Unlock Hormonal Harmony: The Key To Fertility

Elizabeth Bartman, ND

A great question. 

Aumatma Simmons, ND, FABNE, MS

What have you been doing? What’s not? 

Elizabeth Bartman, ND

Yes. Endo as in endocrinology, and then the Axis that kind of combines all of the understanding of the most superficial in-depth hormones. Putting all the pieces together. That was that endocrinology pieces together. EndoAxis became the brainchild name. It’s the creation of Dr. Guy Citrin. He began this journey a few years ago and brought me on about a year ago to help sort out and put together detailed hormone analyses. That’s what it is. It provides a very detailed view of potentially very complex hormonal stories. 

Aumatma Simmons, ND, FABNE, MS

Yes, I know that it’s simplified. Let’s differentiate. I just want to give some context. This is an analyzer for practitioners and patients. How do people use it and access it?

Elizabeth Bartman, ND

Absolutely. Yes, this is a great question. This is a targeted program for providers. For those looking to support patients through their hormonal journeys. We are using, of course, patient lab analysis, but it’s a tool for the providers to be able to upload the report and see in real-time classifications of the high-level hormonal imbalances that are at play. Then get some recommendations on where the next steps or strategies could be to provide optimal outcomes for that individual for that patient.

Aumatma Simmons, ND, FABNE, MS

Okay. Awesome. It is mostly a tool for practitioners. I love that. There are very few but often tools for us, so it’s great. Then what type of testing can you upload? Absolutely.

Elizabeth Bartman, ND

Now we started with urinary hormones and specifically with precision analytical,  The DUTCH test. That’s the Dried Urine Test for Comprehensive Hormones. 

Aumatma Simmons, ND, FABNE, MS

Yes. They’re my favorite. I think it’s a lovely test. That was a few years prior.

Elizabeth Bartman, ND

But we wanted to start with the metabolites story. Because you can run parent hormones and current sex hormones in any medium. You can do bladder, you can do saliva, and you can do urine. You can see what those circulating estrogen, progesterone, and testosterone values are. You can make assumptions on those levels and help support patients with their symptoms. but it’s a pretty high level. It’s almost just, I mean, the service when you just look at those markers and know what’s going on hormonally—what are they doing with those hormones? How are they metabolizing those hormones? How do those metabolites influence their health?  What can those metabolites tell us about utilization processing and environment? Areas that we can further target and treat to give optimal results for those individuals?

I think the only way you can get metabolites in the way you can see that journey is through urine. We wanted to give that deep dive from the get-go. We also include serum testosterone and sex hormone-binding globulin. Then we’re just going to continue to grow and add more blood tests that complement the adrenal pictures, add more inflammatory markers, and add in organic acids. It’s not even static; my background, my baby, is genomics, genetic medicine, and environmental health. Bringing that into how it relates to sex hormone production and metabolism, I think, will be quite the advanced programming here. But starting slow and yet powerful and impactful with the urinary form and the metabolites.

Aumatma Simmons, ND, FABNE, MS

Absolutely. DUTCH test, in and of itself, just has so much information and data that you’ve already gathered, and then analyzing and going through all of that information takes a skill set. Let’s talk a little bit about—I guess I’m curious—is this the type of tool that is going to be helpful for the specialized kind of hormone doctor? Or is this going to be a tool that’s for a newbie that I’m edging my way into hormones and trying to figure it out? Someone help me a bit about you, and I would go a different way.

Elizabeth Bartman, ND

We want to provide high-level information. When we’re assessing those labs, I think a lot of providers see them married and doing urinary testing, there are so many studies out on, especially our 4-hydroxy estrone, for example. We want to know those levels. You see them here, and what do we do with those results? I think there’s a lot of overwhelm and almost information stagnation where it’s, nope, I don’t want to learn anymore. I know what to do. I know what to do with these little protocols. Let’s say in our safety zone, we want to help providers feel comfortable and confident in using this urinary advice and urinary testing tool, especially on their complex patients, but for anyone by monitoring their hormonal journey. 

I think the way we filtered it out is built into little digestible pieces. It says, Here’s your high level; here are yours, don’t miss these points. If you just want that 32nd bird’s-eye view. Then we dive in and we said, okay if you want a little more information here, some more assessment, and if you want to dive deep and know here are the genomic variants that can be involved in this pathway issue, here are the environmental factors. Here are the dietary factors: The medications. We expand and get a lot more depth and detail in our strategy and analysis section. There is something for everyone. If you’re an advanced and seasoned practitioner, but you have a complex case and you just want a second opinion and some different perspectives, we have that. Then if you’re a newbie just getting your toes in, I just want to know a little bit about getting used to this first before I dive deeper. Then you can take snapshot notes and still get a good understanding of what’s happening. 

