This is a 40 yo woman, cycling regularly, with multiple symptoms of hormonal imbalance, including weight gain, breast fullness, night sweats and heavy menses. In addition, she reports GI symptoms that worsen with menses and ovulation. This is a 40 yo woman, cycling regularly, with multiple symptoms of hormonal imbalance, including weight gain, breast fullness, night sweats and heavy menses. In addition, she reports GI symptoms that worsen with menses and ovulation.This patient has been experiencing multiple complaints that she describes as hormone related for 5-6 years, presenting now because they have been getting progressively worse over time to the point that she now cannot live a normal life. As stated above, these symptoms include weight gain, breast fullness, night sweats and heavy menses in addition to alternating constipation and diarrhea that worsens during menses and ovulation.40FemaleAfter analyzing her symptoms it became clear that some were related to estrogen excess (weight gain, breast tenderness, heavy menses), some were related to estrogen deficiency (night sweats), and some were related to hormonal fluctuation (alternating constipation and diarrhea as progesterone relaxes the GI tract). However, the sum total of her symptoms pointed to an E:P imbalance, with an excess of E relative to P. As a first step, to help her liver’s ability to function and ultimately to decrease hormone levels I felt that the best initial approach was a 10 day detox and to see what happened.I recommended a 10 day detox with Ultraclear Plus, a medical food with nutrients that support detoxification and support the liver (Metagenics) as well as Advaclear (Metagenics), a blend of green tea, pomegranate, watercress, and artichoke that enhances and balances Phase I and II detoxification. On follow up two weeks later she reported absolutely no improvement, feeling bloated and having increased bilateral breast tenderness, not at all what was expected. I decided to target her E:P imbalance in a more specific and powerful fashion by the following regimen: CDG Estrodim (Orthomolecular): 1 cap bid which has folic acid, I3C and DIM to improve estrogen metabolism ProGyne (Progena): 3 caps daily which has a blend of herbs designed to serve as adaptogens to normalize the E;P ration. These herbs are: Angelica sinensis extract (4:1) (Dong Quai) 100 mg, Eleutherococcus senticosus extract (Siberian Ginseng) 100 mg, Medicago sativa extract (4:1) (Alfalfa) 100 mg, Avena sativa extract (10:1) (Oats) 100 mg, Punica granatum (Pomegranate) 100 mg, Cimicifuga racemosa extract (Black Cohosh)(Standardized to 2.5% Triterpene glycosides (27-deoxyactein) 50 mg, Glycyrrhiza glabra extract (4:1) (Licorice)50 mg, Vitex agnus castus (Chaste Tree)50mg, Boron (Citrate)1 mg Invite multi (Invite Health): 1 pkt daily Orthomega (OrthoMolecular): 2 caps bid, an omega 3 blend with EPA 420 mg, DHA 300 mg per capsule. Progesterone cream: 20 mg qhs day 1-25 of cycle to increase progesterone levels. Advaclear (Metagenics): 1 cap bid to improve detoxification (see above). Because of her extreme discomfort I scheduled a prompt return visit. She returned 10 days later , feeling SLIGHTLY less bloated with only minimal improvement. Since we were going in a positive direction, albeit slowly, we decided to continue the regimen for a month. One month later she stated she was feeling “the same”. However, on detailed questioning, she said that her period was actually a little lighter and her bloating was better. Unfortunately she still had many of her other original symptoms. I then changed her regimen by replacing the ProGyne with a hormone balancing shake (Estrium by Metagenics)2 x daily and adding a probiotic (UltraFlora IB) daily and IgG 2000 (Xymogen) 2 caps bid because many of her cycle related symptoms were GI in origin. We met again 3 weeks later and she was doing “much better”. Even though she was improving she wanted to stop the Estrium (poor taste) and try another hormone balancing capsule. I substituted PMS Soothe (Xymogen ) 1 cap bid and continued her on the Estrium (modified elimination) diet her. I am so happy to report that when I saw her again one month later she was doing very well (FINALLY). All of her symptoms were improved, the only symptoms left were decreased libido (not unusual as her hormones were now being efficiently cleared) and some water retention. I prescribed Water Ease (Designs for Health) 1 cap bid and Viriligen (Xymogen) 1 cap bid to treat those symptoms. A great positive sign was that she felt so well she didn’t have the need to meet for a follow up visit for tree months! How gratifying it is to know that the functional approach will work as long as we as providers do not get discouraged and continue to peel away the layers in order to find the solutions. Would anyone have handled this case differently? How?