"Going DUTCH"
This post will end up being a (hopefully short!) series, because I don’t know yet how the story is going to end. This is really just the preface. But there’s a LOT of information here, so it seemed to make sense to go ahead and start documenting now. And I did NOT get activated for my on-call shift today (hooray!), so I’ve actually got the time to set it all down.
Out of all my blog posts, the one that’s gotten the most overall ‘attention’ is the one I wrote last year about menstrual cycle tracking. (This past spring, I was asked to turn it into an article for Built By Strength, so there’s another version of it on their platform, too.) So, although this current entry is about more than just periods, my humble opinion is that the aforementioned post is worth reading before you launch into this one, especially if your high school science could use some brushing up.
Personally, I’ve always had a slightly short cycle (26ish days), but it’s also always been pretty consistent. I’ve never had major symptoms with my periods, and have only lost my cycle twice: once in 2012 after major life upheaval + stopping the birth control pill, and again in early 2018 following an aggressive weight cut. Both times, it was absent for 3-4 months, then right back to 26-29 days once it returned. In short, it’s never been something I’ve had to ‘think’ too much about.
Which is why it was pretty weird when, about a year ago, my period caught me by surprise by showing up a full week early (while at a friend’s mountain house on vacation, naturally). I rolled my eyes, borrowed a handful of tampons from one of the other girls, and chalked it up to Murphy’s Law.
But then it happened again. And again. And again and again and again.
Until we were suddenly at a full year of consistent 21-22-day cycles.
As a healthcare provider, athlete, and woman whose body had always made a reasonable amount of sense to her — I was mystified. This didn’t seem pathologic, because the timing was perfectly regular and the periods themselves were unchanged. For those same reasons, it also didn’t seem like perimenopause (I would also be unusually young for that — my mother was 50; I’m only 36). And it also didn’t fit with my understanding of anovulatory cycles, because symptom tracking revealed rock-solid consistency: absolutely everything, from sleep to appetite to body temperature to mood to athletic performance, rose and fell in the same pattern on the same days of each cycle.
So I wasn’t necessarily ‘concerned’, but I was pretty annoyed. The two-week luteal phase of the menstrual cycle (the last 14 days before the period starts) is generally fixed in length; any fluctuation of the number of days in a cycle generally reflects differences in the follicular phase (first two weeks). And, for most naturally-cycling women, ‘week 2’ is the sweet spot where we feel and perform best. In other words, those of us who have cycles shorter than 28 days have a double burden: we have to deal with our period more frequently, AND we’re missing out on potential ‘great days’ where we could reasonably expect to be performing at our best, looking our leanest, and feeling mentally positive.
I first learned about DUTCH testing back in 2018, when I was researching hypothalamic amenorrhea. I didn’t pursue it at the time, because back then, I knew what was going on; I had cut down to an unsustainably low weight (a good 20# less than my current, far more functional size) and my body just needed some time and some calories. Indeed, after a few months, the ship righted itself.
But this new situation was making less sense to me. I knew the testing wasn’t cheap, so I dragged my feet for cycle after cycle, tracking the symptoms. But when I didn’t have any more clarity at the one-year mark, I finally decided to take the plunge.
There’s a two-page questionnaire that goes along with the samples, to give the company a better idea of your specific symptoms and what kind of ‘context’ their data will fit into.
DUTCH offers several different varieties of testing for both men and women; I chose the middle-of-the-road option, their original product, which they call the Dutch Complete. (I found a $50 discount code for it, too, so feel free to send me a DM if you’re thinking about ordering!) There is also a ‘cycle mapping’ option, which I declined because it would have taken much longer and actually seemed a little unnecessarily detailed for my purposes, although I’m glad to know it’s there as a future option if need be.
The kit is mailed to your house, and you collect 4 or 5 samples within about an 18-hour timespan.
The logistics of the testing are pretty easy; you’re basically just peeing on filter paper. For women, collection should be done during the progesterone ‘peak’, so right around the transition from ‘week 3’ to ‘week 4’ (somewhere in days 19-22 of a standard 28-day cycle — though obviously earlier than that for me!). The first collection is at 5pm, then another at 10pm/bedtime, then overnight (only if you naturally wake up to pee, as I always do!) — then again upon waking, and finally two hours after waking. You let everything dry for 24 hours, then pack it all up as directed (it takes EIGHT stamps) and send it back.