Aumatma Simmons, ND, FABNE, MS

Amazing. I want to dive into the deep stuff. I’m curious for a practitioner. I’ll just take myself as the case study, and maybe other providers will resonate. I edged my way into doing that testing probably 10 years ago and certainly over a while then, You, Dr. Carrie Jones, and you guys were so instrumental in me being able to apply that to the fertility patients that we work with. Now, 10 years in and probably 100 DUTCH tests later, I am at that place where I don’t even know if there’s stuff that I’m missing. What are the patterns that you see in someone well-versed in this? What am I missing from a DUTCH test? Maybe I thought this would be helpful for practitioners who specialize in fertility. It could be helpful for patients just to hear how we think about things from this whole holistic, naturopathic perspective that has to do with their hormones and their fertility. I want to serve both audiences, and I’m coming at it this way. What are we missing? What are these patterns that we could potentially be missing out on that are recognizable to experts yourself and that we could benefit from learning?

Elizabeth Bartman, ND

Absolutely. I think when we’re building out these patterns, it’s a relationship. When I was building up the sex hormone patterns, I started with progesterone for cycling women or for women in general, especially for our fertility cases. Want to know what progesterone’s doing in the lead? We compare that to their estrogen, and then we look at that estrogen detox. We’re looking not just at a ratio of how much 2-hydroxy is favored over four or six of these intermediates of phase one detox. But we’re also looking at not just the percentage but how m of estrogen is moving into a phase one metabolite. Are they transferring it into that initial clearance out of the body, or is it high in circulation? They have beautiful two-hydroxy, but it’s only a quarter of their actual estrone in circulation. That’s a problem. They’re not biotransforming it through phase one detox or that it’s recirculating it. We called that out of our patterns. It’s a poor clearance, a poor initial clearing form, and then we call out the methylation ratio, and the methylation is what we can capture in urine. It only reflects phase two for the category estrogen. That’s the two in the 4-hydroxy. 

We are seeing that ratio and then being able to gauge whether it is too low or too high. These are all our Goldilocks hormones, or are is it just? How does that compare to all this other information that we’re bringing in? It’s looking at 12 different relationships. Then testosterone is brought into the pattern as well. In addition to DHEA and, of course, the metabolites of the androstenedione 5-Hydroxyindole, Etiocholanolone, all of our intermediates, and what that is about that journey. When we’re looking at what could be missed, I think some patterns often do go missing. I do think that looking at that initial transference of estrogen into phase one metabolites, I would hear a lot on consultations; their two hydroxy is 95% preferred. It looks great for hydroxy; it’s nice and low. This looks beautiful; methylation is looking good; it’s balanced. I don’t think I need to worry about detox, and the other estrogens are looking at the high end or even above that kind of ideal target luteal range. We need to look at that idea of roles to have. 

This half of estrone is getting biotransformed, if you add up to four and six hydroxy metabolites, we come to half of that estrone or more. If it’s not, what’s going on there? Do we need help? Is it getting recirculated because of poor phase three detox, which we’re not counting those too? But elevated irregularities, for example. Do we need to do some further investigation there? Do they just need more improvement through phase one by reducing refined sugars in the diet and reducing alcohol? Is that a problem with that? There arere’s still maybe some areas that have increased fiber, primarily fish oils. Decreasing inflammation can help with that transformation. 

I think that’s one that I’ll often see skipped because it’s easy to make patterns look great. The high chart looks beautiful. The other one, I would say, gets the low-hanging fruit with fertility by looking at the progesterone-to-estrogen ratio. When progesterone slowly doubles, even below its ideal range, that’s half the cycle. That’s about it. We need to optimize that progesterone, and we need to make sure that estrogen has that balance. But another one is that, even if estrogens don’t look too high, patients are struggling, maybe with estrogen dominance symptoms, that 16-hydroxy metabolite is very estrogenic as an intermediate, it’s not nearly as estrogenic as estradiol. 

But we do want to consider that as well for both our fertility patients and just women’s health in general. Because if you have a patient and they’re maybe their progesterone does look pretty good it is balanced with that estradiol. Maybe we’re not too concerned on the estrogen dominance front. But yes, here’s a patient who’s struggling with fibrous cystic breasts and bloat and a lot of menstrual headaches, and their 16 hydroxy off the charts. That’s an estrogenic intermediate we’ve got to address. We don’t want to miss that. We wouldn’t see that in blood, we wouldn’t see that in saliva. That’s a nice one. That, again, you don’t want to miss but could easily be overlooked. 

