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Clinical Assessment of Hormone Testing: ZRT Saliva III
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Clinical Assessment of Hormone Testing: ZRT Saliva III

February 9, 2022
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Dr. Alison McAllister, ND
About this class

In this live class, Dr Alison McAllister will discuss ZRT’s Saliva Hormone Profile 3. Some learning points discussed include:

  • The validity of using saliva as a hormone testing medium for hormones and saliva
  • How this test can help you with screening and follow up for BHRT practices as well as for women with PCOS, fatigue, low testosterone, HPA axis dysfunction.
  • Be introduced to ZRT’s test report and interpretation
  • Understand common patterns seen with menopause, andropause and HPA Axis dysfunction
  • Discuss treatment options and understand benefits and limits of this mode of testing

ZRT has been testing hormones in multiple mediums (bloodspot, saliva, urine and serum) for over 20 years. This test is the backbone of hormone testing across the country and is our most popular test. If you test with nothing else but this test people have had amazing successes.

Alison McAllister, ND has been with ZRT Laboratory for over 15 years teaching doctors across the country lab interpretation and mentoring therapeutic interventions. She is a routine lecturer for A4M, PCCA as well as routinely doing webinars for ZRT Laboratory.

This free course is hosted by Rupa Healththe best way to order functional & integrative tests from 20+ specialty labs, reducing your time spent ordering labs by 90% and helping you provide a superior patient experience.

Transcription

Hello. Hi, McAllister. How are you? I'm doing okay. How are you? Am doing wonderful. You ready for this to get going here in about 13 minutes? 15 minutes probably, yes. Okay. Perfect.

So what we'll just have you do is just practice share your screen real quick. Yeah. The audio sounds really good. That's why I'm in my airplane gear. Oh, yeah. That's good. I've got mine right here.

Yeah.

I was just like I could do this at my home, but I think I'm going to go in and do it on the big computer. More official, right? Yeah. Hopefully if I look here, you see me like I'm looking at you, right? Yeah. Okay. Perfect. Okay. All right.

And it looks like we have three people. Hi, everybody. Who's on a little bit early. We're just going to be running through a couple of quick things before we get started here in probably about like 13 minutes or so.

If you just want to share your screen, share the slides, we can make sure that looks all good. And assuming that looks good, we'll just have you leave it on that intro slide. We can hop off and then we'll hop back in at 11:00 going.

I want to know what you're seeing right now. I see your slide, but can I also see the panel on the left hand side? Yes. So you're seeing that? Okay. Yeah. We were actually seeing this earlier during a presentation. So go to the bottom right of the screen. Yeah.

And then where it has like almost like a pop up to the left, next to the minus arrow. Okay. Are you looking on my street? Yeah, I'm looking at your screen right now. So you were almost in the right spot. So where has that plus minus bar to the left of the minus bar is that one that looks like a little pop up? Yeah. Click that and see if that does work. Yeah.

That's not my issue. Sure. I know what my issue is. So let's see it's sharing the wrong. So I'm in two monitors. Let's see if I can stop sharing here for a minute. Yeah.

Stop your share. Do what you got to do.

We got plenty of time. Okay. This is why we do this ahead of time. Exactly that. All right. And then let me share the screen.

Oh, yeah, that's perfect. Okay. Yeah, you're good? Okay. Awesome. So it was just because you were using dual monitor. I have two monitors. Yeah.

I selected the present, like where the presentation mostly is, but obviously it sees only that one page. So I'm just going to go to the next one, make sure the next slide. So now you can see my pace on there. Okay. Perfect. Yeah. So we can just leave this one up.

We'll hop back in in about ten minutes. We'll probably get started maybe like a minute or two after the hour just to get those individuals who have back meetings, things like that to hop in. But we'll get going here. I'll see you at 11:00. Sounds good. Thank you very much. No worries.

Talk soon.

Hello, everybody. Welcome in. We're going to get started in just a minute or so. Give those individuals you may be had a meeting right before this, the opportunity to hop right in, but we're super excited to get the class going today. And again, we'll get it going in just about a minute or so just to give those individuals who are running about a minute or two late that opting to hop in. So bear with us here and we'll get started in just a moment.

It's always interesting how silence makes those seconds go last so much longer. But with that, we'll go ahead and get it started. And for those of us who are hopping in along the way, no worries. We'll make sure that they're all caught up since the recording will be sent out following this within the next few days. But welcome, everybody, to today's Rupa University live class presented by Rupa Health, the simplest way to order specialty lab work. My name is Adrian Martinez and I'll be your host for this afternoon. Today we have a very special guest in Dr.

Allison McAllister, here to discuss the clinical assessment of hormone testing specifically in regards to the Zrt saliva three test. So before jumping in, a couple of quick housekeeping items, everyone joining will be muted by default. But don't fret. If you have any questions, feel free to use that Q amp a button down in the bottom right. And we'll host a live Q Amp a session at the end of the presentation with Dr. Mcallister immediately following the Q and a yours truly, we'll be doing a quick walkthrough of group of health, chatting about who we are, what we do, why we're so passionate about functional medicine, as well as showing you how you can order the test that's chatted about today during the session. And then finally, if you have to jump early, no worries.

We'll be sending out a recording of the session along with the slides within the next few days. So with that, let's go ahead and jump in. I'd like to introduce Dr. Mcallister for those of you who are unfamiliar with her. She is a naturopathic doctor who's been with GRT for over 15 years, teaching doctors across the country lab interpretation and mentoring therapeutic interventions. She's a routine lecturer for AFR PCCA, as well as routinely doing webinars for Zrt. So we're so lucky to have you with us today.

I'll go ahead and let you take it from here. But welcome in. Hey, and thank you very much for having me. It's always an honor to be asked to speak. So I'm really excited to talk about this today. And I was asked to talk about if CRT had one favorite panel, what would it be? And I decided there was really no better panel to talk about than our hormone profile three. And I also thought we could just take a second to introduce and talk a little bit about saliva testing because there's lots of people that have that question.

And obviously we could talk all day. I could talk all day. But we're going to have to sort of tailor it down. So if there's any questions, we'll get to them. And if there's any that come up after this or if you're listening to this in a recording, we're always happy to take them. So we're going to talk about our homeowner profile three today, the CRT's most favorite test. My name's Alison Mckellster.

I've been in practice for over 20 years, so I feel like I'm finally legit and teaching doctors for that whole time. So I've been interested in hormones. Interestingly. My background is integrative oncology. And then I got into hormones and have been doing that passionately for the last 20 years. So we are going to talk today about saliva testing, about who are your hormone patients, about the hormone profile three. I've got some cases I pulled so you can kind of see the report.

So the first time you order it isn't the first time you get to see the report. And then we're going to talk a little bit about treatment. This isn't an in depth treatment, but just sort of some of the bigger concepts of treatment. And then we can kind of look at that. And I also wanted to introduce you a little bit to Zrt. So Zrt has been in business for over 20 years. We may be coming up on 25.

There's always a little bit of an argument about when it technically started. This is David Zava. He's the owner and basically runs the company for CRT. So he's the owner and director of CRT. And we have over 80 employees. That is our building. And we're bursting at the seams.

And CRT is unique in that we test all body fluids. Many people think of GRT, however they get introduced to it. So they think of us as a saliva testing lab or a blood spot testing lab or neurotransmitter urine testing lab. But the fact of the matter is we test all testing mediums saliva blood spot, which is a finger stick, dried urine, so cards that you can pee on, and then CRM testing as well. So we're doing major NIH research, major University research all the time around the world, actually. And we're using all of these different methods all of the time. And so where that makes me unique is that we feel very passionately.

We don't have just a hammer to tell you. There is no one perfect test. There are questions that you have about your patients that need to be answered. And depending on your patient and depending on the hormones they're using, etc, one test may be more appropriate for them than others. So there are different tests and different questions, but we're going to talk about saliva today. So saliva testing methods basically boils down to two methods, the most standard method. And we're not going to go into huge detail about this, but it's basically an antibody testing or a Lysa testing.

It's this idea that you have these Wells that have antibodies on them and you're kind of attaching the hormone to that, and then that changes the color, and then you can find out how much samples in there. Grt is unique in that we run an extracted sample, so we clean it up, and then we go ahead and run that. That's especially important for estradiol. And we also do what's known as LCMS testing. So LCMS stands for liquid chromatography mass spectrometry. Get some points on that for Scrabble. But basically that is a very precise way of looking at hormone testing that is not dependent on creating antibodies, which is a big pro for that testing.

If you go to that address and you see a peak there, you know, it is that hormone. It can rarely get confused, but not nearly as much as antibodies, which sometimes we have to be a little careful about certain things, but it's much more expensive. So we do testing in both, and we run all of our lives of testing against LCMS testing and vice versa. So we're keeping them very much in sync. But we do actually offer both and can do certain things with LCMS that you can't do with L, Isa and back and forth. So let's talk about the pros of saliva testing. I must admit that saliva testing for hormones is my preferred way of testing hormones.

