Female, age 33 – Hormone imbalance, sleep problems, chronic illness

A 33 y/o female reported to the clinic with a CC of hormone imbalances. Height 5’4”, current weight 180 lbs. In her history she cited weight fluctuation, extended and irregular menstrual cycles, sleep irregularities and chronic illness as evidence of hormone imbalances. Prior to entering our care, she had blood work done for thyroid function. She did not produce the report for our review, but did mention that it had been viewed by the group that had run the panel and her general practitioner M.D. She was told that conclusively it was “unremarkable.” Despite several requests for her to provide us this information, she declined. We proceeded with treatment. Also noted during her history were digestive disturbances such as heartburn ongoing for one month prior to her visit, food sensitivities, and sluggish digestion with frequent constipation with one bowel movement per two days on average. Additionally noted was abnormal anatomy of an additional kidney on the right side with accompanying proteinuria.

Descriptive Symptomatology

Weight fluctuation: Patient states fluctuating almost 100 lbs. over the course of a few months (variable between 3-6 months) in the range of 120-220 lbs. She reports that this weight loss/gain is without any alteration in her diet or exercise routine. Exercise consists of 30 min/day by 3x/ week and an additional 2 day of weights or cross training. Diet consists of 1700-2000 calories daily of meats, fruits, vegetables and starches, moderate amounts of sugars, and alcohol 1-3 drinks /week. Also, self-reported occasional binge drinking once every 8-12 months of 1-2 days of bingeing. Patient states that when gaining weight above her ideal range, she would restrict calories and increase exercise. Conversely when losing weight below her ideal range, she would reduce activity and increase caloric intake. Ideal body weight range was 135-145. Anecdotally noted was her comment of having a closet full of extra clothes sizes ranging from 2-16 in order to be prepared for a change in size overnight such that she could not wear the same size clothes from the day before.

Irregular menstrual cycle: Patient states that her menstrual cycle was irregular for 2-3 years, starting around age 29 and through age 32. Most recently in the past eight months has been regular with 14 days of menstrual flow out of a 28-day cycle.

Sleep irregularities: Patient states that she has trouble falling asleep, staying asleep and oversleeping. Depending on what period of time she was referencing she described both hyposomnia and hypersomnia, as she had difficulties with each. These episodes were regular and 6-7 nights/week. She also stated the regular use of common stimulants, such as coffee, to maintain alertness during her workday.

Chronic illness: Patient states that she is “always sick.” Defined as some sort of sinusitis, cough, chest cold, sore throat, etc. for at least 2-5 days and usually 3 episodes monthly.

Clinical Assessment
The multi-symptom, multi-system nature if her condition suggested a blood-related problem. Her metabolic fluctuations, sleep irregularities, menstrual irregularities, and chronic illness were the main focus of her CC and suggested the endocrine system. Due to the report of “normal” blood work and the lack of proper function, the working diagnosis was systemic inflammation. This working diagnosis also explains the food sensitivities. Other findings were right-sided temporal bulge cranial fault, hypochlorhydria, Ileocecal valve spasms, functionally inhibited muscles and some areas of spinal subluxation.

The course of care we decided on was the SHAPE Program as described in the Program Guidebook. A weekly urinalysis was performed. The baseline UA showed protein and all other parameters were within normal limits. Also Applied Kinesiology techniques were used to address right-sided temporal bulge cranial fault, hypochlorhydria, Ileocecal valve spasms, functionally inhibited muscles and areas of spinal subluxation.

The first report of change in symptoms was at the weekly check-in. The patient noticed an increase in energy overall and a decrease in digestive complications with more regularity. Also noted was a drop in body weight of 8 lbs. The UA was normal.

On week 2, patient reported an increase in restful sleep with less sleep disturbances with a total of three or less nights of disturbed sleep. She also reported a weight loss of 7 lbs. and that she was down a size in her clothing. Also noted was a headache, that the patient described as “normal,” but failed to mention in the history because it was “always there.”

