Applying Therapeutic Order to Assessment and Treatment
Kimberly Windstar, MEd, ND
Corina Dunlap, ND Cand
A 29-year-old female was referred to our clinic for infertility treatment after she and her husband had been trying to conceive unsuccessfully for the past 13 months. Her husband had a semen analysis, which she reported was normal. The patient had become increasingly stressed and sad due to their inability to conceive despite conscious attempts and previous treatment. This is not an unusual presentation, considering that a significant number of women between the ages of 15 and 44 years are infertile. As of 2010, 16.6% in this age group have been found to be infertile and 11.9% have received fertility care.1 Our interactions with this patient consisted of 1 office visit and 3 follow-up phone consultations at 2, 11, and 17 months.
Pertinent findings in her history included the following: irregular menses since menarche, current presentation of oligomenorrhea with menses as far apart as 140 days, and signs of hyperandrogenism. The patient also reported increased hair loss, cold intolerance, cold extremities, constipation with straining, and morning fatigue. Family history included a sister with irregular menses and infertility; however, parents and grandparents had a normal menstrual history, no thyroid abnormalities, and no trouble conceiving.
Physical exam was significant for a BMI of 19.97, waist-to-hip ratio of 0.75, oral temperature of 97.9 °F, hands that were cold to the touch, and a thyroid that was non-tender, non-nodular, and not enlarged. Achilles reflex was 1+ bilaterally, with diminished return, and remaining deep tendon reflexes were 2+ bilaterally. Abdominal and cardiovascular exams were unremarkable. Conjunctiva was pink and healthy, and capillary refill was 3 seconds.
The patient’s lab work collected by her primary care physician 2 months prior included the following: TSH, 2.74 mIU/L; Free T4, 1.02 ng/dL; Free T3, 2.99 ng/dL; negative TPO antibodies; CBC WNL; and FSH 7.2 mIU/mL.
The Therapeutic Order
The Therapeutic Order is a philosophical assessment and treatment guideline based on the principles of naturopathic medicine.2 In the Therapeutic Order’s hierarchy of healing, Level 1 is based on re-establishing the foundation for health by identifying and removing disturbing factors and instituting a more healthful lifestyle. Level 2 focuses on stimulating the healing power of nature. Level 3 restores weakened or damaged systems. Level 4 corrects structural integrity. Level 5 addresses pathology by prescribing specific natural substances, and level 6 employs the use of pharmacologic substances for pathology.
Treatment of our patient initially focused on thyroid function, for the primary purposes of improving the patient’s fertility, decreasing her risk of pregnancy loss, and optimizing healthy fetal development. Based on this case presentation, our highest level of focus in the naturopathic Therapeutic Order was Level 6, which involves the use of specific pharmacologic or synthetic substances to address pathology.2 It is well documented that oligomenorrhea is the most common presenting symptom associated with infertility with TSH levels greater than 2.5 mIU/L.3,4 Recent literature also states that TSH levels above 2.5 mIU/L increase risk for pregnancy loss in the first trimester by 6.1%.5,6 Based on The Endocrine Society’s 2007 guidelines for thyroid and pregnancy, TSH levels above 2.5 mIU/L in the first trimester, and 3.0 mU/l in the 2nd and 3rd trimesters, are considered abnormal.5 Thyroid hormone has been found in follicular fluid and on thyroid receptors present on the granulosa cells, which supports the hypothesis that T3 has a direct effect on the human oocyte.3 Thyroid hormone may also play a role in endometrial development and successful implantation. Glucose absorption and usage in the decidual layer is dependent upon thyroid hormones and TSH.3 Based on the above rationale, we started this patient on dessicated thyroid, 15 mg daily.
Myo-inositol is the most common stereoisomer of inositol, the 6-carbon cyclic polyalcohol also known as cyclohexane-1,2,3,4,5,6-hexol. A constituent of certain phospholipids, myo-inositol plays a role in a number of signaling and secondary messenger systems involved in insulin signal transduction, intracellular calcium concentration, and cell membrane potential, among others. Naturally-occurring in some foods, myo-inositol is not considered essential because it is synthesized in vivo from glucose-6-phosphate. In women with polycystic ovary syndrome (PCOS), a deficiency may contribute to the pathogenesis of insulin resistance, due to a defect in availability or utilization.7 There is increasing evidence to support the role of myo-inositol in women with PCOS, for improving frequency of ovulation, insulin sensitivity, and menstrual cyclicity.7,8 In one study, there was an 88% increase in menstrual frequency, and 72% of participants maintained normal ovulation after being given 2 g BID of myo-inositol for 6 months.9 Calcium signals have been shown to be upregulated in oocytes following myo-inositol supplementation, thereby enhancing meiotic progression during oogenesis and overall maturation.7 Due to emerging evidence, myo-inositol has been classified as an insulin-sensitizing agent for women with PCOS. In another study, administration of myo-inositol (2 g BID for 3 months) to women with oligomenorrhea and clinical hyperandrogenism reduced hyperandrogenemia and improved
Vitex agnus-castus, also known as chasteberry, was given as a 250-mg capsule daily, due to its impact on menstrual disorders and infertility. It is hypothesized that Vitex exerts an effect on the anterior pituitary by stimulating luteinizing hormone (LH) and, consequently, improving corpus luteal function and the production of progesterone.10 In a double-blind, randomized-controlled trial, 57.6% of women either became pregnant or resumed normal menstruation after taking 1.8 mL of Vitex extract, compared to 36% taking placebo.11
Natrum muriaticum (LM1, 5 drops by mouth daily) was indicated for this patient, based on her reserved disposition, constipation tendency, cold extremities, and infertility presentation.12,13 Similar to the prescribing method frequently used by Dr John Bastyr in a general practice or primary care setting, a homeopathic remedy was chosen based on the patient’s presentation and characteristic symptoms revealed during the initial visit.14
Two months into following the above treatment plan, the patient conceived. We advised her to continue thyroid medication and discontinue myo-inositol, Vitex, and Natrum muriaticum. The patient achieved a successful full-term pregnancy, with the delivery of a healthy baby girl without complications. During her pregnancy, she maintained appropriate TSH levels on
15 mg of dessicated thyroid. Post-partum, she discontinued her thyroid medication, and was still asymptomatic at her 17-month follow-up.