Aumatma Simmons, ND, FABNE, MS

Those are good. Those are great patterns. When, and this may not be exactly the pattern that you were talking about, but I’ve seen lately a higher E3 than E1 and E2. Sometimes they even look like they’re super low, but then they’re over-converting to E3, and they have a high 16OHE. Curious about that.

Elizabeth Bartman, ND

I agree, I do see that one top that a fair amount of E3 and 16OHE-1. E3 is technically chemically speaking 16OHE-2. These are the metabolites or phase-1 intermediates of estrogen through the CYP3A4 enzyme. They’re both partners in that. The CYP3A4 enzyme is a powerhouse enzyme. It’s responsible for over 60% of the metabolism of a lot of our environmental and medication toxins. I know, so it’s the 3A4 and 2D6 that are our big powerhouse in ways.

Aumatma Simmons, ND, FABNE, MS

Yes. I just got the chills. I know where this is going down.

Elizabeth Bartman, ND

When we’re looking at why an enzyme might be upregulated, we have to look at the promoters upstream of that transcriptional response. With 3A4 because it’s such a powerhouse and it’s involved in so much, there can be medications that promote more transcriptional activity upstream. There can be medications that suppress what you see as low. That could be a medication as well. But there’s been some involvement. There can be supplement involvement. St. John’s Wort is a very potent promoter of CYP3A4 enzymes. This is why a lot of antidepressant meds say do not take it with St. John’s wort, because now of the serotonergic influence of St. John’s wort, it’s necessarily because St. John’s Wort is interfering with the ability to get the prodrug, which is the active component of that SSRI. 

Aumatma Simmons, ND, FABNE, MS

Problematic. That’s a little problematic.

Elizabeth Bartman, ND

But you’re exposed to a lot of xenoestrogenic polyaromatic hydrocarbon phenols. These are things that require CYP3A4, among other enzymes, to react, and they’re going to be increasing transcription so we can get them out of the body and take with it the estrogen as well. 

Aumatma Simmons, ND, FABNE, MS

Interesting.

Elizabeth Bartman, ND

Environmentally, especially, estrogen this upregulation of both the 1B1 and the 4-hydroxy. Also. that 3A4. I think that when you can get overlooked sometimes, and I feel one of my biggest things to shout from the rooftops, is do not suppress that enzyme, but your preference for 16OH, yes, that is estrogenic. Yes, we want to make sure we have balance but don’t get balanced by inhibiting that enzyme because. It is upregulated for a reason, and it may need to be to pull out our toxins or other exposures. By doing so, we become more toxic. That’s the end of this thing.

Aumatma Simmons, ND, FABNE, MS

Interesting. Have you seen it upregulate at all with too much iodine or hidden sources of iodine that maybe we didn’t compensate for?

Elizabeth Bartman, ND

I think so. Thyroid in general, over-conversion of the thyroid can upregulate the transcription of several of our enzymes active thyroid can be a problem as well, but more for the reduced activity for the CYP3A4 underactive thyroid and increased 5-alpha reductase transcriptional response to interesting kind of feedback to try.

Aumatma Simmons, ND, FABNE, MS

Yes, so if you want to jump to that pattern, the 5 sorry say that enzyme again? 5-alpha reductase—that one we are often feeding the thyroid and PCOS, which are kind of feeding each other. Is it through that enzyme?

Elizabeth Bartman, ND

It can be partially through that enzyme, It’s also, of course, so things are high. Progesterone is a big one for the thyroid as well. Progesterone supports thyroid conversion and thyroid balance. When women with PCOS, don’t ovulate regularly, tons of that means they don’t ever mature with any regularity or success. The progesterone overall tends to be pretty low. If you don’t have that progesterone, you don’t make thyroid. That’s a big one. That can just be a trigger for that thyroid relationship with PCOS. 

When we talk about the genomic factors with androgen dominance and PCOS risk factors, it’s the SRD5A1, which is the 5-alpha reductase. Is that one able to be upregulated just genomically? You can have polymorphisms that increase preference for that pathway, and that is often associated with PCOS; it’s driven by insulin. I think insulin is a factor in that pathway. 

Aumatma Simmons, ND, FABNE, MS

Okay. Yes.

