about the four hydroxy pathway four hydroxy metabolites are formed from the cyp 1b1 enzyme in the liver and Target tissues and it has some binding affinity for the estrogen receptor so once again we're in the cells trying to neutralize and remove estrogens and estrogenic activity and we're maintaining some binding affinity and activity so maybe there's some you know maybe some of that is okay but it's probably not ideal if you're trying to detox but the defining feature of four hydroxy is that it's unstable and it forms reactive or oxidative Quinones and these combine to DNA and cause damage the for hydroxy E1 is also slower to go to phase to go through Phase 2 methylation than two hydroxy so it's slower to be neutralized he here in this graph the first two columns or the first two sections show tissue um from mamory fiber adenomas and adenocarcinomas and then the third one shows normal tissue from women with a history of breast cancer and the final one shows normal tisue UE from women without a history of breast cancer just from regular biopsies and the white bars show the two hydroxy E2 and the black bars show the four hydroxy E2 and you can see the four hydroxy is higher in the fibroadenoma and the adenocarcinoma tissue and the 2:4 ratio is a lot closer in the normal tissue of patients who had a breast cancer history so they're they're a lot more equal is what I'm saying and then in the patients without a breast cancer history they had more two hydroxy to four hydroxy um this study found an increased risk of embrace invasive breast cancer in patients with higher unconjugated serum estradi so higher active estrad and in patients with a higher four hydroxy over four methoxy ratio so so that means that more for hydroxy in those patients was associated with invasive breast cancer and they also found that patients with higher two hydroxy metabolism had lower risk this study looked at a few things so I'll just go through the conclusions that they found um they looked both in women uh human metabolites and um human samples and then they looked at petri dishes and mice so four hydroxy metabolites were increased in women with breast cancer compared to controls and four hydroxy metabolites induced malignant transformation and tumorogenesis in nude mice for hydroxy metabolites uh were found to have compromised the spindle assembly checkpoints so if you remember back to Cellular mitosis we want those checkpoints so that we don't um replicate cells that are bad and and are not functioning very well and this is a mechanism for carcinogenesis and then they took transgenic mice so they had genetically increased their cyp 1b1 and these mice developed mamory cancer um this study is pretty interesting they took urine samples and lung tissue samples from healthy controls and from patients with small cell lung cancer and what they found is four hydroxy metabolites were higher in the small cell lung cancer tumor tissue versus normal lung tissue and they found the same pattern in urine um in a 2014 study of urinary estrogen metabolites and BPA in Korean adults higher BPA was associated with higher for hydroxy metabolites and higher parent estrogens um breastcancer.org talks about BPA having weak um estrogenic activity and that perhaps if you have breast cancer you want to have less BPA but it also on its own increases the risk of some other cancers now that we talked through phase one we're going to talk through how phase two happens and how problems with Phase 2 might influence phase one and therefore some of our risk factors for phase one yeah so the compt enzyme or catacol o methyl transferase it uh methylates the catacol estrogens the two and the four hydroxy and low compt activity has been Associated um with increased cacal estrogen so it sort of if you can't go through phase two you can back up and leave these cacal estrogens hanging out for a longer time and if you remember when we talked about it the cacal estrogens do have oxidative potential especially the four hydroxy and so when they back up and they're hanging around for a longer time we have a higher potential for oxidative damage cellular damage DNA damage and all of those things that we don't want um slow compt activity has been linked to endometriosis endometrial cancer breast cancer and uterine fibroids although there's mixed data on the fibroids which I'm going to talk about in a second um so essentially comp deactivates the Catal estrogens by deactivating them it prevents them from causing DNA damage and if the comp is not working well we can have a buildup of these two and four hydroxy estrogens and any of their negative impacts so there's a common a set of common polymorphisms in the compt enzyme as many of us probably know uh the val8 met or I'm going to call it Val met is associated with slower activity than the wild type and a meta analysis of studies looking at comp polymorphisms found that this Val 158 met was associated with breast cancer susceptibility in Asian women there are several