Weirdly, the cross-country trip was the part of the process that took the longest — the lab is located in Oregon, and I’m in North Carolina (and this was also during peak coronavirus craziness) — so it took them eleven days to receive my kit, and then another two weeks to run it.
When all is said and done, you receive a 15-page PDF with a full breakdown — which is pretty cool to look at, even if you basically need a degree in biochemistry to interpret certain pieces of it. I feel like I probably shouldn’t share my own full report right out loud on the internet, but to show you what it looks like, here’s a link to a sample report (again, NOT mine) on the DUTCH website.
This screenshot is from my phone, so will be blurry; if you want to see it in more detail, this is page 7 of their sample report.
In my own words, here’s my summary of my results:
(1) Cortisol: 'free' cortisol is elevated (which was not a total shocker...), but metabolized cortisol (which they say is more important) is appropriate.
(2) Melatonin: perfect. (This makes sense; I rarely have trouble falling asleep; it's the 2am wakeups that get me... which is more of a cortisol thing.)
(3) Creatinine: also perfect (they did ask on the form if I supplement creatine, and I said yes — but it didn't seem to have an impact numerically).
(4) Organic acids: this was the first interesting thing. I fully admit that I had sort of forgotten about this section because I didn't expect it to show me anything useful — but totally unexpected was that they found a “likely significant” B6 deficiency! I would never have suspected that, because I eat all the B-6-containing foods (turkey, chicken, grass-fed beef, avocado, pistachios) — and I actually also supplement B6 (it's in my ZMAs). However, the report interpretation (see below) makes the point that some of the hormone stuff at play here (specifically, the low E1 estrogen) is probably inducing/amplifying the deficiency. (B12 and glutathione are actually trending in the direction of deficiency as well.)
(5) DHEA (precursor to estrogen/testosterone): within acceptable range, but low “for age”... which brings me to...
(6) Sex hormones: this is where it gets really interesting — because, basically, EVERYTHING IS LOW.
the most striking thing is that both of my progesterone metabolites are very low, nearly in postmenopausal range (!)
of the 3 primary estrogens: E3 is good, E2 is meh, and E1 is super low (which means some of the downstream metabolites are low also)
the androgens are overall the ‘most normal’ thing — 5 of the 8 are okay, including testosterone — but the other 3 are low.
So, moving on to interpretations:
The biggest overall shocker is their very first sentence. Apparently, these extremely low progesterone levels mean that I either collected at the wrong time and “missed” my progesterone peak (which isn’t possible, because I got my period 9 days after doing the test) — OR... that I am not actually ovulating! Whereas this whole time I have been absolutely 100% certain that I was, because — as I said above — the physiological / emotional patterns of each cycle are distinct and consistent. However, these results suggest that I've been wrong about that all along… and if I’ve been wrong about that fundamental assumption, well, then the whole rest of the picture suddenly makes a bit more sense!
The low hormone levels explain the short cycles, for sure — and if it really is a lack of ovulation that’s the culprit, that also explains why the change was so abrupt.
This also explains the (relatively mild, but certainly annoying) adult acne that I’ve dealt with lately. It’s specifically on my chin, which is supposedly caused by estrogen excess, which didn’t make sense to me (since I don’t have any other symptoms of that) — but considering how stupid-low the progesterone is, the estrogen actually is excessive by comparison, if not on an ‘absolute’ level.
Another very important thing that suddenly makes sense is why my bone density has inexplicably never been in line with the amount of weight training I do. (I've had a couple DEXA scans for body composition purposes; getting the bone density score is just kind of a bonus.) It's never been ‘abnormal’, but the tech also comments every single time on how it isn't as high as would be expected based on my training + the rest of my physical parameters. It finally bumped up a little bit this year after a deliberate strength/massing cycle, but through 2018-19 it had dropped a few tenths on each successive scan. That always seemed so strange to me, because although I wasn't training at quite the level that I am now, there have also never not been barbells involved!