Elizabeth Bartman, ND

But I think thyroid and, as you ask, progesterone go hand-in-hand, but I think it’s progesterone more so that it’s driving the thyroid issues. I do want to circle back to the 3A4 because, as the other features of estriol and 160H, these aren’t cortical estrogen, so they don’t methylate.  Methylation is beautiful, if not high. They’re kicking out all 2A4. If the 16OH and the estriol, they’re primarily bile conjugated and excreted out in the stool, which is pretty direct. It’s the sulfate and glucose that you want to make sure is intact. If you’re seeing those, build that. Again, anytime you’re working with metabolites of estrogen through phase one support by reducing things that could increase that transcriptional response, and a lot of that is decreasing alcohol decrease in environmental estrogenic exposure between and checking in on their meds because they could be on promoters. Not that we would want them off of those, but that could be pulling that 16 through and then making sure that they have good gut health and that they’re pooping every day. They’ve got to get that out, and they’re ensuring that their bile is conjugating healthily. Supporting bile, supporting stool, checking in on their gut health, and potentially making sure that they don’t have elevations in hyaluronidase or opportunistic bacteria that could be augmenting their estrogen clear. 

Aumatma Simmons, ND, FABNE, MS

Yes, that’s good. I wanted to loop back around CYP3A4. Also, as we see, pattern E3 is high, and 16OH is high, 40H is within range. Then 2OOH is maybe lower within range. Then we would still try to have more of that estrogen cleared out of the CYP2A1 pathway.

Elizabeth Bartman, ND

Without the idea of an adding or something to upregulate. Yes, exactly. That’s not my first approach. Always backward; work with the gut first. Because you’re pushing phase one, I think it can be a knee-jerk response to want to throw in when there’s estrogen dominance, which sometimes becomes a mess in the stomach. But I think there is that kneejerk response to say, Let’s just give them, and it’s wrong, but it can exacerbate estrogen symptoms somewhat for, I would say in my experience anyway, a lot of women suffer because if they can’t. If they’re not getting it out fully, then you’re just pushing it through this one phase and it’s stuck in a pool. It’s going to be a problem. It’s more avoidance of the things that could be pushing negatively through the other two. The 3O4 or the 1B1. That doesn’t change the fact that we’re hydroxy. We want to stay low. That one’s upregulated by poly-aromatic hydrocarbons. I will throw this out to you. This is smoked in charbroiled meat products, cigarette smoke, and even hydrocarbons in the environment. People who live in densely populated cities get a lot of that exposure.

Aumatma Simmons, ND, FABNE, MS

That’s also up-regulating CYP3. Can do both. Yes.

Elizabeth Bartman, ND

That’s right, we want to see this one. We want to remove as much as we can. If you’re living in a city that just cleans up the air, that’s in your immediate vicinity. But in that case,.

Aumatma Simmons, ND, FABNE, MS

Yes, with the air filter.

Elizabeth Bartman, ND

Yes. You want to take away the things that you can that would be maladaptive and increase the protective things. Fish oils are great for increasing 1A1 and hydroxylase production. Interestingly, rosemary is great for pushing 1A1 without augmenting estrogen and creating push into 2-hydroxy acids. It’s more supportive and nourishing. Way to go with that, 2-hydroxy way increases fiber, making sure that methylation looks good, that sulfation and liquidation, in addition, are working, and then ultimately making sure that they’re pooping every day. Okay, start there.

Aumatma Simmons, ND, FABNE, MS

Yes, that also.

Elizabeth Bartman, ND

But yes, I think. In a big lab. I would see sometimes providers who, because grapefruit is a big inhibitor of 3A4, this is why a lot of meds also say don’t take grapefruit because it inhibits metabolism of any kind. I’ve seen providers where, because they are getting too much 16, and we want to push it more too, we’re giving them a little bit of grapefruit every day. Again. I think we want to embrace that 3A4 is working well. We do want to suppress its response because it’s working overtime for a reason, and then we just complement and support the other downstream metabolites and pathways. Check the cells for oxidative stress using our nerves and promoters using free radicals, scavengers, and antioxidants. Then for the glutathione. Good. for all of us.

Aumatma Simmons, ND, FABNE, MS

Yes, lovely. We talked a little bit about estrogen and progesterone disharmony. We talked about these estrogen metabolism pathways. Are there? I’ll just ask you because I’ve got my theory. I don’t know if anyone has said yes to this, but I have found that a lot of women with endometriosis don’t have classical estrogen dominance like I was taught in school. But repeatedly, I’ve seen that the 4OH-E is the one that is off the charts; their other estrogens are usually low, and then they’re not metabolizing through the other. It’s just 4OH-E that’s elevated and it’s always a head-scratcher when I see it. Then, I’m sorry, but you need to go get worked up for Endo, and 95% of the time it’s spot on. I don’t know if there’s anything to the theory, but.