studies on comp genetics and uterine fibroids and we do have some mixed results um the Val 158 met polymorphism is both associated with an increased and a protective impact on uterine fibroids so we want to make sure that we're careful if we're going to try and only influence compt activity which we don't recommend here um on when a patient has uterine fibroids so um the point that I want to make here is that the literature is mixed but one study found that green tea extract protects against and can shrink uterine fibroids in part via reduced compt activity and I want to Circle back to phase 1 estrogen at this time these metabolites are oxidative and our concern with compt is that we want to remove the oxidative metabolites from phase one well if giving green tea is extremely antioxidant which is one of the mechanisms that they think it helps fibroids um then maybe it takes care of some of the jobs that compt is meant to do by reducing the oxidative metabolites in the system so it's a little bit of a a walk around to make sure you understand that but that's where green tea can slow down compt but also protect against Phase One issues so the compt enzyme basically is an important final step in estrogen detoxification and it works on the two and four hydroxy metabolites and it reduces their oxidative potential green tea slows compt and it's a powerful antioxidant so the point of talking about compt in this way is to say there are multiple ways that we can help phase one and compt is one of them another point is that fast compt activity has not been associated with estrogen related health issues and we do see fast comp coming up on the Dutch test we get a lot of questions about if that is problematic or not we don't see any evidence that it is but just remember on the Dutch test we're only looking at estrogen metabolism slow compt activity may not be a serious risk if the patient has is healthy and has good antioxidant status so let's look at an overview of estrogen metabolism the cyp11 makes the two hydroxy metabolite and this is our happy pathway it has low estrogen receptor binding Affinity it's oxidative but it's stable and it's been found to be non-estrogenic anti-estrogenic it inhibits cell growth and proliferation and it's rapidly cleared by the comp enzyme the CP 1b1 is estrogenic but it's mainly known for its potential for DNA damage and reactive oxygen species it makes the four hydroxy metabolite and it has um estrogenic and genotoxic effects and it's slower to be cleared by the compt enzyme than the two hydroxy the cyp3a4 makes the 16 hydroxy metabolite and it's known for being estrogenic it has a moderate to high estrogen receptor binding Affinity it's inflammatory mitogenic angiogenic and proliferative the compt enzyme is makes the two methoxy and for methoxy metabolites these inhibit carcinogenesis they have low to no estrogen receptor binding affinity and they are stabilizing and neutralizing for the phase one metabolites now let's go back to our non or our modifiable risk factors now that we've talked about estrogen detox I wanted to go through a list of related items alcohol what I have in blue here alcohol consumption seditary lifestyle and obesity have all been associated with higher 16 hydroxy metabolites and they're also associated with higher risk of breast cancer and endometrial cancer and endometriosis and uterine fibroids and tobacco use is associated with higher for hydroxy metabolites so we can see these things can impair healthy detox and they're also associated with negative Health impacts of estrogen and then supporting healthy detox we typically focus on the 1 A1 pathway just uh going down that two hydroxy pathway more this is done via sorane and cruciferous vegetables Resveratrol we also have glutathione and green tea and rosemary now I've highlighted in green those ones that um promote greater two hydroxy metabolism we've also seen these have beneficial impacts on breast cancer risk in some studies and then the glutathion and green tea are antioxidants so I also showed that they do um although they don't promote more two hydroxy metabolism they help us resolve the oxidative potential of the phase one metabolites now uh how do we measure estrogen metabolism a couple of uh philosophical points and then we'll get into some examples so estrogen metabolism is commonly measured in ratios because there are large variations in estrogen levels and these ratios help us understand which metabolite is more prevalent regardless of the levels now I've given an example here where we have a woman's estradi throughout her entire cycle and if you look at the gray background versus her results in green you can see that she does follow the pattern but she doesn't hit her Peak estrogen at the same time as as it would be expected now most women follow the pattern hers is a little off imagine if you measured her one day Dutch test on day 19 in hers her her estrogen would look very high for a ludal phase but she's probably actually in her