It's super easy to do. You can do diurnal rhythms throughout the day.

It's painless, so people don't mind doing it so much. Clinical revolution, I think, is huge for it, mostly because the ranges are so nice and tight. It was developed to pick up those low normals and those high normals. Most testing, like serum, for instance, has a very broad range because in the development of the lab assay, the whole goal was, do you have this hormone? Do you not have this hormone? Do you have a tumor? Are you in failure? So saliva testing was really more geared to pick up those nuances. And as a result, clinically, it's really helpful. It's very consistent. It shows supplemental hormones.

So if people are using topical or oral hormones, it's really nice to do and to see those levels and get consistent results and be able to monitor therapy. I just bumped it. And really it's relatively inexpensive to do. A profile like the one we're talking about in serum is oftentimes something like a $1500 test if patients don't have insurance. And you certainly don't want to be drawing blood four times throughout the day to try to see something like cortisol. So saliva testing has lots of pros with it. And many people wonder, well, how in the world does saliva even work for hormones? But the fact of the matter is the saliva gland itself is actually hugely vascularized.

It also has a lot of lymphatic tissue around it as well. And that's all draining and being actively transported through the cells of the saliva glands and into saliva. So this is a known recognized way that saliva gets in. It's not just passive diffusion. The cells are actually taking it up and processing it. So when we look at what kind of hormones do we have in there, the thought is really that saliva is really representing what's bioavailable, because in order to get into the saliva, you've had to recruit it from the bloodstream, from the lymphatics into those cells, and then those cells are excreting it. So that makes saliva sort of a really nice use for that.

Now there's cons, right? I think the biggest one and why we developed went from saliva to developing blood spot was actually if people have problems with saliva testing, if you've got showgrins, it's pretty mean to ask someone to do saliva testing. They can do it. They can collect 30 minutes the same time every day and collect it. And we've had people do that, but it's pretty hard on them. So saliva testing is you have to be able to produce saliva. So that's probably one of the biggest cons or challenges people have. We can also see sometimes that patients will use sublinguals or Trojans at various times over the last 20 years, those have become more popular, less popular.

But obviously, if you're sticking a hormone directly under your tongue and then you're turning around and spitting it because all those lymphatics are draining right there, that saliva level is just off the charts and not really consistent. So we don't want to use saliva in those situations. But one of the other big cons, I don't know if it's a Con is really that research is still way ahead of clinical practice. So if you're sharing patients with multiple different doctors, they may not be familiar with saliva. And there's lots of politics about why that is. Most universities, by the way, and hospitals do run saliva testing, but research is way ahead. There's 11,000 studies that were done with hormone tests in saliva recently.

So you go to PubMed and you put in hormone in saliva, you're going to get a pretty serious number of cases. But proportionally, it's smaller. So a lot of people are just not used to it. It may not be 100% covered by insurance. That's the reality of that. But we do have a variety of different coverages all across the United States, and then it's been some people just don't like that. But let's look at what it can do, because really, most people do it well.

Now, this is from an old database. This is the end of 170 people. Zrt has a database of over 2 million. At this point, and this is a nice study of what we can do when we pull the data to look at, say, challenging our ranges, which we do about every five years. And what we're going to find there is we can look and say, oh, my goodness, look at this, look at where we pull this data. Is saliva telling us the story we expect to see. So in the far right there you see the expected ranges and I apologize, that's a black box.

But what you can see is that people within that bright green is sort of where we expect the normal physiological range to be. And you can see that this is based on age. Women are within the pre menopausal range. And then, oh, how about this? At about age 45, you start seeing the big drop down that you expect to see, and then really by 55, you see this new post metapausal range. So when we ask the question, is it consistent? We want to be able to see all the ranges telling us what the literature, what we know physiologically supposed to happen. And so this is kind of a fun example of how you can actually see it doing its job. This is another fun graph that I just sort of pulled out.

This is just under 20,000 people samples looking at DHA and cortisol. And this is really what the studies have shown with DHA and Cortisol over time is that DHA really starts to drop. It peaks when you're sort of in your 20s and then it's downhill from there. And that cortisol eventually does go up. So it doesn't go up until you're in, like your 70s and above roughly, but you can start to see that gradient. And so you can see how physiologically testing has to be able to be backed up by what the research and the physiology is. Sown, so that's kind of a fun way that we can use our data in the research world to look and see.

Are we doing a good job? Is the data showing where it should be? Are the ranges where we should be, et cetera? Now, the other question I often get is things like, well, saliva and you're using hormones and where does it come from? We're not going to go into hugely into that detail because I want to be able to talk more about cases, but certainly hormone usage with saliva testing has been used, not as many as I would like and not on as many hormone trials as I would like. So if you've got a million dollars and you want to do a study, give us a call. But you basically can look at saliva and progesterone versus saliva and serum. There's been studies with saliva, serum and urine looking at progesterone studies in particular. And where does these hormones go? Saliva is very reactive to topical delivery of hormones, which is a plus, but it means you have to adjust levels and you have to make sure that people are testing at the right time so that you can see consistency in how their lab levels are doing. So this is just an example of saliva and serum. And you can see this is someone where it was a hormone naive patient, and they went ahead and used hormones and then looked to see where did it show up? And essentially, there was very minimal bump in serum and there was a very big bump in saliva.

So this goes back to what's your question that you want to ask for your patients? And are you testing in the right medium to be able to ask that? I'm going to add another part of that, which is are you testing in a way to actually adequately measure how you're supplementing? So that also goes into this discussion as well. And so these have looked at whether you apply hormones topically, and you're looking at them, are they in the saliva? Are they in urine? What parts in serum? What parts in other tissues? So this has been looked at. These are lots of examples, although I must say that the latest study research has actually kind of moved on to the ins and outs of testing. They're just using it. So in the research world, most of the studies are going to be like cortisol levels in elementary school children, well after their mothers were pregnant in a refugee camp, things like that. Those are kind of standard ones or high testosterone levels in men who make risky decisions on the stock market, for instance. That's the kind of studies that you'll see now.

So we want to know our target. We want to know what our question is. But first we need to know who are we talking about? So in this whole cycle of hormone testing, the number one thing is choose our patient, recognize our patient before we even start talking about what testing it is. And all patients will come in and say, I want to do hormones testing. I want to test that. But I think a practice is slower to grow if you depend on your patient coming in with magic words. And if you start identifying, oh, my goodness, these symptoms or symptoms where hormone testing is going to give me some ideas of where to go with my treatments, they're going to give me answer some questions that this patient has.

They're going to allow the patient to see why their symptoms are happening. You will find hormone patients everywhere. And this profile that I chose is one that there are certain practices that they do this test every single day on every new patient, and they've been doing it for 20 years with really good success. So that's why it was my favorite one to choose. First, we're going to recognize our clients. We've got them everywhere. Right.

When I first started at Zrt, the only women who tested their hormones were menopausal. Women.

Now we test everyone from the age of, like, we've got three year olds, four year olds on up in testing different hormones. Not usually hormones, thankfully, but you can start seeing like, women got better. They brought their perimenopausal daughters and they brought in their reproductive age young girls who had endometriosis or irregular period. So, you know, there's so many symptoms. Menopause continues to be a huge driver. They are a huge driver in the health care force. They take up a huge, oh, I shouldn't say take up.

That's the wrong language. But they make up a large proportion of patients that you'll see in your office for lots of different things. And so the most common ones are obviously visomotor symptoms, headaches, sleep, memory. I want to put anxiety a little bit on there, libido as well, but there's a myriad of different symptoms that we can see with menopause. I think the buzzing nerves or zapping ones is one that people might not know. Also burning tongue, that's another hormonal symptom. So there are lots of hormonal symptoms.

And everyone has their own voice that's coming along with us as to what theirs looks like. But thankfully, women have also, in the growth of hormones over the last 20 years, brought in their husbands and their sons and said he's got some challenges, too, whether that's erectile dysfunction or anxiety.

And so I'd say most men will come in with depression, libido issues. But anxiety has been a big one for me in identifying patients with low testosterone. So look for that symptom. That's not one that's really reported, but I have to say all my younger patients who are under 50 who had low testosterone, all reported pretty severe anxiety. And we could argue cause or result of low testosterone. And I think that's a very important discussion to have. But it's definitely one that you can see.

Right? So if we start identifying these patients, we realize they're everywhere. There are biographical hormone replacement patients, but they're also Adrenal cases. And who doesn't have Adrenal issues? Right now, everyone who's got thyroid problems has hormone problems. Neurotransmitters. Guess what? Estrogen is a really great neurotransmitter, and it upregulates serotonin in five different ways and how you metabolize these hormones. So we start looking at these. We've got hormone patients just all over the place.

