Doctor Detective with Bryan Walsh


In this week’s case study, Doctor Detective meets a woman suffering from adult acne.  But he quickly discovers that acne is the least of her problems.  With sex hormone, cortisol, and blood sugar imbalances, can Doctor Detective help get her back on the right track?  Find out below.

Eat less and exercise more. It’s generally a great prescription for improving health and improving body composition. However, it doesn’t always work.

Even with an awesome exercise plan and a rock-solid diet, some people suffer from mysterious symptoms and complaints that seem puzzling, given how much effort they put into their fitness and health.

When we meet clients who have problems that exercise and nutrition — not to mention their own doctors — can’t seem to solve, we know there are only a few experts on the planet to turn to. One of them is Bryan Walsh.

Dr. Walsh has a sharp mind, a fitness background, a degree in naturopathic medicine, and extensive additional training and certifications. His wife is a naturopath too. (We bet his kids are the healthiest on the planet.)

So, when clients have nowhere else to turn, Dr. Walsh turns from mild-mannered dad and husband into forensic physiologist. He pulls out his microscope, analyzes blood, saliva, urine, lifestyle – whatever he has to. And he frees up the physiological jam.

That’s why, when Dr. Walsh volunteered to work on a monthly case study feature with us, we jumped at the chance. By following along with these fascinating cases, you’ll see exactly how a talented practitioner thinks; and you’ll also learn how to improve your own health.

In today’s case, we’ll meet a client who came to Dr. Walsh with a single complaint: adult acne. However, upon further investigation, Dr. Walsh discovered that she was suffering from problems with her sex hormones, blood sugar, and stress hormones.

Learn how “Doctor Detective” Walsh unraveled the mystery and helped this client achieve surprising results.

The client

It’s not every day that a young woman with a great diet, exercise plan, and attitude walks into my office with health complaints. Lots of them, in fact. That got my attention right away.

Jill was 34 and healthy. But she had adult acne. Yeah, acne – y’know, the stuff you’re supposed to grow out of, right around the time you lose your crush on Justin Bieber and quit breaking into your parents’ liquor cabinet? Well, Jill’s acne never got the memo that it was time to move on.

Jill was a woman on a mission. She’d been to many conventional doctors who merely put her on a variety of topical and oral medications, which included antibiotics (minocycline, tetracycline, clindamycin), as well as Differin®, Retin A, and azelaic acid. When that didn’t work, she tried alternative treatments such as natural acne washes, zinc and chromium supplementation, and honey masks.

Nothing helped. Doctors told her nothing was wrong, and that she’d just have to live with the breakouts.

After two years of trying everything, not only was her acne unimproved, but she now experienced frequent urinary tract infections (likely from the antibiotics). She was frustrated. She knew something was wrong.

But what? She looked fit and healthy. She ate well on an organic diet. She exercised regularly. At 5’9” and 130 lb, her weight was normal. She was even upbeat and positive.

Yet acne was only one of her issues.

Jill believed she also had hormone imbalances. She’d been trying to get pregnant for 10 years with no luck. She and her husband had pretty much given up on her dream of having a baby.

The client’s signs and symptoms

I examined Jill when she came into my office. She had significant acne and mild facial hair growth. Other than low blood pressure (100/70), all other physical exam findings were normal.

I dug deeper, scribbling notes as I went. Jill described the following:

Signs / Symptoms My thoughts – potential issues
Feels lightheaded if she skips meals Blood sugar
Feels tired in the afternoon Thyroid, adrenal hormones, sex hormones, anemia
Experiences breast pain, swelling, cramps, pelvic pain and irritability during her menses Sex hormone imbalance
Depends on coffee to get going in the morning Adrenal hormones, anemia, low thyroid
Has cravings for sugar and salt during the day Blood sugar, adrenal hormones
Suffers from bloating and gas Dysbiosis, infection, poor digestion
Battles with bouts of depression, anxiety and “emotional instability” Neurotransmitter imbalance, sex hormone imbalance, blood sugar

Aha, I thought. Based on her medical history, her signs and her symptoms thus far, Jill’s probably experiencing blood sugar issues (i.e. reactive hypoglycemia), sex hormone imbalances, digestive dysfunction, and possible adrenal hormone imbalances.

After being “Doctor Detective” for many years, I like to think my instincts are pretty good. Still, I’m a cautious guy. I don’t like to jump to conclusions. So I turned to the diagnostic tests for confirmation.

The tests and assessments

Taking a good medical history and critically evaluating symptoms often tells you everything you need to know about a case. However, there are some things you can’t learn just from asking questions.

I can’t see into clients’ blood vessels or cells, or guess the chemistry of their urine. Lab testing gives me insight that I can’t get from conversation. In fact, labwork is one of the most useful tools in my arsenal.