ovulatory phase so you see very high estrogens and if you look at her metabolites they're going to be high as well but if you look at them in a ratio you can probably see her uh her dominant pathway and that's going to help you make better decisions for her because as we can also see if we look at her estrogens across the cycle and we take all the different phases into account she doesn't actually have high estrogens so really um ratios can help us control for these varying levels the metabolic actions are also not isolated so the two hydroxy and the 16 hydroxy be made in the same tissue and the two is anti-proliferative and the 16 is proproliferative so looking at them in ratios tells us which one dominates it and which which is you know which is possibly influencing your patient symptoms now we do want to say that if you measure your patients for hydroxy and it is high or there 16 hydroxy and it is high we're not saying that you shouldn't address that if the ratio is good but we need to take all of these pieces into account we also follow estrone metabolism when we're looking at estrogen metabolism this is because estrone is more abundant at all stages of life and this is especially important in postmenopausal women um stable ratios are found in numbers that are more abundant basically and much of the research we have follows the estrogen metabolism due to its abundance at Dutch we found that the E2 metabolism ratios vary more day-to-day than the E1 or the estrone metabolism and the stable ratios are more clinically reliable so if you measure your patient's estrogen metabolism on one day and it's prone to changing every day then that's not something you want to base a clinical treatment plan on so the just a quick start before we look at cases the steps at measuring estrogen metabolism are as follows we look at the parent estrogens of course the level of parent estrogens matter then we follow estrone metabolism for the reasons I've just explained then we look at population ranges for the metabolite levels and then we look at the ratios now let's look at some examples so this first set of examples examples that I have here is uh a single woman who measured her full Dutch several days throughout the same cycle and on the first set of an example we have high estrogens and the middle we have low and at the end we have medium level estrogens and if you just take a quick glance at her pie chart and her methylation fan gauge you can see she's getting almost the same result on the ratios despite the very different level of estrogens that she has so um even while the estrogen levels are fluctuating her metabolite ratios are stable that's uh that's what we want for clinical treatment plans so now let's start by looking at a case now this is a premenopausal 41-year-old female and she's not reporting significant estrogen related symptoms in fact her testing appears to be around adrenal and androgenic concerns so she's got some anxiety as one of them her parent estrogens are normal and that makes sense she doesn't have a lot of estrogen related symptoms her phase one metabolites are pretty healthy we see her pie chart is dominated by the green which is the two hydroxy pathway her actual two hydroxy is in a very normal range and the four and 16 are low which is fine she's a slow methylator although the slow methylation doesn't appear to be causing a lot of four hydroxy buildup she is still a slow methylator and her two hydroxy is okay too so it looks like this is possibly not bad for her estrogen levels however her complaint was anxiety so we do want to point out that although we're only measuring estrogen levels here compt activity does also affect catacol amines right it's a catacol Oyl transferase that methylates the catacol estrogens and so catacol amines are stimulating neurotransmitters she may also be slow at breaking down her catac colines so just a brief note compt is really supported by magnesium B6 B12 folate choline methionine and tri Glycine and that might be something that she could address and we might see a change in her anxiety from that although the Dutch test does look at her cortisol which we're not going to look at today and so there would be a lot of other ways to look at causes of anxiety for her so I just wanted to review this point that compt also methylates catamin this was a pretty normal case and now we're going to look at some differences so this is is a 28-year-old cycling female with endometriosis she has a great diet and lifestyle and she has started to have significant endometrial pain with her Menses so she came in to try and figure out what else she could do to help herself if you look at her test results and her parent estrogens you can see they're low and I wanted to use this case as an example because we get a lot of questions about how can a patient with endom iosis pain have low estrogens well we do see it estrogens being higher definitely can make that pain worse for some patients and so that's a modifiable risk