That's not going to be our issue. So this is what the combination this is a combination kit, but I wanted to be able to show kind of what it looks like. So you've got these tubes, you get a big tube in the morning. So those collect all your hormones, test your morning cortisol, and then the rest of the tubes throughout the day is actually looking at your cortisol throughout the day. So we don't pool samples. Some labs will do that. They'll have you collect very small levels throughout the day and then just pull them.

But things like testosterone have a diurnal rhythm, and there's been some research that if you don't get to the peak testosterone level right off the bat, that you might not get the big benefit. So that's kind of what that looks like. And on our website, we have sort of videos on how to collect it. I don't know if Rupa does, but they can link to them and then hits come right back in, just sort of behind the scenes. We open them up one at a time and bar code them immediately, and then they go back into the lab and then the results go back to river. So this is what the test report looks like. It's pretty stackable.

And so just so we go through it, you get your patients, you've got all the hormones on the side, you've got ranges on the right. You've got the patient's results.

We're going to give you different ranges based on their menopausal status or what hormones they report they're using at the time of testing. And must be said that there's no hormone usage or symptoms that are going to change the labs. Right. The samples are what they are, but it does allow us to change ranges for you to set the commentary, etc. E. So we're going to go ahead and graph what we can. We're going to graph cortisols and testosterone.

We're going to graph testosterone and DHA by age because they decrease and change over age for men especially give you all the ranges, just in case your patients forgot to give us that, we're going to give you a list of the symptoms that the patient told us the time of testing that they had, which Interestingly, sometimes patients tell us everything and you nothing, and sometimes it's the other way around. We try to group those symptoms into different grouping. And that's what you see at the very top, which is their symptom category score. And that's just another way of looking at their symptoms may or may not correlate with their lab results itself. And then we do individualized comments. So we're going to pull their results. We're going to pull their symptoms, we're going to pull their hormone usage.

And we're going to kind of synthesize that into a report that's made specially for them, which is fine. We're going to also give you history reports, as the patient has done those over time, so that you can see like, are we making progress or are things still kind of where they want? So let's look at some examples. So this is a 50 year old woman. This is like the really typical coming in postmenopausal woman that you're going to see tomorrow. She's average height, average weight. She's in post menopausal. She hasn't had her period for a couple of years and she just doesn't feel great.

So you can see here, you can see her estradiol where it is. I do like to use these sliders, but I like to look and see where the ranges are as well. And you're going to see right here that there's an optimal range of the 1.3 to 1.7. That optimal range is sort of a high postmenopausal level, low premenopausal level. So the goal is not to necessarily put someone into a super physiological dosing schedule, but really to kind of get them into just a slightly higher level. So her extra dial is kind of just hanging in there, barely progesterone is just barely hanging in there. Testosterone the same.

And within that range of testosterone, I usually like to see it in the 30s or 40s. That's kind of ideal. Dha is just barely hanging in there, too. I like it between five to ten, maybe five to eight. It's pretty typical for 50 year old. And then we can see the cortisols. And I went ahead and pulled up the graph so that you can see the cortisol in this one, because in this patient, we could talk all day for her.

We could have quite the nice chat about like, what would you do? And I think hormone wise, it would not be crazy to see this patient and say, I'm going to put her on estrogen and progesterone and a little testosterone and maybe a tiny bit of DHEA and adrenal support. I can't look at this lab and think that's a bad idea. That would be very reasonable. You could also look at this patient and say, you know what? She doesn't want to do any of these hormones. She's pretty okay hormone wise. But we want to address some of the cortisols. And I wanted to pull out the cortisol in particular because this is a fairly common profile that you'll see for people.

And I must say that almost more than any of the hormonal imbalances, cortisol imbalances are probably the most number one hormone imbalance, you'll see.

And I could have said that three years ago. So it's really common. But yeah, we could treat this woman in a variety of things. My biggest worry, the only hormone this woman really has is cortisol. So of course, I'm really worried about her bone health, which is really a concern when the only hormone you have is cortisol and you really don't have very much androgens you don't have any estrogens and you have really nothing to sort of keep those bones around and healthy. So the thing I like to pull out with the cortisol here is that she has a pretty nice rhythm from the morning throughout the day. But if you look at her evening level, she's really dropping.

Now, salivary cortisol is going to tell you what's happening right then and there. So one nice thing with saliva is you can go ahead and you can test them in saliva. You can have them do something like the latest word old puzzle or some math questions or swim or exercise. And then you could test them again. And because cortisol is testing or changing in the saliva about every ten minutes or so, you could get these snapshots in time, which really allows you to see how cortisol is shifting. That's the beauty of it. It's not looking at hours and hours averaged together.

It's looking at today, right now, right here. How do you feel? So you can see her cortisol is kind of bottoming out in the evening. She's kind of done, and then she has a little bit of a bump up, and some patients will report that bump up, even though it's totally within normal range. Very happy to see it. 0.50 .6 is totally fine for a nighttime cortisol. This is someone who certainly could be struggling with a lot of low exhaustion in the evening time because of that cortisol bottoming out and because that was collected in the evening. And we do report times for you, but because that was reported evening, who knows when she really started dropping, she could have dropped mid afternoon.

So we don't care. As a laboratory, when you do have your patients do their cortisol, they can do them at any time. But ideally, we sort of suggest that they do before they eat breakfast first thing when they wake up within the first few minutes of waking up at around lunchtime in the evening time and at night time before bed. And then that way you get kind of the spread all over. If you have patients who have, you know, really weird symptoms that say 02:00 in the afternoon and you want to do the cortisol, that's fine. As you can see, we actually graph it by the time they actually did it. So the graph is not going to be we're going to move those dots closer together, for their part, just based on when they did it.

So here's another very typical report that you'll see. This is someone using hormone replacement, which is what I thought I'd like to pull out for you so you can see her extra dial. We shifted our ranges now because she was using them. We now have a good extra dial level. You can see it's right within the optimal range. And then progesterone. She was using a topical progesterone at this time.

Testosterone, however, is still really low. Dhea is even worse. This is another 51 year old woman, and then cortisol looks okay in the morning, looks good throughout the day, and then actually starts getting a little high normal at night. You'll see that a lot. These high normal cortisols, they really can get people problems sleeping. But I think the story for this patient is look at their DHEA and look at their testosterone. Now, when it comes to treating these patients, I find that if you don't address the DHEA as well as any testosterone, let's say the person is like, I really want to do testosterone, that's fine.

But make it like the icing on the cake. You can do tiny doses of testosterone, but if you have good support of DHEA, that person is going to get much better symptom control, so they're going to be a much happier camper if DHCA is a big part of their picture. All right, here's another one. I mean, look at this poor patient. She's coming in pre menopausal now, low estrogen, low progesterone, low testosterone. So this one I don't know why I think it cut it off. I think I may have it in the other one, but one of the questions I always have with the pre menopausal woman is, is she on the pill? So the pill will naturally suppress your ovaries and basically take out all your endogenous hormones, which is what CRT is testing.

This asset is not going to see the ethanol estradiol or the progestins that this patient may be using, so it's going to suppress it. Do we want to put a 30 year old woman with low hormones who may be having a regular period on hormone replacement? I think that's a really interesting kind of philosophical and kind of like hormone doctor question. The fact of the matter is that I don't think we really should be at first. Now, if a premature ovarian failure, that's another whole beast, right? They've got to have a high LH, high FSH. Their bodies basically quit on them. That's an autoimmune process that may be a vascular problem. But regardless, those people need to be on hormones.

But if you just do a snapshot in time and you see these low levels, should we just jump on it and do it? My thing is maybe short term, but the fact is that a 20 or 30 year old with low hormones really should be making their own hormones. And if we can't see that with LH in fish showing that there's a brain problem connecting those ovaries, then I'd say we need to dig a little deeper, maybe be a little persistent. These are patients that can do really well with seed cycling or Vitax herbal therapies as well as maybe doing some hormones to kind of mitigate things or to try to kind of kickstart that cycle. But I think we always have to ask the question, why are we seeing these patterns? So anyways, at this point, we have really low estrogen and progesterone testosterone as well. But for a young person, look at their DHA and then look at their cortisol. So DHA, ideally five to eight really is rarely over ten after the age of 25. And look at how high the evening and night time cortisol is.

This is a very typical pattern of someone with high stress. And truthfully, when I see DHA this low, I often think to myself, well, it doesn't matter how good the cortisols look. If your DHA is that bad, I'm going to really think that there probably is even more adrenal issues than we even know. And I think this is someone where whether we call it the cortisol steel or whatever, I mean, really the only hormone they're really making is cortisol. So we're going to see potentially all sorts of other symptoms that are going to go along with this because everything is being prioritized to cortisol, which is the most important hormone, tier one hormone. You don't have cortisol, you're not doing very well. Right.