Elizabeth Bartman, ND

It’s an interesting association. I don’t know that it’s established as a culprit of endometriosis, but yes, I do have endometriosis, contrary to what I was taught. It’s not an estrogen-dominance condition. It is worsened by estrogen dominance, for sure. If you have high estrogen, you’re going to make the symptoms intense because you have endometrium tissue outside the uterus.  All of that tissue would get that response from estrogen. But so it’s going over a review article very recently because I’m so, so fascinated. We live in a toxic world. Estrogen stops so many hormonal concerns. One of them is exposure in utero is strongly correlated with the risk of endometriosis as an adult.

Aumatma Simmons, ND, FABNE, MS

Did I see somewhere that also phthalates specifically correlate with the endometrium?

Elizabeth Bartman, ND

Specifically, the phthalates are in the hormonal estrogen mimicker. Phthalates are everywhere. They’re in our perfume, our lotions. That’s true. Your hormones. I think it is undervalued, but it’s strongly correlated with endometriosis. Those exposures. I think then it’s the retro-verted endometrial tissue instead of being fully developed into a nice external flow, it’s the reverse flow, and that’s where that endometrial tissue ends up in that perineal cavity. 

I had this one case in school. She wasn’t my case. It was a case study of a gal who had endometrial tissue in her nose. Every time she menstruated, she would get a bloody nose. You get epistaxis; you can go anywhere, but it’s most commonly in the pelvic region. It’s going to wrap itself around the fallopian tubes and the ovaries, and it’s just external inside that uterine tissue. Any time you get an estrogenic response, it proliferates, causing problems and pain, and fertility becomes a concern. However because the phthalates can increase, they are also associated with higher four-hydroxy production. I could see that connection, and that’s interesting that you get a lot of I think. It makes a lot of sense. 

Aumatma Simmons, ND, FABNE, MS

That’s why I don’t. I just kept seeing it, and I was like, Wait, you have endo? Okay. Do you also have Endo? You too. I was, wait. All of them have had high 4OATs. I don’t know if there’s anything to that; I have yet to find a study on it. But definitely. It makes a direct association. I love it. You just made sense of this theory.

Elizabeth Bartman, ND

I’m not sure about the case study. Yes.

Aumatma Simmons, ND, FABNE, MS

Yes, I think that would be so valuable because, honestly, so many women come with endometriosis-type symptoms, but they’ve never been worked up for it. They just internally are; maybe I have endo, that fear thing. Laparoscopic surgery is not something you want to take lightly. They’re always like, I don’t know. What can you do? Can you figure it out? I’m going to do a DUTCH test, and then we’ll see. Yes, and this is my little hack to say, Yes more testing, or no you’re probably okay. Let’s work on other stuff, and then you can still save the testing for later. If you have symptoms.

Elizabeth Bartman, ND

But I will shout out because of the other thing that EndoAxis does. We are a tool to help evaluate complex hormonal patterns, starting with the DUTCH but expanding to zero and expanding to other tests as well to enhance that story. But the other big thing that we’re doing is customizing formulations based on these patterns so that providers don’t have to scrape, search, and pull in this product, and it’s the right dose, I mean, to get this product. But I don’t care for these other sites. I don’t care for all this stuff.

Aumatma Simmons, ND, FABNE, MS

Yes. I don’t want this other stuff in there. 

Elizabeth Bartman, ND

We give you what they need for that pattern or hydroxy in particular. One of my favorite blends we’re using in this beautiful NRF2-promoting blend of TruBroc, which is a Glucoraphenin with mustard seed, which is Myrosinase to help optimize cells for cutting from that oxidative stress of 4-hydroxy. Remember 4-hydroxy, the big issue is that when it doesn’t methylate, it goes down the quinone pathway to become a 34 estrone quinone, and those are what results in that DNA that over time can lead to oxidative stress, cellular change, and even cancer risk. 

That’s another interesting feature of endometriosis. There’s an increased risk of endometrial cancer, which again correlates with the 4-hydroxy. But with a sulforaphane stain, enhances phase two clearance, and supports the NRF2’s ability to regulate. Couples nerve from the key protein to help improve the production of glutathione and catalase and estrogen so that we have these potent free radical scavengers to suck up all of that quinone response and repair DNA, making sure that we’re structurally sound. 