factor we can look at but if estrogens are low looking at the metabolism might give us more insight her pie chart reveals a strong 16 hydroxy preference and if you look at her pie chart carefully and we'll show it a little bit closer in a moment her four hydroxy looks like it's in range for its relative percent but if you look to the left you'll see we have these sliders I'm using these sliders today because separating out the metabolites and comp comparing them to the two hydroxy is also important because she has such low two hydroxy her four hydroxy might be more dominant in her tissue even though it's in a normal range so we want to take these out separately and the pie chart can be a little bit deceiving when there's a lot of 16 hydroxy the four hydroxy can look more normal but if you see that the two hydroxy is low like this then you may also consider that the four hydroxy might be dominant now she's a really good methylator so let's follow the case for a little bit longer for another point so her initial report we did treat with dim dim is a cruciferous extract that really powerfully promotes the 1 A1 pathway and in fact it promotes it so powerfully it can lower E1 and E2 they sort of just get sucked down that pathway usually I only use dim if I want to lower E1 and E2 and in most cases when I saw levels like this I probably wouldn't use it but since she had endometriosis and significant pain i' decided that lowering her parent estrogens might be a good idea but after introducing dim she got a new symptom along with Improvement in her endometriosis pain she developed vaginal dryness so we decided to remove the dim and focus on ground flax organic soy foods and sulphoraphane which is much gentler and her endometriosis pain remained improved but her vaginal symptoms returned to normal after we got rid of the dim so looking at the 2 to four hydroxy independently was helpful for her case to see it was also out of balance and I will also add in which I didn't say before uh for hydroxy being oxidative oxidative stress is a major component of endometriosis pain so um definitely using more antioxidants might have been helpful for her too her 16 hydroxy may be associated with estrogenic symptoms even if the parent estrogens aren't high and uh the final Point dim powerfully activates the two hydroxy pathway which can lower estrogens and this may not always be desirable okay next case this is a 52-year-old postmenopausal female with hot FL lashes night sweats and vaginal dryness her pie chart shows she has high for hydroxy metabolites and her methylation is fast so although her actual for hydroxy if we look at her dial isn't High she um compared to premenopausal females for example she wants to raise her estrogens using hormone replacement therapy because she's having low estrogen symptoms and so if you can imagine if we raise estrogens and she has a relatively high for hydroxy she's going to be prone to going down this pathway much more she's also very close to higher 16 on her um when we when we isolate out her 2 to6 ratio although uh she's still well within the green so we're probably not going to worry about that because her methylation is fast supporting the two hydroxy pathways way while considering hormone replacement therapy might be a good idea another possible approach if you give her HRT is to make sure she has lots of antioxidants so that she can neutralize the oxidative potential of for hydroxy so let's just review consider the potential of her low metabolites to cause harm a lot of the studies we looked at did use postmenopausal patients so even low metabolites May cause harm but if we're going to add in HRT just remember those metabolites will increase and then considering the impact of dim so dim isn't the only thing we can use to push the two hydroxy pathway we can also use pruit forus vegetables ground PLA and soy um and we can use antioxidants as well to improve phase one and Phase 2 detox now we we have a another tricky case this is a 40-year-old female she is cycling but her Cycles are irregular she has high estrogen symptoms which means for her fibrocystic breasts mood swings and heavy menies if you look at her pie chart her 16 hydroxy is high and actually if you look at both her 2 to 4 and 2 to6 balance you can see that she's favoring the 16 the four hydroxy for both of those and the two hydroxy is low her parent estrogens are low this is probably because we caught her in the wrong time of her cycle because she's irregular and having low parent estrogens at this time is not a big deal we don't necessarily need to do a full Dutch test a second time at the right time in her cycle because we know her pie chart and her methylation gauge are consistent throughout the cycle or they are for most patients and her symptoms do fit high estrogens so she has a healthy Phase 1 metabolism we might consider supporting the 1 A1 pathway and for her possibly using dim is okay since her Cycles are irregular she might have high estrogens at another