I like to start small with some basic tests. Sometimes these are all I need. I always start with a good blood chemistry panel plus a salivary hormone panel. Jill is also a candidate for a digestive function panel, but we opted against it for now.

The test results

Blood chemistry panel

When read correctly, a good blood chemistry panel speaks volumes about a patient’s internal physiological processes. Here are some of the significant findings from Jill’s blood chemistry panel:

Marker Result Lab Reference Range Thoughts
7 mg/dL 5-26 Borderline low – possible liver issues or protein metabolism issues (i.e. digestion)
Globulin 2.4 g/dL 1.5-4.0 Borderline low – Possible protein metabolism issues related to digestion
LDH 133 IU/L 100-250 Borderline low – reactive hypoglycemia (blood sugar fluctuations)
WBC 4.7 x10^3/uL 4.0-10.5 Borderline low – possible immune suppression
MCV 94 lF 80-98 Borderline high – B12/folic acid deficiency (common with digestive issues)
Alkaline Phosphatase 35 IU/L 25-150 Borderline low – Possible zinc and/or vitamin C deficiency
Uric acid
2.5 mg/dL 2.4-8.2 Borderline low – possible B12, folic acid and/or molybdenum deficiency
3.087 uIU/mL 0.450-4.500 With borderline high TSH and borderline low thyroxine, these were enough to suspect thyroid issues, but would be evaluated later.
Thyroxine 0.5 mg/dL 0.3-1 Normal.

You’ll notice that even though none of these values were outside the lab reference range, I still flagged some of them as problematic. Why?

Well, what most people don’t realize is that, except for lipids (cholesterol, HDL, LDL, etc), the range provided by the laboratory is derived from blood samples taken from people visiting their doctor. In other words, sick people. Healthy people go to the doctor far less often than sick ones do.

Therefore when your doctor says your blood work is “normal”, s/he’s really saying: “You are as healthy as 90 percent of people visiting the doctor today” and “Congratulations! You probably don’t have a weird unusual disease!”

That’s not enough for me. I don’t just want to know that people are surviving. I want to know how to make them thrive.

So we look at blood panels a different way: as a means to evaluate health and optimal function.

In addition to the findings above, we also saw evidence of possible dehydration (slightly elevated albumin, hemoglobin and hematocrit) on the blood chemistry, which could be masking an anemic tendency on her blood work. If someone is dehydrated, their anemia will be harder, if not impossible, to spot on a blood chemistry test.

Is it plausible there are a lot of dehydrated anemic patients walking around today being told there is nothing wrong with them today? You bet. More than most people realize.

Hormone panel

Hormonally, Jill had a number of things going on.

We ran a month-long female hormone panel to track her hormones over the course of an entire month. The results appear in the graph below. Note that normal estrogen for a female cycle is in blue, normal progesterone is in red. Jill’s results are in dashed green.

Hormone panel results – click to enlarge

Based on this graph, you can see that Jill has fairly normal progesterone levels and timing, but estrogen starts and ends elevated throughout the entire month. This tells us that estrogen is dominant. This consistently high level of estrogen, and its effects on her tissues, helps explain many of her symptoms during menses.

But perhaps the most significant finding with regard to her acne was what we found when testing her testosterone.

Marker Result Lab Reference Range
Salivary testosterone 67 pg/mL 5-20 pg/mL

Although many people assume that testosterone is a “male” hormone and estrogen is a “female” hormone, both men and women produce both types of hormones. They just differ in the relative amounts.

Elevated testosterone in women is more common than people realize. High testosterone causes everything from infertility, low libido, mood issues, difficulty losing weight, to the more obvious signs like acne and facial hair growth.

As far as Jill’s acne was concerned, we felt this was the smoking gun we were looking for.

Cortisol panel

To add insult to injury, Jill also showed chronically low cortisol levels throughout the day (as you can see below — her results are mapped on the blue line), which is consistent with reactive hypoglycemia.

Cortisol, also known as a glucocorticoid, has powerful influences on maintaining healthy blood sugar levels. When people with low cortisol skip meals, their blood sugar drops too low, and epinephrine is released as a backup plan to increase glucose. It is epinephrine that causing the shakiness, lightheadedness, and irritability experienced between meals.

Cortisol panel results – click to enlarge

The prescription

We may be “health gunslingers for hire”, but we ain’t supplement junkies. Nor do we respect practitioners that send patients out with grocery bags of supplements. It’s simply not necessary. Some people need more than others, but there is no need to take a supplement without proof that you need it.

We also don’t believe in protocols for specific conditions. For example we don’t have an acne protocol, or even an acne supplement. Instead, we look at which physiological pathways are dysfunctional and seek to improve those pathways using targeted nutritional approaches.

That being said, let’s find out what we did for Jill.