We have blended it with TruBroc, Glucoraphenin, and Myrosinase, and then it has a little pomegranate, EGCG, green tea, and CoQ10, and it’s just beautiful. I love this combination. It’s great for endometriosis. It’s protecting the cells. It’s great for berberine, which is another one that can be promoted through elevated 16-hydroxy in particular.  

That formulation targeted that path. This is another fun feature because of that understanding of what enzymes are involved in metabolism. The blends target the enzyme, so whether we know if they have a polymorphism or not, if there’s a dysfunction in a pathway, we know that an enzyme needs help, and so we target that pathway without the nutrients necessarily for the hormone but for the enzyme. 

Aumatma Simmons, ND, FABNE, MS

Cool. I love it. Okay, so can we jump to cortisol? I feel that’s another big fertility-specific area. So I’m curious if you can just share patterns that are outside of the realm of what most practitioners are, which is, if it’s within the range that DUTCH test, it’s good, and you’re good. But the metabolizing of the cortisol, the metabolizing of cortisone, all that stuff is just so nuanced, I find.

Elizabeth Bartman, ND

Absolutely. Yet, we mustn’t miss. I turned away when, if I think back to school, the way I was taught to look at the adrenals was to run an ASI, an adrenal stress index, not the salivary test. It’s looking at those key points throughout the diurnal curve of free cortisol, and then we make assessments of that. I remember at school thinking, I’ve just crashed. I have all this super low cortisol, and then I run a DUTCH test, and I realize, I’ve just got a rapid metabolism. I shouldn’t be taking anything, and I’ll get to this. The free cortisol was so ingrained to just look at that free diurnal. That is important because it shows us at the moment what their output to our universal stress is to wake up in the morning, and then what the response to stress throughout the day, or are there stressors that are spiking them when they should be starting to decline or not? 

That’s not a diurnal rhythm in assessing those key points. That’s the free cortisol. It’s only 1 to 5% of cortisol at any given time. You’re looking at how those measurements. Metabolized cortisol. This is 90% of all the free cortisol that was made on the day of testing. We have to look at the two because it’s the relationship between those that have the biggest impact on health and where we want to treat it. If you see someone who has beautiful free cortisol, they have this great diurnal rise. They wake up in the morning, and they’re getting that nice spike in cortisol. It’s within rays coming down in the afternoon. It’s nice and dark at night. Yet their metabolites only emit black light. There’s a problem with clearance. There’s a problem with an intensely total production. Free cortisol, that graph is only 5%, at most of the free cortisol at any given time you’re seeing 90% is not looking good. What’s the discrepancy? More often than not, we see that pattern with hypothyroidism with low, specifically low cellular free T3. It goes beyond just looking at a TSH, T4, or T3, you want to look at the reverse T3 as well. How are they incorporating and utilizing that thyroid? They don’t need help because thyroid and adrenals are interconnected; we need to treat both. Now just ensure that we’re evaluating and addressing what’s going on. So often, I’ll see providers just look at the stress pattern and not at the metabolite. Just know they’ll base their treatments on that. 

Then, for example, if they have a high-stress pattern, they’re overshooting their morning cortisol, or they’re shooting up in the middle of the afternoon, but their metabolism is low, and you’re not addressing that, liver health, or adrenal support. Then just like that, the nutrients to rebuild, just adrenal function in general, just target phosphatidylserine, Magnolia, and Chamomile—the things I would call them. What can happen? On both sides. Drop on both ends because now you haven’t treated the root. You didn’t treat the fact that the metabolites were compromised; there was something that happened. That’s a big thing to remember. What we catch and what we’re looking at is that relationship. Again, conversely, you said flat line, not to say flat to you, low-free cortisol. I mean, how to address cortisol through the root; that person’s got a lot of exposure to cortisol. That’s a lot of inflammation in their bodies. Their liver is exposed to all of that cortisol, which can increase that.

Aumatma Simmons, ND, FABNE, MS

In the metabolized.

Elizabeth Bartman, ND

Yes. To be metabolized that was produced and circulating cortisol had to be processed to the liver. That’s a lot. Then if you were only looking at the free cortisol, but they’re so depleted, we’ve got to get that. Then you get more hydrocortisone. You’re putting kerosene on a burning fire. If you only want to treat the HPA response. We want to calm down the inflammation in the body. That’s very pro-inflammatory. That’s a high excess T3 pathway. To get it out of the body, check the thyroid in that case too for the opposite problem and then address it. Yes, these people are going to feel exhausted because they have no diurnal response, but they’re kicking out a lot of cortisol. They are exhausted but inflamed, anxious, and agitated. These are people who support that inflammation of blood sugar; get them on adaptogenic herbs that support that free rise a little more sufficiently, and they’re not hypertensive. Licorice is a great herb here because it slows the metabolism of cortisol while also augmenting immune function and reducing inflammation. 

