CASE STUDY – SUBMITTED BY DR AZIZAN ABDUL AZIZ
33 year old Filipino ladyworking as a babysitter to twins for the past 3 years.Just got married 3 months ago.Came with complaints of severe facial acne and irregular period ranging from 35 to 62 days for the last 2 years.Associated with abdominal pain, backache, grumpy, forgetful and tired in the morning during her period.However, no history of constipation.
On examination: Severe acne on whole face.Height: 147.5cm,Weight: 50kg, BMI: 23
A Blood test done 12/2/15( at another medical centre) on Day 8 showed:
Hb: 12.9g/dl, FBS: 4.4mmol/L,Fasting Serum Insulin: 7uU/ml
Tot. cholesterol: 5.5mmol/L,HDL-C: 1.3mmol/L;LDL-C:4.0 mmol/L:TG: 0.5mmol/L
TSH: 1.220 mIU/L; FT4: 17.9 pmol/L; FT3: 5.3pmol/L
Serum Cortisol (9.25am): 325nmol/L
DHEA SO4: 7.6 umol/L
Serum Testosterone: 2.4 nmol/L
Serum Oestradiol: 156pmol/L
Serum Progesterone 1.8nmol/L
Discussion on case:
Working in a foreign country, and taking care of twins from birth is very stressful.This could lead to hormonal imbalance from improper dietary intake of proper macro and micro nutrients and insufficient sleep.
Thus management of case is through lifestyle changes.
1) Diet : reduce refine carbohydrate,coffee, sugar.
Avoid the above first thing in the morning, especially as it would affect hyperglycaemic hormones production like Cortisol, Estradiol,DHEA, IGF-1 etc. with increase blood sugar level with the above food intake.Eat sufficient protein ,essential fatty acids to assist in hormone production.Sufficient fruits and vegetables.
2) Supplement with Zincand Chromium. This is helpful in acne management.
3) Appropriate topical acne skin care
4) Hormone supplementation.
Hormone profile should aim at 75th centile of the reference range given by the lab to be optimal.
The serum FT4, Cortisol, Oestradiol and Progesterone are not optimal.
The symptoms such as morning fatigue, menstrual irregularities, poor memory, mood changes could be due to relatively low thyroid levels. Thus starting patient on:
- i) Thyroxine, using Oroxine 50ugm on waking up in the morning daily. Start on low dose and monitor for palpitation in patient.
- ii) Since patient is stressed chronically, mood changes occurs. Thus supplementation with natural steroid such as Hydrocortisone 10mg on morning will be helpful. This will also help patient to tolerate thyroid hormone supplementation when the Cortisol level is low. If patient is put on Hydrocortisone (catabolic hormone), an anabolic hormone has to be put on to balance the anabolic-catabolic process such as Oestradiol, Progesterone, DHEA where indicated pending on hormone levels.
iii) Oestradiol and Progesterone are low.
This could contribute to menstrual irregularities, mood changes, abdominal pain, backache.
Start treatment with micronized Progesterone, Utrogestan 100mg before bedtime from Day 20 to 30 initially (in view of her menstrual cycle vries from 35 to 62 days). Progesterone is given during the second half of menstrual cycle.
5) Expose to morning Sun and ensure adequate sleep.Regular followup is required to review patient’s symptomatology and repeat hormone level where necessary.
In this case, the patient has stopped working and gone back to her home country.
Reference: The Hormone Handbook by Dr Thierry Hertoghe