Edison's patients get into Addisonian crisis and they don't do well. So we want to sort of look and see if we can kind of bring this back to balance and then support this patient. So here's another example. This is another 54 year old woman. These are common ages that we'll see people hot flushes and vaginal, dryness and foggy thinking and fatigue. Well, if we look at these right, estrogen is less than detectable. So it's zero progesterone, barely hanging in there, but it's barely hanging there.

For a postmenopausal woman, we have no testosterone. Dha is one four with a gimmer. Ideally, we want that five to eight. So she's dragging. And then cortisol is also just done. You can't even make cortisol. So this is someone where we have tons of symptoms of hormone imbalances and tons of Adrenal issues.

And I think the other question is like, well, what do I do first? Do I do all of this first? The answer is, you can. Okay. I think there's sometimes I hear myths or people maybe misunderstanding. People say, oh, well, you have to fix the Adrenals first. The Adrenals are a project. My friends, they take a long time to fix. I tell all my Adrenal patients, I said, look, I am so hoping that you're going to feel better really quickly.

But this is a process that at least for every year that you've been going through these Adrenal issues to get here, we've got to give you at least a month, which for many patients says, you've got to give me a year. Now, that doesn't mean they're not going to feel better. I think it's important that we expect our patients to have some changes and something different within the first month. And that's just because if you start waking three or four months before you start feeling better, one compliance or patient's ability to stay up and continue doing things when it's not really changing may not be appropriate. But the other thing is that statistically we get placebo effects as it takes up to three months for, say, hot flushes nights. But it really should change a lot faster. So what could we do? Well, as far as saliva testing goes, when we look at this profile, we don't care.

Right. As a laboratory, we have no invested interest in any supplement company. We don't make any hormones. We are not invested in any hormone company left. So we're going to just go ahead and say, how do you want to dose it? What do you have on your shelves? What's your goal for this patient? If this is someone where you're like, oh, my gosh. They really need to get better. They're 54, they are a physician.

They're running three different jobs. They are looking after their 90 year old mother and they have a twelve year old at home. All of this factors in to what you do with these patients. And then we can talk about manufactured products, we can talk about bioidentical compounding, we can talk about herbal therapies. There's lots of different ways that we can sort of approach it. Now, I find just as a segue that a lot of times these patients who have nothing don't respond as well to the herbs as I want them to. They definitely do for adrenal support.

They do pretty well for that. So my role is thumb when I advise using things like hydrocortisone, I usually like to see three really low cortisols and a lot of symptoms. But in terms of like estrogen and progesterone, you know, we could do patches, you could do sublinguals, although you can't follow up with saliva testing. So sometimes it's nice if you're going to follow up with saliva testing to do something that you can easily measure, which is basically everything else other than sublinguals. But we can do injectables, you could do patches, you could do creams. There's really no wrong way to do hormones. So all of those are sort of an option.

And this is an interesting one. And why I pulled it was because she's tested for many years. So she's got two years. You can see a cascade of her symptoms. This isn't new for her, although if you look at the far right, the very far right column that you see under the 320 was actually she was still perimenopausal at that point. So she has had basically increasingly poor hormones, sex hormones as she's fully gone into menopause. And then her cortisol is just really tanked.

So I don't know what happened. Well, there's lots of things that could have happened between February of last year and January of this year, but we can really see it in the cortisol picture for her. And then when we look at her symptoms, what I thought was really interesting is she is actually getting better, even though her lab results are not looking as great. But the things that are really improving for her, Interestingly enough are her cortisols. I have a feeling there's more to this story, but I mostly just wanted to pull it so that we could see that we are going to report this. So very quickly you can look at this and be like, oh, okay, she's reporting that things are actually getting better. I find that very hard to believe with this patient.

So I have a feeling there's more to this story. So here's another case of another really typical 59 year old woman using estrogen. She's using progesterone as well. I pulled some topical progesterone levels. No reason, just did. But people do oral progesterone. It's totally fine to test in saliva that's oral, but they swallow the capsule totally fine.

And they do not stop their hormones, by the way, to do testing. So we want everyone to test using their hormones twelve to 24 hours beforehand. And you can see her testosterone DHA much, much better than some of the previous ones that we've seen. But we're seeing sort of a flattening of her cortisol curve. So that morning level is only at a four kind of at that lower end and then sort of going high normal at night. So this pattern is one you often see in this cortisol pattern, often see with someone who's really having problems going to sleep because of a high night cortisol, having poor quality sleep during that time, and then also not necessarily sleeping late enough. So early morning awakenings.

You'll see that a lot of times when people have low cortisols in the morning and when I sort of tell my patients when I'm giving them analogy of what's happening, it's sort of like there's this magic number of cortisol that your body has decided it needs to wake up or alarm you. And when your cortisol in the morning is lower, that means it doesn't have to rise very much from the nighttime level to that level in order to activate that sort of alarm switch. So you often get sort of early morning awakening with these lower cortisols. And the goal in treatment for a lot of these patients is to really push that cortisol up high in the morning and then even drop it down at night. Now sometimes with those high night cortisols, I tend to do more adaptogens at that night time with the idea that I don't necessarily want to suppress it too much because if we look at this as if it was one day followed by the next, this high normal cortisol is going to be followed by a low normal morning. So if we drop that night time too much, could we, in fact, give them more problems in the morning or during the night when eventually their cortisol sort of drops down? And I think the answer is yes. So I tend to go more Adaptogenics at night time.

That might be something as simple as just ashwagandha. And then I might very well do more stimulating herbal therapies combinations, maybe something with rodiola or ginseng or even licorice in the morning to try to push that cortisol up. But in terms of the estrogen and progesterone balance, this person's looking really great in the ratio that gives us an idea of the estrogen and progesterone balance. And the ratio is there as a tool that you can use to see whether you need to increase estrogen or decrease progesterone or increase progesterone, whatever, whichever way it directs. The most common is to see it below, which is progesterone deficiency relative to estrogen. And you can kind of help guide that and make those decisions to sort of push that up so this is another one where you can see a history report. I just thought it was kind of fun to sort of show that over time and you can see that her testosterone has been kind of slowly decreasing.

Things have been popping up and down for her, but her cortisol made a really big shift. But I wanted you to see if you look at the yesterday, how consistent her levels are. The only reason they're a little different for her is she's changing sometimes, like in her progesterone. She stopped it for a couple of days where she hadn't done that the previous one. So that's why you're seeing it drop by half. But in general, one of the questions I get a lot, it's like, oh, saliva isn't consistent when in fact, actually it's extremely consistent. But you have to keep the variables consistent.

So you have to be consistent about when you do your hormones and when you do the testing. And then they can be really consistent in monitoring over time. So once again, you can kind of see what things are improving and what things are not just as a quick snapshot in time. So treatment wise, we're not going to go into this because we're going to kind of have to wrap up a little bit. But I think the biggest question is like, how do I fix this? And I think that's an important question that sometimes you want to ask even before you choose your test, because, say, if you wanted to really do sublinguals and you knew that is the way I wanted to do it, maybe saliva testing isn't the best option. Maybe you better do like a blood spot in that situation because, you know, in follow up tests, you're going to be monitoring your blood spots so you can compare apples and apples. So that's definitely an issue.

Here at the lab. We talk a lot about bioidentical hormone replacement. These are hormones identical to what your body makes. They're used in the same way in the tissues. They're detoxed the same way in the tissues, but they may be manufactured or they may be compounded. Both are really good options for people. And as far as use of hormone replacement therapy, I just wanted to pull up a couple of interesting articles because new articles are really coming out all the time about hormone replacement and the usage of them.

And really NAMS, which is the North American Menopause Society, really came out with guidelines that basically said, hey, if you're younger than 60s and you have had hormones in your body within ten years, you probably have benefit in using hormone replacement. If it's greater than that and you have symptoms or you haven't been away from hormones, then perhaps you shouldn't do it. But basically, these windows of safety in that first ten years after menopause or within ten years of stopping hormones and wanting to restart them again, there's more and more positive articles coming out about the use of bioidentical hormones. And in fact, in my 20 years here at CRT, I've watched the women's health initiative trial came in and women were on Premarin, and then they came off of permirin. And at the same time, we've seen a huge surge in bioidentical hormone replacement therapy. In fact, most manufactured product at this point are also bioidentical hormone replacement, with the exception of progestins and the fact that there still is no pharmaceutical testosterone manufactured for women. So you have to compound to get those dosages that you want.