Aumatma Simmons, ND, FABNE, MS

Is that so that over-metabolizing cortisol is a need that the body has because cortisol is anti-inflammatory? Is that too much inflammation? We need to have more cortisol to decrease inflammation, or is it the cortisol over-metabolizing that is causing more inflammation?

Elizabeth Bartman, ND

No, cortisol is produced because of inflammation. The signal from the body to the brain is some sort of inflammatory trigger, usually cytokine IL-6. A big reason why we might see this over-metabolized is excess adipose tissue or a more metabolically active fat tissue. Adipose tissue releases a low-grade level of IL-6. This is an inflammatory cytokine, and that’s going to be in circulation, affecting our blood vessels. It’s also going to be crossing into our brain, and at a rate, got some stress here, and the brain’s kicking out CRH. I’m not knocking on those adrenals, saying we’ve got to make some cortisol. Adipose tissue. It’s a unique endocrine gland. It kind of misbehaves sometimes, at no fault of its own. It’s protecting us. It’s trying to protect us. That’s evolutionarily doing the thing. But you want to sequester that cortisol for metabolic purposes, pull cortisol out of circulation, and over-metabolize it. It’s not that they aren’t making cortisol; it’s just that it’s getting metabolized too efficiently, too quickly. That’s there. It’s affecting the body. That means that there is inflammation present. The metabolized cortisol is high because there is a response somewhere in the body. It could be fat tissue, pain, chronic pain, joint pain, muscle pain, headaches, or other one is more environmental stressors. Even so, 60% of our immune system is regulated by our low-grade dysbiosis can be a factor that’s just driving up that inflammatory response in the body. Yes, I think of it as the fire hose being wide open. It’s like trying to just get it, get it naked, and get it out. Yes. Leading what we have at the moment for our receptors to be stimulated, okay, let’s stimulate. You’re lacking a nice?

Aumatma Simmons, ND, FABNE, MS

Yes. The fires are so intense compared, I need this so that I have energy that putting out the fires is more urgent than needed to function in my life.

Elizabeth Bartman, ND

It’s not keeping it around long enough for our brains to utilize it and get it. Cortisol is waking in response to get all the benefits from a hot rise. The nutrient upregulation of the acetylcholine dopamine response. That’s where we get a foggy brain and get achy, agitated, and tired. Then once they’ve awakened in response either, yes, they agree. That’s the ideal; it’s okay. They agree they’re making and utilizing cortisol efficiently. Clearing it. If you don’t get that rise in the morning. This is something that you can determine in the salivary cars, as would be the DUTCH Plus. You use the urine for metabolism. But you are looking at the in-the-moment production of cortisol using saliva, a much more sensitive marker for that. Watching what they call the cortisol waking in response before you even open your eyes you take this first salivary sample of you haven’t gotten out of bed you put this little swab in your mouth, and you’re collecting all that cortisol should be nice and low. Because you haven’t had a response yet. But then you open your eyes; you’re getting sunlight.

Aumatma Simmons, ND, FABNE, MS

Very importantly.

Elizabeth Bartman, ND

The activity of cortisol nourishing by 50 to 160% in those 30 minutes. We can see that within a few minutes. We can see that the rise starting. We want to capture that at the 30-minute mark, and then we want to capture the 60-minute mark to see if there’s a keep rising, does it come down, or does it come down too fast? Are they overutilizing or not sustaining their cortisol? But the important part is that 0 to 30, waking for 30 minutes. If you’re not getting a rise of 50 to 160%, that can lead to all sorts of dysregulation in your immune system, fertility, HPL response rate, and diurnal. All of our bodies are very diurnal, and they’re active. We’re not in a good rhythm, and that can be seen in cortisol in particular. We’re not going to have that same fertility response; that would be the way to describe that. But infertility and your risk outlook are.

Aumatma Simmons, ND, FABNE, MS

Yes, we spend so much time trying to optimize the diurnal response because that’s going to be the foundation for fertility hormone regulation. Everyone’s so focused on those. If we get the foundation, then we might have a great house to build.