With the Therapeutic Order in mind, our primary focus was to employ the principles of treating the cause and “first, do no harm” (use of least force). Therapeutic Order Levels 1-3, 5 and 6 were employed. This included the following: homeopathy for Levels 1-2, myo-inositol for Level 3, and Vitex for Levels 3 and 5. For Level 6, dessicated thyroid was used. Level 6 and all but 1 of the levels below this were well indicated in this case, due to the need for achieving successful conception (and as quickly as possible, given this woman’s emotional stress regarding her fertility) and protection of the developing fetus. Although it was difficult to ascertain which element was the key component in helping the patient achieve pregnancy, the clinical significance is that elements used together had the desired outcome.
Given the opportunity to work with the patient long-term, the treatment approach would be to address therapeutic Levels 1 and 2 in more depth. Our impression of the case is that the underlying constitutional propensities are what contributed to the patient’s pathophysiology and her eventual chief complaint of infertility. Our aim was to uncover these patterns, bring awareness to their underlying source, and encourage an enduring healing process. We also fully evaluated all determinants of her health. The application of energetic medicines such as homeopathy, flower essences, and being present with the patient as witness may have been employed to support and encourage not only the removal of disturbing factors, but also the establishment of long-term health.
Kimberly Windstar MEd, ND is a full professor at NCNM and held the position of chief medical officer at NCNM clinics from 2011-2013. She developed a residency position for graduates interested in women’s health, advanced gynecology, female endocrinology, and colposcopy. She is the lead author for the Women’s Medicine Chapter of the Foundations Project and has published articles on the topic of cervical dysplasia, escharotic treatment, and naturopathic medicine.
Corina Dunlap, ND Candidate is in her 4th year of the Naturopathic Medicine and Integrative Medical Research programs at NCNM. She received her BA from Smith College with a focus on medical anthropology and international relations. Her primary interest is the study of natural medicine in environmental health, infectious disease, public health, women’s health, and Ayurveda.
- Carson SA. McKenzie LJ. Evaluation of Infertility, Ovulation Induction and Assisted Reproduction. Updated June 23, 2013. Endotext.org Web site. http://www.endotext.org/female/female7/femaleframe7.htm. Accessed July 20, 2013.
- Zeff J, Snider P, Myers SP. A Heirarchy of Healing: The Therapeutic Order: A Unifying Theory of Naturopathic Medicine. In: Pizzorno JE, Murray MT, eds. The Textbook of Natural Medicine, 4th ed. St. Louis, MO: Elsevier; 2013:18-33.
- Evers AS. Paracrine interactions of thyroid hormones and thyroid stimulation hormone in the female reproductive tract have an impact on female fertility. Frontiers in Endocrinology. 2012;3(50):1-8. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3355884/. Accessed July 20, 2013.
- Poppe K, Velkeniers B, Glinoer D. Thyroid disease and female reproduction. Clin Endocrinol (Oxf). 2007;66(3):309-321.
- Negro R, Schwartz A, Gismondi R, et al. Increased pregnancy loss rate in thyroid antibody negative women with TSH levels between 2.5 and 5.0 in the first trimester of pregnancy. J Clin Endocrinol Metab. 2010;95:E44-E48.
- Vadiveloo T, Mires GJ, Donnan PT, Leese GP. Thyroid testing in pregnant women with thyroid dysfunction in Tayside, Scotland. Clin Endocrinol. 2013;78(3):466-471.
- Papaleo E, Unfer V, Baillargeon JP, Chiu TT. Contribution of myo-inositol to reproduction. Eur J Obstret Gynecol Reprod Biol. 2009;147(2):120-123.
- Lisi F, Carfagna P, Oliva MM, et al. Pretreatment with myo-inositol in non polycystic ovary syndrome patients undergoing multiple follicular stimulation for IVF: a pilot study. Reprod Biol Endocrinol. 2012;10:52.
- Papaleo E, Unfer V, Baillargeon JP, et al. Myo-inositol in patients with polycystic ovary syndrome: a novel method for ovulation induction. Gynecol Endocrinol. 2007;23(12):700-703.
- Marshall K. Polycystic ovary syndrome: clinical considerations. Altern Med Rev. 2001;6(3):272-292.
- Gerhard I, Petek A, Monga B, et al. Mastodynon(R) bei weiblicher Sterilitat. Forsch Komplementarmed. 1998;5(6):272-278.
- Murphy R. Homeopathic Medical Repertory, 2nd ed. Durango, CO: Hahnemann Academy of North America; 1996:661.
- Morrison R. Desktop Guide to Keynotes and Confirmatory Symptoms. Albany, CA: Hahnemann Clinic Publishing; 1993:258-262.
- Grimes MJ. Dr. John Bastyr: Including Bastyr’s Clinical Homeopathic Materia Medica: Philosophy and Practice. Self-published; 2005.