And, finally, something new that I’ve been dealing with over the past couple of months has been numbness/tingling in my hands. A lot of it is consistent with median nerve compression, a.k.a. carpal tunnel, which my PT thinks is happening as a compensation for (once again!) my underactive midline — apparently the wrists will compensate for a lack of core stability when things are heavy overhead. However, there’s lots of research linking chronic B-vitamin deficiencies to neuropathy in the hands — I always thought it was just B12, but there’s actually some evidence specifically supporting B6 as a treatment for carpal tunnel! (Who knew?!) So it seems possible that even this could potentially be related.
At any rate, I’m extremely glad I did this testing and got this information while I'm still firmly in ‘cycling age’ and can make some changes!
So, after poring over their flowcharts (which you can see on pages 3 and 7 of their sample report) and the specific-to-me interpretations from DUTCH, here's what I’m doing as first steps:
restarted rhodiola (which I've taken before, but not recently). It’s intended to support the adrenal glands and therefore encourage them to make more DHEA, which should then lead to more estrogen.
restarted B-complex (which I’ve also taken before, and actually still had a full bottle of!). This one is really just a Band-Aid at this point — as I said, I eat plenty of B-containing stuff, so the hope is that once the low estrogen is corrected, that the vitamin deficiencies should naturally self-correct.
am going to start chaste tree berry, also called Vitex or monk fruit. This one seems to be pretty well-known among fertility/naturopathic circles — it’s supposed to support the pituitary gland to aid in healthy ovulation (which is how women make progesterone). The DUTCH report recommended this, which made me remember that my PCP (who practices integrative medicine) actually recommended it once too, back in 2018. I never followed up on it back then, but I’m definitely curious to see whether it will help now. (For more info, Dr. Lara Briden has a quick primer on it.)
and one other thing that I’ve done is to restart my krill oil supplement and deliberately increase my dietary cholesterol — more shrimp, and one whole egg (=with the yolk!) every single day. I know that sounds funny, but look back the top of that flowchart on page 3. Cholesterol is the precursor to making pregnenolone, which in turn is the precursor to both progesterone and DHEA — both of which are low for me. And while I tell my patients all the time that dietary cholesterol isn’t the same as the cholesterol levels we see on a lipid panel, I somehow conveniently forgot that we actually legitimately need to eat some cholesterol. Most people naturally get enough (and we make our own cholesterol in the liver, too, so it's not like diet is the only source) — but thinking through this process made me realize that my dedication to macros over the past 3 years has led me to instinctively stick mostly to foods that fall easily into one category (carb, protein, fat, or veggie). But cholesterol is mostly found within the overlap — i.e. eggs with yolks, fattier cuts of meat, non-skimmed dairy. So, while I know I get enough ‘dietary fat’, I see now that it’s been coming mostly from nuts, nut butters, avocado, and olive oil (which aren't animal products, so they don't contain any cholesterol). The DUTCH report actually made zero mention of this, and I admittedly have no idea whether it will actually make a dent, but I’m sufficiently experienced with my nutrition that this is not a particularly tough change to make, so it’s worth a try.
In summary:
rhodiola for estrogen (via DHEA, via adrenal support)
chasteberry for progesterone (via ovulation, via pituitary support)
dietary cholesterol for both DHEA and progesterone (via pregnenolone)
and B-complex as a temporary Band-Aid (for just a tiny percentage of the issues) until we get the above stuff on track.
Next steps, if need be, might be St. John's Wort (which, per the flowchart, seems to increase both DHEA and E1 estrogen) and/or actual DHEA supplementation, if the rhodiola doesn't seem like it’s doing enough. But — one thing at a time. Let’s give this stuff a few weeks and see where we are.
As I said, there will undoubtedly be at least one more post on this, because I don’t know yet how it’s all going to play out. But this is exactly the kind of self-experimentation that intrigues me. While it’s obviously slightly annoying to have an ‘issue’ to solve in the first place, it’s also weirdly fun to receive new information, adjust my perception, dig into the data, and use logic to make a plan.
Stay tuned. (And feel free to hit me with any questions!)