But basically, there's more and more research showing that there are benefits in cardiovascular research. So more discussion now is happening about, like, how long should people be on and what's the safety profile for that? And even that North America menopause society is sort of backgrowing and saying maybe if you've been on it for this whole time and you're doing great, we should just stay on it, which is, of course, what you'll hear from lots of lectures. There are groups that, however you may run into in your practice. You want to do hormones. And I want you to just have a heads up that there are risks in starting hormone therapy if someone has been many years away from hormones. So they've been ten or more years away from hormones or they have cardiovascular risk. So anyone with diabetes has cardiovascular risk.

If you've had a stroke or heart attack, it's been more than ten years. So like the seven year old diabetic woman who comes into your practice and says, I've got osteoporosis, is hormones the best thing? It's a risk, there are risks, there's benefits. But basically the thought is as to why there's a risk is that estrogen is a great endothelial antivascular molecule. And so there seems to be thought that estrogen can destabilize atherosclerotic plaques and potentially this atherosclerosis that has built up when you've been away from hormones would then become unstabilized. That's one theory as to why you could see increase in strokes and heart attacks. If someone's been away from hormones, may there still be a benefit? Yes. I mean, every day I talk to providers who say, you know what, there's this risk of storing a heart attack, but they don't have a history of huge amounts of asteroids.

We've really looked at that. Their lipids are really good. And they, on the other hand, have a very real risk of osteoporosis, which is really bad right now. So it's always a game of risk benefit. So you're going to choose your patient, you're going to talk about hormones. You're going to do your baseline, start with the therapy follow up. You can just follow up as soon as a month.

You've got to allow that system to kind of come into balance again so you can retest again in about a month. Some people will do it anywhere between one month and three months. And then the follow up testing. I usually tell people if you get it right the first time, that's great. But oftentimes it does take one more time, sometimes two more times, but usually one more time to sort of prove that what you've chosen to do is the right dosage and the right plan and that they're going to be good. And then you might just do it once a year after that or anytime symptoms change.

So this is some of our most popular panels. A lot of times people start with the profile three, right, because they want all those cortisols, but when they retest the hormones and follow up, they might not want all those cortisols yet. Cortisol is a project, right. You might not be ready to test that after a month, but you might be ready to see if the testosterone dosage is good. So you can usually step down to home on Profile one, but similar tests that I wanted to fly these combination profiles. And I'll let Adrian talk about these. But that's the one where we bring in testosterone and that looks like this.

So this is adding our blood spot to it where we've got that full testosterone or thyroid panel on top of that hormone profile three that we did. This is probably our second most popular panel to look at those thyroids. So we're looking at those antibodies. We just introduced what we call the Wellness Matrix. So the Wellness Matrix is looking at that same profile we talked about, but also like TSH and insulin and hemoglobin, a one, C vitamin D. It's actually a great one, too, for looking at a lot of sort of recently perimenopausal postmenopausal women who kind of want a glimpse as to what's happening with all of their systems, cardiometabolic and thyroid. So those are really great.

But I also wanted to just bring it up because it shows like Zrt is actually doing tons of testing. Of all the tests we do, we actually test the smallest number of analytes in saliva, but it is still our mainstay it's still what we're really passionate about, and we do a ton of it. So Drat. Difference, I think some of the biggest things is that your patients tests are going through the same essays and the same links as every one of our research studies are going through. We are constantly looking at that from a scientific point of view of testing our ranges and testing our controls, running multiple controls, and you have clinical support. So determine your questions and find out what you want to test and then never hesitate to reach out before testing. Either Rupa or Zrt are happy to help you with that.

There's no right way. There's no best lab or best test. It really comes down to what's the question you want to have answered and what are you going to do with that information? And then where do we go from there? And I wanted to thank you. So CRT has consultants as testing through Rupa. You are welcome to call us and we are happy to go through reports with you and answer questions and help you on your way. And you never should hesitate to do that. So I'm going to wrap up here and thank you very much.

And I'll let Adrian take over here because I know he wanted to be able to talk about it as well. Yeah, no worries. Thank you so much, Doctor Allison. That was amazing. We had so many questions coming into the chat. So I think that speaks to just how important this topic is. Right.

So without wasting any more time, let's just hop in. So just so the attendees are aware, I'm just going to go through the questions that were asked chronologically. Right. So the very first question that was asked by Doctor Bruce is does the RT service New York State? They do, yeah, we do. We can't do all of the testing in New York. New York. You have to jump through a lot of Hoops.

But we do have testing in New York State. Yes. Okay. Beautiful. So that actually brings up a very important point that I'll get to you in a moment. You can order directly these tests through CRT in New York State, but you actually can't order them through Rupa in New York State. So huge call out there.

Second question.

It shows only bioidentical or all types of supplemental hormones in regards to this test. Yes. These are antibody tests. So they're looking for estradiol, they're looking for progesterone, they're looking for testosterone. So if you are using, say, Provera or SNL estradiol, those are structurally not estradiol or progesterone. So they will not show up on this testing. Now, we do have LCMS testing.

In our LCMS testing, we can test for SNL estradiol. If you wanted to do that, you certainly could. But yeah, you have to look at bioidenticals because that's what it's structurally looking for. Beautiful. So the next question would be, does your saliva testing measure oxytocin? It does not. I'm not aware of any lab that's testing it at this time commercially. Sorry.

Got you. Yeah, no worries there. Next question. So this was asked during the slide regarding saliva and serum progesterone following Precutaneous application of progesterone. What about dry urine testing? So dry urine testing, that's another whole topic. You have to bring me back for that one.

Crt developed urine testing. We do it topicals. They tend to be really underrepresented in urine. So, for instance, I once saw someone using five milligrams of topical estradiol, which is a massive dosage, and their urine levels were low. So we could talk a lot more about why that is or what it is. But urine doesn't. It's not as linear prediction as to whether you see increasing dosage and increasing levels.

So I really love urine for looking at how someone metabolizes the hormones. Right. Because you're peeing them out. That's what your body is doing. And I think the patterns of how you pee it out is really the best test for your intestine. Yeah. So next question would be why don't you pull the estrogens and progesterone following up on that? I understand why you would testosterone only in the morning, but can't eat two and P fluctuate throughout the day.

They can fluctuate a little bit throughout the day, but once again, they should be really peaked in the morning time. That's when every bit of research suggests that they're peaked at. And obviously we could go chasing or we could pool it, but we really haven't found it. We found such good clinical correlation with doing the morning levels. It's cleaner, it's more consistent that way for patients. Right. You're trying to compare Apple storages and frankly, people want to put on their hormones, so they do their hormones the day before the test.

They wake up in the morning and they do that big tube, collect their sample five minutes later, they're putting their hormones on for the rest of the day. It's not going to interfere with the cortisol testing the rest of the day. So it makes it really nice, easy and straightforward for them from a practical standpoint as well. Yeah, that makes sense.

How was the optimal PG E two ratio determined? We actually have a little bit of a blog on that. And that actually came in a long time before I was even part of the laboratory and was actually part of Doctor Zava and Jonathan Lee, John Lee work together that came up with the ratio. John Lee, what your doctor didn't tell you about menopause? He was a huge proponent in the estrogen progesterone ratio. So it's been a useful tool for us, mostly with topical progesterone, with oral it's not as useful, but it is just a straight calculation and division problem. Sure. Yeah, it's a great tool. Got you.

Are the ranges defined in the report specific to the test or clinical range, irrespective of type of testing? Yeah, I'm not too sure I understand. So the ranges are going to be set based on information that the patient tells us. So we set them on menopausal status. We set them it means like for a pre menopausal woman, when did they collect it? Did they check in alleviaphase or Follicular phase? We're going to set it for how they're using their hormones. If they're estrogen receptor or you're using estrogen replacement therapy or using oral progesterone or topical progesterone. And that's how the ranges are going to be set. So it's dependent on the patient telling us that information.

If they tell us nothing, which many times they don't, then we're going to be able to only set it based on their age and then a puzzle status. It is, however, an easy fix for us because if someone does anything wrong, we know that samples immediately barcoded. So we know that paperwork and we know that sample came in together. And if you call up and say it says that it's Mildred sample, but really, she had her brother Bob do it, we can change everything about it, but we still know that that sample and that paperwork came in together. So the lab results are the lab results? Yes, of course. So the next question. Thanks for answering that one.

If cortisol is tanked and melatonin is low and trending towards estrogen dominance, are you suggesting HRT? And are there any natural ways to increase low hormones? Yes. So if you have the hormone replacement as cortisol, a lot of times, yes. Frankly, that's why a lot of times you're testing them, they've got all your symptoms, you may be tried melatonin, you've got adrenal support on board. Hormones are maybe the next big thing to do. It what increases it naturally. I think they're really hard sometimes to increase it. I don't think this used to be as big a problem as it is.