time in the cycle this might be a good case to run a cycle map for because it's hard to find when she's having a FAL phase or when her when the right timing is for her one-day test but you could also go ahead and assume she has high estrogens or you could use gentler support to improve phase one and see how it goes so in patients with a regular Cycles I'm just going to repeat this metabolite ratios are still accurate even if samples weren't corrected collected at the right time if our two hydroxy is low a careful review of her parent estrogen levels compared to phase 1 metabolites can help and separating out the 2 and four and 2 and 16 ratios can help you see how strong her preference is for one side or the other a little better sometimes so now we have some treatment considerations and um I want to talk through the philosophy of treat ing phase one metabolism and also Phase 2 we have a lot of this information in our steroid Pathways which is a really helpful resource but it doesn't tell you everything about what you should do with that pathway so when we're thinking about Phase 1 estrogen metabolism we have to remember that these metabolism pathways are still detox Pathways so even though we don't like four and 16 hydroxy we don't want to block those Pathways because those metabolites are also possibly detoxing other things in our body so the basic approach is if two hydroxy is not adequate or another metabolite is dominating then supporting the 1 A1 the the healthy pathway is the safest way to approach it this is typically done with cruciferous vegetables if you want to be gentle or dim if we have high estrogens on board um and then this list caffeine soy fish oil flax seed Etc is a great list um we have all the resources to look into these studies in the back with four or with the 3a4 pathway I also want to point out that this pathway metabolizes a lot of drugs so if your patient is on any medications you might want to make sure before um before influencing this pathway that you're not going to influence how their medication is detoxed many providers probably know that um there are certain drugs that give you a warning about not drinking grapefruit juice for example while you're taking that drug because it can um cause problems with how the drug is metabolized and actually raise how much drug is in your system possibly too much and then our CP 1b1 here you can see that things that increase it are things that we don't want anyway and I just want to point out a p in this table actually means polyamino hydrocarbons where we used it earlier in the presentation to mean pulmonary arterial hypertension compt enzyme we reviewed this magnesium choline B6 B12 folate betin and trimethyl Glycine and our Dutch interpretive guide is a really useful tool for looking at estrogen metabolism as well so um click the link in the chat to become a provider and then you can get access to our Dutch interpretive guide so let's just go through a summary of estrogen metabolism really quick estrogen metabolism is or estrogen is a powerful hormone it has tons of health benefits but if it hangs around or is too high it can also have negative impacts you can increase the risk of um breast cancer for example heavy menes increase the severity of endometriosis and uterine fibroids so detoxification of estrogen is an important step in regulating estrogen levels base 1 detox has three Pathways the two hydroxy pathway is protective the 16 hydroxy pathway is proliferative and estrogenic and the four hydroxy pathway is genotoxic and oxidative Phase 2 detox neutralizes Phase 1 metabolites the compt enzyme methylates Catal estrogens the two and four hydroxy and conjugation is also a neutralizing phase 2 pathway such as the sulfation on the 16 hydroxy measuring estrogen detox you want to follow the estrone pathway use both the levels of metabolites and the ratios of the metabolites and then the important ratios you want to look at are the 2: 4 the 2 to6 and then of course the pie chart that we have as well as the two methoxy to two hydroxy and the ratios are seing of course in the pie chart and the methylation gauge thank you so much for letting us talk to you about estrogen metabolism today hopefully you've gotten a really good feel for how to read it and what these metabolites mean okay unfortunately we don't have enough time for questions today but if you follow us um on Instagram at dut test we may be able to answer some questions there or you can email us info Dutch test.com thank you all for joining us today watch your inboxes tomorrow for a link to the recording and to access the resources we shared today you can learn more about the research behind the Dutch test at Dutch test.com resesarch and make sure you visit the become a provider tab at Dutch test.com to register for an account so that you can gain access to even more hormone Education and Research don't forget to follow us on Instagram at Dutch test for more hormone education tips from our clinical e experts and more