Elizabeth Bartman, ND

Exactly. Yes, it’s working on the root of the deep foundational work, and then everything else just becomes easier. Everything else just happens. To wake up, you die. 

Aumatma Simmons, ND, FABNE, MS

Everything is so much better. 

Elizabeth Bartman, ND

Yes. I’m light in the morning now. The daughter is under pressure. Do some jumping jacks, but just get that body moving, and I think movement throughout the year is needed to keep that circadian regulation going. The other thing that’s interesting with the cortisol rise is sleep. I get patients all the time. Often, we get this done over time because people aren’t sleeping. But it’s almost a vicious cycle because if they’re not sleeping, or if you’re not going If they’re not sleeping, they’re not getting that nice response in the morning. They’re knocking that a sharp rise in cortisol and adenosine are complementary, in the brain. They buy the same receptors. Cortisol blocks adenosine from binding, making us tired, so we feel energized. Coffee does the same thing, which is why we get a little perk from it for blocking, adenosine is provided. But we should. As it goes down, we should be getting more and more adenosine binding. We should be feeling more and more groggy, seeing that a stimulus is being produced, or experiencing norepinephrine surges. The more active we get, which happens with cortisol. The more active we are, the more cortisol response we get, the better our adenosine production, and the better our  CAR response at night. I will have patients all the time who say, No, I need to work on sleep. I don’t know if you need that because that will help you sleep. I think that.

Aumatma Simmons, ND, FABNE, MS

Yes, that’s so good. That CAR is important, and it is very interesting. There’s some research saying that CAR is the biggest predictor of life span compared to everything else. Yes, it’s a pretty powerful necessity that our body has to help make that cortisol in the morning. Very important for all of you nonpractitioners who are trying to get pregnant after I go get some sunshine, do some jumping jacks, Dr. Liz said, get that and get if you’re dragging and you need coffee to wake up and you don’t function, your brain is still off before your coffee. Those are all the people that need that stimulation of cortisol awakening in the morning.

Elizabeth Bartman, ND

That programs the body for the rest of the day. You don’t get that awakening. You’re tired all day long. Absolutely. Yes. Go for a walk in the morning as part of your routine. 

Aumatma Simmons, ND, FABNE, MS

I love it. I love to drop my child off at the bus stop in the morning because it gets me out, and it’s 15 minutes in the sunshine, and he’s. Mom, can you be a car rider? Can you drop me off in the car? I’m, no, this is my time. The time I get sunshine and all that. Yes. It’s so good. Thank you so much for being with us. For practitioners who are listening, how can they get support with EndoAxis? Where do they go to get started?

Elizabeth Bartman, ND

On our website, it’s www.EndoAxis.com, where you can sign up to be a provider. We haven’t officially launched yet, but we are coming in March 2024.

Aumatma Simmons, ND, FABNE, MS

By the time this is launched, you guys will be out.

Elizabeth Bartman, ND

Yes, look for us, EndoAxis.com. It’s free to sign up, so there’s no commitment on your end. Play around with us. Upload some DUTCH reports. Read some reports, see what the input is, and see if you’re getting what we want this to be as a second opinion-type system. You just want to have it run by another medical professional. You get an automated version of that, and then you get access to our catalog of all of our amazing supplements, we had 26 launched along with the programs, lots of targeted, in my opinion, have beautiful, very targeted blends to address not just the hormones but also the enzymatic dysfunction that’s leading to these hormonal imbalances.

Aumatma Simmons, ND, FABNE, MS

I love it. For those of you listening in, I am sure you can already tell Dr. Liz’s brain is amazing. Just amazing. The value for those of you who don’t know, Dr. Liz is that a lot of brains behind EndoAxis. When you see that report, you can say, Whoa. This is the creator here, you guys. Dr. Guy is also brilliant and has contributed so much to this. The amazing minds behind this is what I’m getting at. 

Elizabeth Bartman, ND

Yes. It’s been a great, amazing experience, and an amazing team that I’ve been able to work with and collaborate with. Yes, we’re just here, and the beauty of this is that it’s just going to continue to advance and grow from here. We are not limited if you’re going through this is my other just have not public service and I’m not going per se but just buy a little plug, give us feedback, and give us insights. We want to know how to make this accessible and beneficial to all providers. Yes. Use us, check us out, and give us feedback. Just know that we’re going to continue to grow in advance.

Aumatma Simmons, ND, FABNE, MS

I love it. Thank you for joining me today, Dr. Liz. For those of you listening, you will see us again very soon. Take care and have a blessed day.