I think what women today do go through harder menopauses that historically they did. And I think that's a lot of times because our adrenal situation is so much harder now that women get to menopause and they're like, I can barely make cortisol. And now you want me to take over all these other hormones, which is what happens. I think the adrenal glands are like, whatever, you're good, you got to do what you can do. So I think we really are seeing, because of the stress of patients lives, that by the time they get to the point where the adrenals are supposed to be really kicking in and helping out more, they really just can't. So I've seen herbs. Herbs could definitely make a huge difference in supporting symptoms.

I just haven't always seen them make a huge difference of improving lab values. So those are kind of two different things. And really that may be fine, right. Like low and stable may be fine for that person, but it depends on what your goal is. If you've got osteoporosis, you might want to bump those patients up. And precursors, like pregnant alone may be enough for some people. Like that patient, that case that we saw where everything was low, like pregnant alone might be a great one for that patient because it would feed all of that system.

We don't care where it goes. They're low in everything. But, yeah, it can be really hard. It really can. Yeah, absolutely. Yeah. I don't have a magic stick.

I wish I did. I think we all do. Magic wand would be great. Perfect. So I've got a little situational question for you. Okay. So a patient with breast cancer and a history of bipolar disorder with a low libido, is it still a good idea to do this panel? Her doctor says no HRT.

Yeah, right. I think the question is, what's your goal? If your goal is to say, well, we'll test you and then point out that you're low, but we're not going to do anything with it. Then why spend the money on doing it? Right? I think that's a really good question. Maybe we should take that money that we have and we should do a GI test or we should test the vitamin D or we should test neurotransmitters or something that we can make actually a huge difference. So I think at the end of the day, it's like, yeah, you're a little bit bound by what you're going to do with the information, but if you're not going to act on it, don't open the book.

Yeah. Patients will be unhappy and you'll be frustrated. Yeah. Awesome. Doctor, I'm not sure how much more time you have, but we have just a couple more questions. Beautiful. And just a quick call out for those of you who have to jump right now.

If you have another meeting or something get you. Don't worry. We will send out a recording of this session as well as the slides within the next few days. So I appreciate you sticking around for a few more minutes and just another quick call out if you do have some additional time. I'll be walking through a quick demo of Rupa Health following this Q and A session. So last, I guess, three questions here is what does high Dhas mean or low DHS? Yeah. So DHA is actually made from a different part of the adrenal gland or different layer, essentially, than cortisol.

Is there's some crossover? But essentially it's a different section. The DHA is our adrenal androgen component. So it peaks at 17. It actually turns on at around age nine when kids start getting stinky. So seven to nine, third graders, fourth graders, start using the deodorant, et cetera. Their androgens start kicking in. And that DHA is what you're kind of seeing in action.

So that peaks up. It peaks at 17 to 20 somewhere in there, and then it comes down. So that's just sort of normal physiology. Dha is a massive hormone. It's the most prevalent hormone we actually have in our body. We know really insufficient amount about it for how big a role it plays. So it can turn into androgens like testosterone, it can turn into estrogen, depending on the tissue type.

So when it's high, you'll see it with Polysystic ovarian syndrome. You'll also see it in athletes, and you can see it with insulin resistance. Those are kind of the three big groups that will constantly or consistently see it high in. If you see it low, it tends to be with adrenal issues. So HPA axis dysfunction oftentimes after a long period of time. So there's lots of different ideas of like, well, which one goes first with cortisol ball the DHA. I don't think it's as quite linear as a system as we'd like it to be, but it definitely goes along with HPA access dysfunction is kind of the biggest reason for it to be low.

It can also be low because you're not making any of the hormones sort of upstream, like pregnant and conversion from cholesterol. And that's a thyroid dependent step. So if you have someone who is low in everything, you might think about that. But I think DHA has a huge role to play in vitality in the body. It has a huge role to play in the immune system. And so when we see DHA's being low, you often see someone who doesn't have as good muscle mass. They can't move their muscles the same way.

So you tend to see lower vitality and you can also see lower. Androgens so symptoms of deficiency tend to be low androgen symptoms, libido, muscle mass, that kind of thing. And that's what people really notice when they start taking it, right? Yeah. Thank you for that. That's great. Last couple of questions here. So we have a practitioner who hopefully is still with us who asks this question.

They've been seeing a few patients with very high progesterone without supplementation. Any ideas as to ecology or treatment strategies? Yeah. So it's important to know that we don't really make too much progesterone. So when you see it on lab testing, first of all, contact the lab, whether it's our lab or any lab. If you see lab results that don't make sense, call the lab, because a lot of times we'll be like, oh, yeah, we know exactly what's happening. The biggest thing that we see with progesterone is it's in a lot of antiaging facial creams and nighttime moisturizers, dry skin moisturizers. The more Hollywood they are, the more likely they are to have progesterone in them.

Or there's something in there that's cross reacting with the assay. So we can't totally tell exactly what it is. We know that some will report progesterone and others will not. However, they don't have to report everything that's used on the skin program. So antiaging creams, especially at this time of year, is probably the number one thing every once in a while with hormones. These are very sensitive to topical delivery. So every once in a while you'll see people where they've gotten their hormone exposure from their partner that they live with or they work out at a gym and they use the same dumbbells that someone who's using testosterone just before you want to wipe out all that equipment.

But hormones, we can see it. We can usually tell exactly what's going on for that person. So that's not uncommon to see, but I just usually have them avoid those antiaging creams for about three days before they do their test. That's so interesting. Almost like second hand hormones. It is second hand hormones. Exactly.

We have contamination because the challenge that we have as a laboratory is we can test that sample over and over and over again, and it's consistent. So it's the sample itself has a hormone in it, and then the question is, is it just something they touched and then touched to their lip and did it that way, right. Or got on their face and did it that way? Or is this someone who's getting it over and over and over again? We have seen, you know, women who are getting doses of, say, their husband's testosterone because he's using we see sometimes people using really high levels. And the partner's getting this dose of testosterone every day and she's getting acne and she's irritable and she's got oily skin and her hair is falling out. And it's all because she's getting his testosterone every day. She's not using it. And if you ask her, are using testosterone, she'll say no.

That's super interesting. Yeah. I mean, that even brings to mind I'm currently treating my dog with the topical cream that has a steroid in it. Yes, absolutely. If we tested your cortisol, your levels would be really high. Wear gloves. The hands are really good.

I used to absorb hormones. Absolutely.

So last question that we have here, does thyroid medicine altered the hormone testing? I feel it does not.

Thyroid medication can alter hormones only in the way that thyroid medication does. So thyroid controls the speed of how you detox and all that. But once again, this is an antibody test. It's looking for extra dial. So doing thyroid isn't going to affect that. Now, if you test your thyroid hormones with us, then, yes, being on your thyroid hormones will make a difference as to whether we are going to see high TSH, low TSH, whatever. But is the thyroid going to impact your estradiol levels of progesterone testosterone only so much as it changes how you absorb creams, how you detox creams, that kind of things or any medications? Sure.

Yeah. That was awesome. Dr. Allison, thank you so much for joining us this afternoon. Any last couple of call outs? I think the biggest thing is just keep asking questions. If there's any questions that come up, we're happy to take them from you. If you collect them later and send them over to me, I'll certainly answer them, get them back to you.

And these questions I think that you've asked today have been so good. And I would just encourage people to really reach out, talk to Rupa, talk to the labs, find out who's doing something, challenge them, get your questions answered. There's a lot of misinformation out there, and you should just try to someone who has your best interests at heart is just going to tell you everything and all of your options, because at the end of the day, we're caring for patients. We don't treat labs, we treat patients, and we want them to have the best experience they can have.

That's an amazing message. Dr. Alison, thank you again so much for joining us. You're so welcome. My contact information is right on the screen. So if you have any questions, feel free to reach out directly. And again, just to reiterate, we will be sending out a recording of this presentation along with the slides.

So if you missed anything, join late. Had a jump early. No worries. You'll have access to everything that we discussed today. But with that, I'm going to go ahead and jump right into Luca Health. Yeah. Again, thank you so much.

That was so awesome. I can't wait to have you again on. That was wonderful. Oh, you know, I'll do. It perfect. I love talking more about it. All right.

Thank you. People love to hear it. Take care, Alison. So with that y'all, I would love to chat about Rupa Health. And for those of you who are sticking around, you might be curious if this is your first time. Joining us today during one of these live sessions, who is Rupa Health? What do you do? Why are you so involved in functional medicine? And to answer those questions, I'm going to walk through just from a high level, really what group of health is and who we are, what we do and why we are so passionate. So I'm going to go ahead and share my screen here and let's just jump right in.