Week 3 report showed a decrease in frequency of illness since the onset of the program, increased quality of sleep, reduction in body weight of 5 lbs., increased energy levels and decreased fatigue during the workday. The UA showed protein and high ketones, so added one extra fruit to her food plan per day.

Week 4 report showed a delay in onset of her menstrual cycle. For the first 9 days on the program she was mid-cycle. That cycle ended during week two. According to her history she expected to have started another cycle during week four. She also reported a decrease in body weight of another 6 lbs., no headache since last visit, also no illness, still sleeping better. The UA showed moderate ketones and protein.

Week 5 report included the onset of her menstrual flow, 19 days since the end of the last cycle. Also noted was one minor headache that occurred after skipping lunch one day and having a busier than normal day. She has been more diligent with timing of meals and since then no recurrences. Also still feeling well, sleeping well, no illness since last visit. also reports a weight loss of 4.5 lbs.

(Week 6 there was no visit, due to scheduling issues.)

Week 7 report showed that her menstrual flow of last cycle lasted only 4 days for the first time in eight months. Also reported was a decrease in body weight of 9 lbs. All of her previous complaints were no longer a concern for her at this time.

The report for week 8 showed that her weight had achieved a desirable level at 134.3 lbs. and a resolution of all other complaints.

At that time we decided to transition her to Phase II of the SHAPE Program but continue to use the SHAPE Drops. This decision was based on the patient value of the drops and concern to maintain her new normal for her menstrual cycle of four days of flow out of every 28 days. We also provided her a calorie calculation of 1900 cal/day along with 30 min 3x/ week of exercise. We set up a follow up consult for 4 weeks, unless she had concerns, then she was instructed to call in sooner. At the 4-week consult, she reported feeling great with no complaints. Her weight had increased to 141.6 lbs. and held steady there for more than 2 weeks.

In this case, where no assistance or solution was offered by standard western allopathic approach, a change in diet and use of the SHAPE Program along with chiropractic and Applied Kinesiology techniques created an environment that the body was able to heal previously chronic conditions. Further studies are needed to validate results in a more diverse population.

Submitted by Danny McLane, D.C., CHTI

Dr. Todd’s Teaching Assessment

Excellent case study!

Significant to realize what really occurred if our theory regarding hypothalamic function is correct, and we think it is.

We believe the patient reset the hypothalamus. She now experiences improved sleep, weight loss and normalization of her menstrual cycle. Remember, the hypothalamus must be satisfied daily by four things: Sleep, exercise, sex and food.

It is important to note the value of the baseline UA. She presented with protein and continuously showed protein. This is obviously her norm as she has an additional kidney.  Therefore, we would not increase protein in her case. Had a baseline not been performed, the practitioner would think it appropriate to increase the patient’s protein intake. In this case, that would have been detrimental to weight loss success. You will note Dr. McLane correctly altered her diet when she was spilling large ketones by increasing her fruit consumption.

We believe the rebound weight gain is tied to her kidney disorder. If a patient can gain a full dress size in 24 hours, the most logical explanation of this would be water retention. Her history dictates such. It is our hope that with her cycles normalizing and her hypothalamus function improved, she will stabilize.

Note the patients desire to stay on the SHAPE Drops. This is very acceptable, and we would recommend .50 ml 2x daily.

Should the patient decide to return to Phase I, we recommend taking a minimum of 7 days off the SHAPE Drops before restarting the program along with the 2 load days. It is our recommendation load days consist of healthier fats such as eggs, nuts and avocados to train the supplement to go after and break down excess fat. Of course, indulging in a fried chicken dinner or alfredo and enjoying some ice cream is acceptable during load days. Once you shut down excess fat intake, the SHAPE Drops then goes after stored, toxic fat. As soon as a patient cheats, the SHAPE Drops will go after the most readily available fat, thus stalling the patient’s weight loss. We have observed clinically that it can take 3-7 days for the body to revert back to stored fat burning mode.