Functional Medicine Case Study

One of the best ways to illustrate how functional medicine works is with a case study.

The Patient 

Mary was a 54-year-old woman who came to me after several years of feeling poorly. She described the following symptoms:

Tired with low energy

Sleeping badly, waking up at three in the morning and not going back to sleep

Perimenopausal, with hot flashes and night sweats, and her libido was low

Joint and muscle pain

Her hair was thinning

Constipation

Regular headaches

She was evaluated by her physician, who found her thyroid to be normal. Her other labs showed a moderately elevated blood sugar that she was told “to watch” and her doctor suggested that she try an anti-depressant.

Frustrated, she came to me for another opinion.

Functional medicine starts at the root cause

Using a functional medicine approach to her symptoms, I listened to her story and found out that her symptoms all started when her family moved here five years ago. It was a very stressful move for her and she didn’t feel that she had handled her stress well. Some of the elements of her life she mentioned were:

She often had to grab something quick for breakfast and frequently ate out or “on the run” in the evening.

She ate a fair amount of pre-prepared and processed foods.

She relaxed with a glass or two of wine in the evening.

Too tired to exercise much.

A stressful job

Two teenagers

Husband who traveled for work

Functional medicine takes into account your entire lifestyle

In assessing her, I looked at her complaints, her lifestyle issues, and considered potential imbalances. I asked her to do some basic lab testing, including an expanded thyroid profile, nutrient levels, and a salivary cortisol and hormonal test.

I started her on some supplements and probiotics, and had her see our nutritionist to help her improve her diet. I also gave her some breathing exercises and tools for stress management.

Four weeks later at her follow up appointment she was already feeling better. She was starting to reduce the amount of processed food she ate, and had fewer headaches, less constipation, and more energy.

Functional medicine can identify the body’s imbalances

Here’s what we discovered:

She has low vitamin D and magnesium levels.

Her saliva test showed imbalanced daily cortisol levels and patterns, including an increased level at night, which often occurs after prolonged stress.

Her estrogen and progesterone levels were also imbalanced, partly due to low cortisol.

Using the data gathered, I gave her a protocol that helped balance her hormones, improve her nutrient levels and lower her symptoms.

We addressed the underlying imbalances and deficiencies via nutrition and lifestyle, adding nutritional supplements as needed to address her stress.

Within several weeks she was feeling significantly better, with increased energy, fewer hormonal symptoms, improved digestion and fewer headaches. She was able to start a gentle exercise program. She no longer needed Ambien for sleep and didn’t need an antidepressant.

Ultimately we addressed the root causes of her symptoms and helped her return to a state of balance and health.

Have more questions about functional medicine? Read our Functional Medicine Q & A.

About Dr. Martha Calihan

 Dr. Calihan is a Certified Functional Medicine physician, and the founder and owner of The Five Stones Healing Arts and Wellness Center (www.fivestoneswellness.com).