So before jumping into what our product is, let's chat about RuPaul. Right. Essentially, what we are at our core is a platform that's designed to make life easier when it comes to tracking, placing orders from all your different labs, tracking where all the results are coming from, managing all the pain points when it comes to the patient experience. So in a sense, making life easier when it comes to anything regarding lab test ordering. And how do we do that? Right. So what we've done is we've brought in 20 plus labs onto our platform, of course, including VRT, where you can hop on and order in one place, as well as track and manage all of your lab test results without having to go to each individual portal to do so. So streamlining that process.

The second and really core component to Rupa Health is the patient experience. My role here at Rupa is the head of Practitioner Partnerships. And so on a daily basis, I'm speaking to our users or practitioners and chatting to them about, hey, how can we make life easier for you? And a lot of the pain points that I'm hearing when it comes to these tests have to do with the time spent. And a lot of that time spent is in regards to managing the patient, sending over FAQ instructions, holding their hand through how to take the test, managing specimen issues, uploading those results into whatever, EHR that you're using from all these different sources. Right. So what have we done to help alleviate those pain points beyond just bringing out all the labs? Well, we built an end to end patient solution that is really designed to offload all the heavy lifting off your shoulders onto ours. Right.

So we'll send over curated FAQs instructions, videos provide multiple payment solutions to your patient to help lower that barrier of entry. To get access to these oftentimes very expensive tests help coordinate phlebotomy, manage specimen issues, you name it, right? So the idea here is to free up time for you and your team. If you do have a team to be able to not focus on all that admin work, to be able to see more patients and really help build your business. So with that, that is group of health from a high level. But what does it all look like? Right? So what I'm going to show you here within the next, say, ten minutes or so is how to place an order on Roof of Health, how simple and streamlined it is, how you'll track all your orders. I'll walk through what the patient experience looks like, and then I'll show you some additional features that we have here at Rupa, including, as you just saw here, one of those features being these live classes that we host. Right? So let's go ahead and jump in to place an order on Rupa is so easy.

All you need is the patient's first name, last name, email address. From there, we collect everything else directly from the patient to complete the order. It makes things more streamlined for you and your operations, of course, as well as ensure the accuracy of the information to ensure that the patient changes addresses, for example, that will be noted in here. This is what your order screen looks like. You'll notice the first sets of tests that you're seeing up at the top were custom bundles. So we can actually create custom bundles here at Rupa, a custom bundle being a set of tests instead of blood panel, a combo of blood panels and tests from one of our partner labs. That way, it's just one click.

And all of those tests that you're looking to add at once will be added into your cart without having to go and search for an entire catalog of 2000 different tests. Right below that you have access and the ability to create a favorites list. A favorites list consists of individualized tests that you're looking to run that you're commonly using. So again, efficiency play here. The idea is you don't have to look through the entire catalog to find all these tests that you're looking to add, including the Zrt saliva profile, three that Dr. Alison was kind enough to just go through with us, right? One click added into your cart straight away. But let's say that I also want to add, say, a GI map.

There we go, right at the top here. And as you can see, this list can be as comprehensive as you wish. If you are looking for a test that's potentially outside of maybe one of your bundles or one of your favorites, you of course, have access to the entire catalog below. I'm not sure if you all saw it before, but we work with over 20 different labs. We offer over 2000 different tests. You can make specific searches. You can run filters looking for whatever test type that you want to run.

So, for example, if you're looking for a blood spot version of a serum test, more likely than not we might have it. Let's simplify that by seeing the specific test type that you're looking to do, these filters make life a lot easier for you from there. Once you've selected the kits that you're looking to add, there's some cool little details that we can do. Right. But if you're just looking to send that test directly to the patient, it's as simple as clicking send a patient, and that's how you order test underfoot it can be that simple. But of course, as I mentioned a second ago, there is some customization that we can do. So up at the top, we can schedule these tests.

So one big thing that we hear about is follow ups. Right? How do we make life easier for follow up with a patient? We want to retest this patient six months down the line generally. And traditionally, what that means is you would have to write it in your little notebook or calendar and manually have to go through and send this test through. With Ripoff, we can automate that process. You can go ahead and schedule this test out for whatever you want it to be sent through, and I'll automate that process. So, again, another way that will help not only drive efficiency, but drive business as well. If there's an add on test available, let's say that I want to add Zon Newman to my GI map.

This button will appear here and it's as simple as clicking that zone and then add on right away. Right? Additionally, it will show the details of this test. You'll be able to see things such as the sample type, shipping expectations, average sample processing time. You can download a copy of the instructions of sale report, and any biomarkers that they're available will be displayed as well.

Expanding that Out I'm sure you're all very curious. How does pricing work? Well, Roof is free to sign up for free to use the way that we generate our revenue. Is there's just a flat 7% processing ordering fee which is tied to each order? So as you can see here, that's broken down straight away as $31. If there's additional costs, such as shipping, we'll of course break that down as well. Now, to clarify on how this is paid. This is paid for by whoever is paying for the order. And what I mean by that is we offer two different options for payment.

We can either build the patient directly, which is how the majority of our practitioners prefer takes another thing off your plate. Right. And we can manage billing directly with the patient, or you can pay for the test yourself and then manage billing separately. Outside of our platform, there's a ton of practitioners and clinics that prefer this, right. For whatever reason. Let's say, for example, that you run a 16 week program and all the costs of the tests are baked into that. That's completely fine.

You have the option of paying for the test. Still, the patient won't see the cost or anything like that. I'll clarify what that looks like here in a moment, but that 7% that you're seeing here. $31. In this case, that is the only way that we generate a revenue. There's no sign up costs, there's no subscription fee, and that's paid for by whoever is paying for the test. So what that means is if you're having us manage billing and billing the patient directly.

Right. Then the patient will be the one absorbing this cost. In effect, Rupert is free for you as a practitioner to use so huge there, right? Additionally, we offer wholesale practitioner rates. So the same prices that you would get going directly and having an account with these labs, unless you have negotiated a special rate with any of these labs, will be the same prices that you'll see reflected in our catalog. So oftentimes, labs will have two prices if you're not familiar a patient price as well as a practitioner price. So if you're referring your patients, for example, to go purchase these tests directly from the labs, they're likely going to be charged a higher price. Right.

So, for example, $360 for a GI map through Rupa. We always charge that lowest practitioner price, whether the practitioner is paying or the patient is paying. So the opportunity for cost savings within our platform for your patients is pretty massive depending on how you're currently operating. Right. So as you can see here, the roof of savings in the circumstances, $166, that service fee being $31, that's 130 plus dollars. That your patient's saving. So that's huge.

Right? From there, you can add notes for the patient. This can be really anything that you want it to be. An example for this circumstance would be let's say that you want the patient to continue to take their supplement regimen. Right. You can go ahead and add those notes in there, but if you're continually having to write the same instructions over and over, we could actually save snippets save you some time, continue to take your steps. Simple as that. Add that note in there and the patient will see those instructions as we send the notes out to the patient.

You can add notes for us. This can be anything you want it to be. And then ICD ten codes. We do have the ability to add ICD ten codes. We have a full catalog built out into here. So if you are looking to add ICD ten codes to allow your patient to submit a super bill for reimbursement after the fact, we can go ahead and help coordinate that. Go ahead and add an ICD ten code in there.

We will send over a template to the patient on how to create that super bill and submit that for reimbursement. So full catalog in here. You can either type the ICD ten code in here. You can even just add a keyword, for example, and they'll go ahead and add that in there. But if nothing else, send a patient. So I showed you just one. How simple it is to send an order on Rupa Health, but also how detailed and customized you can create an order on Rupa Health, so we can either be as simple or as complex as you want it to be in terms of those orders.

But where are we tracking everything? Let's go back to that main dashboard and I'll show you how we're tracking everything right here within our main dashboard. As soon as you send that order out, it'll be tracked within. Here, you can search by patient name, you can search by status of the order. As you can see down below, we'll consistently update the status of your order. So once I have an order that is in progress and I want to look into it, I can see exactly what's going on. So as opposed to traditionally having to go to each individual lab portal to view updates on statuses of my orders, I now have everything in one place I'm able to see. For this example, four different tests, three different labs, all available.

I can see when the sample arrived at the lab, when I can expect those results to come in as well. So I can plan accordingly directly with my patient. Makes things easy, right? Once your results are in, you're notified via email and you're able to hop right back in here and you can download the results. These are the same exact results that you will be receiving directly from the labs. We're not making any interpretations or own version of it. Same exact results that you're getting. You have the option to send the results directly to the patient.

Rupert will never send the results directly to the patient without your consent. You have full control over this. And then you can even schedule a clinical consultation directly with the lab as well. So should you need some additional assistance interpreting the results, you can schedule a clinical consultation with whichever lab you're working with. We interface with them so that interpretation will be with one of the practitioners at that lab. And then should the digital acquisition be available and you have access to that. But again, the idea here, everything in one place, right? Making it real streamlined.