Issue #1 – Blood sugar imbalances

Her symptoms and blood work (low LDH) suggested reactive hypoglycemia, otherwise known as excessive blood sugar fluctuations. This is critical to address, as reactive hypoglycemia in women often increases testosterone production.

It’s crucial for women with this condition to eat small, frequent meals, whether they feel hungry or not. Anytime Jill feels lightheaded or shaky between meals, she’s waited too long and created hormone havoc in her body. Addressing low cortisol will also help correct her blood sugar fluctuations.

Issue #2 – Vitamin deficiencies

Jill seemed to be deficient in a number of nutrients (vitamin B12, folic acid, vitamin C, zinc) solely based on her blood work, so we gave her a high-potency multivitamin-mineral called Complete Multi by Designs for Health (2 caps, three times a day).

We also gave her additional sublingual vitamin B12 (1mg three times a day), as digestive issues can inhibit vitamin B12 absorption. This was designed to help what appeared to be a sub-clinical macrocytic anemia.

Issue #3 – Digestive dysfunction

We had Jill start with a three-week elimination diet to help reduce gut inflammation caused by possible food sensitivities. We also supplemented digestive enzymes (Digestzyme by Designs for Health, 2-3 capsule per meal). Later in her protocol, we also put her on Designs for Health Probiotics Supreme (2 caps a day) to help combat the assumed dysbiosis she had from antibiotic use.

Issue #4 – Hormone imbalances

We needed to eliminate her excess hormones, specifically estrogen and testosterone. This is most easily accomplished by improving liver and gall bladder detoxification pathways, since this is the primary pathway steroid hormones are cleared out of the body. Specifically we used Designs for Health Amino-D-Tox (2 caps, three times a day), LV/GB (one cap three times a day) and Clearvite by Apex Energetics (one scoop three times a day, which also addresses gastrointestinal health).

Issue #5 – Adrenal imbalances

Normally we don’t address adrenal imbalances right away. Rather we support other systems for a period of time, re-evaluate, and see if anything improved. However, given that high testosterone was a key finding, we needed to address the low cortisol to stop the vicious hormonal cycle happening anytime her blood sugar got too low. We prescribed an adaptogenic formula called Adaptocrine by Apex Energetics (2 caps, three times a day) designed to help support the body’s stress response.

Obviously there were other things to address, and additional directions we could go, but this was enough for the next 12 weeks, at which time we’d redo lab testing and evaluate her symptoms.

While this may seem like a lot, it’s all for good reason. For example, if her testosterone is high, we need to stop its overproduction (i.e. due to blood sugar fluctuations) and get rid of the excess levels (i.e. liver support).

The outcome

A few weeks after finishing the protocol, Jill submitted follow-up blood chemistry panel and salivary hormone testing. However, while we were pleased with her symptom improvement, we were initially puzzled by the lab results.

Symptomatically, Jill reported a complete resolution of her acne. She also had an “abundance of energy”, no more gas and bloating, emotional balance for the first time in 10 years, and she felt “happier and more alive” than she had in a long time.

Mission accomplished, right? Not really.

Her testosterone had lowered considerably from 67 pg/ml down to 15 pg/ml, which is a good thing. However her estrogen and progesterone remained very elevated. And now she had high glucose, alkaline phosphatase, white blood cells, and lipids (cholesterol and triglycerides).

Not exactly the direction we wanted to go. Scratching our head we wondered where we went wrong, and where we were going to go next.

But then we got our answer.

One week later, we had our answer. Jill was finally pregnant! As she told us in an excited email:

“…Yet the best, most joyous and most unexpected result was … I found out that I was pregnant! Never in million years did my husband and I think we could fall pregnant with the current state of my hormones and so quickly, after addressing my health concerns.”

Her pregnancy explained the odd lab values that came back post testing. So yes, apparently mission accomplished.


So what can we take away from Jill’s story?

  1. Symptoms of reactive hypoglycemia, including shakiness, lightheadedness and irritability between meals are often correlated with low cortisol.
  2. Blood sugar fluctuations will almost always cause hormone imbalances in women, specifically elevated testosterone.
  3. High testosterone in women can result in mood issues (i.e. depression), infertility, difficulty losing weight, low libido, as well as external manifestations such as acne and facial hair growth.
  4. Getting rid of excess testosterone requires balancing blood sugar to slow down its production, and supporting liver detoxification pathways to clear out the excess that is already present.

In the next article . . .

Jill contacted us a year later, elated with a new baby boy, but with a whole new set of symptoms: extreme fatigue, depression, and difficult weight loss.

We ran a blood chemistry, and it showed a very high TSH (Thyroid Stimulating Hormone) coupled with low thyroxine and T3 (Thyroid hormones).  However, low thyroid hormone was not her primary issue.  Her problems were being caused by something very common today, which we’ll cover next month.

Stay tuned, detectives.

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