So what we've covered so far is how to place an order on Rupa Health where we're tracking all those orders and tests on Rupa Health. Again, everything in one place. But what does it look like from the patient's experience? Right? What does it look like once you hit that send a patient button. So let's chat about it. This is the timeline. So as soon as you place that order on Rupa, the patient will be notified. I'll show you what those notifications look like in a moment.

The kits will be shipped out within 24 hours of payment being received. So that's one thing to call out is Rupa won't shift the kits up until payment has been received. We will send over FAQs instructions, videos on how to take the test to the patient. We'll check in and follow up with the patient. Additionally, you're, of course, notified once the results are in.

So what we're really doing here at Rupa is leveraging technology to provide an experience that has come to be expected in 2022, right? Not only is it going to be providing more of, I guess, a white glove experience for your patients, but it's also going to make it things more efficient and effective for everybody involved. That's the goal here, right? Saving you time so you can focus and build your business and see more patients. This is what the communications look like to your patients. So this is the example. Should the patient be the one paying for the test directly? Hi Joshua. Dr. Jordan has ordered these tests for you.

We'll introduce who we are, and then we'll highlight the different payment options that we accept. So, as I alluded to earlier in the presentation, we offer multiple different payment solutions beyond just cash and credit. We can do HSA, we can do FSA, and we can even do a three month interest free payment plan. All these are designed with the goal to lower the barrier of entry to get access to these tests. If you're a practitioner and you've ordered these tests before, you know how expensive they can be, how insurance doesn't always work with them, right? So we want to provide multiple solutions to your patients to allow them to be able to afford these tests. From there, we'll collect the necessary information to complete the order, of course, shipping information, demographic information, billing information, and then we'll highlight the different tests that were ordered for them.

Should you decide to pay for the test yourself and then build a patient outside of our platform, this is what will look like. And just a huge call out here is nothing changes in terms of the patient experience. The only difference here is the communication such as this because the patient is not paying. So we'll simply collect the demographic information and the shipping information, but we will not show the cost of the test. We'll, of course, show what test was ordered, but we will not show the cost of what that test was. All right. From there, once payment has been received, we will send out a shipping notification and then within a few days, we'll send out an email that looks similar to this.

So what this email highlights is not only instructions and FAQs and oftentimes videos on how to take the test properly, but also how to fill out the requisition forms if there's a blood draw required. We can help coordinate that. We can either send over options based on the lab that they're working with, or we will be able to customize those instructions. And if you're lucky enough to have a trusted phlebotomist or even have one in a house, we can take their information into that directly to the patient. Should the patient have any questions along the entire process, whether it's in regards to how to take the test or they simply don't like the phlebotomy options and lots of additional ones, we can help facilitate that by sending over additional options, whether they're mobile, whether they're in house, so on and so forth. And we'll always be as transparent as possible when it comes to additional costs. You can see an example of our instructions on the right hand side with the Dutch complete test.

So I think it's so important to call out not only are the tests comprehensive, but I think more importantly, they are user friendly. Right. And that's huge.

We'll follow up with a patient. Again, I think something that can easily just be lost in the shuffle of life is simple follow ups to ask a patient how they're doing and what questions they have. Another way that we're leveraging our technology to automate something that is simple but oftentimes manual. And what this has all led to in this experience that we built out as led to is a compliance rate up above 85%. So we're seeing very high compliance rates with our tests that we're sending out for the patients to be completed. From there, you're notified via email as the results come in and you're able to view them all within Rupa, just as I showed you a moment ago. So what I've shown you thus far and I'll hop back to the dashboard so you can see that is really the three core components to help how to place your orders all in one place, how to track and manage all your results as well as the patient experience.

Right. But we're more than just a place to come place your orders. You're all currently all you guys are still with us here are part of the Rupee University. So Rupa University is a series of live classes that I host on a weekly basis that are sponsored by Rupa Health, where we bring on practitioners who come to chat about important topics, labs, tests, whatever they see fit that are impacting the functional medicine landscape and that we think are important as well. Not only you, but they think are important. And clearly you do as well for joining us today. So we host these on a weekly basis and they're free to sign up for.

And you have access to them within your Rupert dashboard as well. All the recordings, all the slides, anything that you would need. Additionally, we host a webinar, excuse me, a podcast. We have a magazine. So we're consistently and constantly putting out content to help practitioners who are a part of Rupa grow and learn functional medicine, as I'm sure you all know, is a fast paced environment.

And we want to be able to help those that are involved and passionate about function grow along with us. So as you can see, you have access to the magazine here, you can hop onto the Root Cause Medicine podcasts. So beyond just a place to be able to place all your orders, we do consistently put out content as well.

Another quick call out would be just the ability for us to work with not only solo practitioners, but clinics as well. So if you're a solo practitioner or a large clinic, we can invite staff members to join and be a part of the account. Everybody will have their own login. If you have multiple practitioners, for example, we can really work with anybody of any size. So with that, I did see, I think a couple of questions maybe coming through the chat. So happy to kind of answer those as well. But if you need anything else, let me hop in and share my contact information.

So I'm going to send out a follow up email to everybody who attended today. So if you are interested in setting up some time to learn more about Ruba for your clinic specifically, feel free to reach out directly. I'm going to go ahead and answer these last couple of questions before we hop off. So do we create the superb? No. So we actually don't create the supervillain. The patient will be the ones creating the super bill. But we'll go ahead and send over a template to walk the patient through how to generate that superb.

So if the patient pays, they want a receipt from the practitioner. How can that work? I'm not sure if I completely understand that if the patient pays, they want a receipt from the practitioner. Can you just shoot me an email? Maybe we can hop on a call to clarify what you mean by that. And then when will Rupa come to Canada? Oh, my gosh. This is a huge question. Hopefully very soon. We love Canada.

We have so many amazing Canadian practitioners who join us on a weekly basis in these classes. I cannot wait for us to expand up north.

And I think the rest of the questions were in regards to some chat. I think the rest of the questions might have been regards to Dr. Allison's questions. I'll see. For patients who don't pay on time, do you remind them? Okay, there are some questions in here. How to sign up, please. Oh, my gosh, you guys, these are great questions.

So to sign up, super easy. And thank you so much for calling that out. All you're going to do is you're just going to rub the Help.com right here at the top there's a button that says Sign up for free. It's free to sign up for as I just mentioned a moment ago, it takes just a moment. We do integrate as well with the NPI registry. So if your information matches up, it's as simple as just typing in whatever information and questions that we asked for. The most heavy lifting involved is knowing your MPI number.

But just go to Ruperthealth.com, sign up for free and you're good to go there. Medicare patients. Super good question, Kathy. So we can do Medicare through diagnostic solutions only at this time for patients who do not pay on time, do you remind them to pay? Yeah. So great question, Doctor Conrad. So I'm assuming this is in regards to the three month payment plan. So with that payment plan, we actually go ahead and send those tests out after the very first installment.

So it's a three month installment program, right? Three month insurance or three month payment plan. And so after the very first payment, we'll go ahead and send that out. Now, after the next couple of months, of course we will remind the patients, but I do believe it's basically auto bills on the same month. I can follow up with the operations team.

So what insurance do we work with? I believe it's just general insurance now the traditional insurance. Doctor Conrad, if that's what you're asking about, insurance, as I'm sure you know, is very difficult within these tests to accept. So we can actually do insurance at this time only through Genova tests. So Genova tests, you have the option of switching the pay from cash pay to insurance option, and then we'll go ahead and collect the insurance directly from the patient. But insurance like types of insurance, just like commercial insurance, standard commercial insurance.

Awesome. So I think that might be all the questions. And again, I appreciate all of you for staying on. We have a number of people that are staying on. So if you do have any questions, reach out. I'm going to go ahead and again send out a follow up email to everybody. So if you have anything or need anything, please let me know.

Don't hesitate. More than happy to hop onto the call with any of you to chat about Rupa getting signed up and how we might be able to fit within your practice. And we had one last question come in. That is a super important question. Does Genova still require a licensed provider? So Ruba actually requires a licensed provider. So in order to order through Ruba at this time, you do need to have an MPI number. That said, we are releasing a program hopefully within the next very near future called physician authorization.

Essentially what physician authorization is is a program that allows practitioners whose licenses or certifications may be limiting in their ability to order labs directly to order labs. Right. So we would do that by bringing on a signing physician and signing doctor who is licensed in every single state. And if your licenses for example, don't allow you as a naturopathic doctor to order from Genova, for example, you would be able to order from Genova using this program and again that should be released very soon. It's called the position authorization program so look for a huge press release coming out regarding that. But again, I appreciate you all so much for sticking around with us and Dr. Allison's presentation, we really appreciate every single one of you for joining keep an eye out for an email coming from me later this afternoon as well as an email within the next few days with a recording as well as the slides attached to it.

So we appreciate you so and I look forward to connecting with you very soon.

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