Sample 1: Functional Medicine Visit Summary

Bone Health • Hormone Therapy • Vaginal Health • Brain Fog  • Prevention

You're at an important decision point, and I love how thoughtfully you're approaching this. Let's
review everything clearly so you feel grounded and confident moving forward.

 

Bone Health

Understanding Bone Density

Bone density was evaluated using a DEXA scan (Dual-Energy X-ray Absorptiometry), a medical imaging test used to measure bone strength and evaluate risk for osteopenia or osteoporosis.

Current Findings

 •  Spine (L2) T-score: -2.3

  • Osteoporosis threshold: -2.5 or lower

What This Means

A T-score compares bone density to that of a healthy young adult.

  • Normal bone density: Above -1
  • Osteopenia: Between -1 and -2.5
  • Osteoporosis: -2.5 or lower

Current findings suggest bone density is approaching the osteoporosis range, which is why ongoing monitoring and prevention are important.

Why Bone Health Matters

Bone loss often develops silently over time. As density decreases, the risk of:

  • Falls
  • Fractures
  • Mobility limitations
  • Loss of independence

can increase significantly.

Plan

  • Repeat DEXA scan for comparison
  • Continue monitoring bone health progression
  • Consider osteoporosis specialist evaluation if needed

Hormone Therapy (HRT)

Understanding Hormone Replacement Therapy

Hormone Replacement Therapy (HRT) may help support bone health, menopausal symptoms, and overall quality of life during and after menopause.

Current Context

  • Approximately 8 years into menopause
  • Approaching age 60

Timing is important when considering hormone therapy, which is why treatment is being approached gradually and carefully monitored.

Potential Benefits Being Considered

  • Bone protection
  • Brain health support
  • Brain fog improvement
  • Heart protection
  • Hormonal stabilization
  • Overall quality of life support

HRT Plan: Personalized Approach

A gradual “low and slow” approach is being used to help the body adjust comfortably and reduce side effects.

Estradiol Patch

  • Prescription: 25 mcg patch
  • Starting dose: approximately ¼ patch
  • Gradual increase over time depending on tolerance and response

Progesterone

  • 100 mg nightly

Progesterone is being used alongside estrogen therapy to help protect the uterine lining.

Possible Side Effects

  • Sleepiness
  • Bloating
  • Fluid retention

Brain Fog

Estrogen may help, but is not a guarantee

• Brain fog in menopause is multifactorial:
     Hormones, Sleep, Neurotransmitters (especially dopamine)

Dopamine Support

The visit also discussed dopamine-related support using Mucuna, a supplement sometimes used to support:

  • Motivation
  • Mental clarity
  • Libido

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Important Note

Hormonal therapy may improve symptoms for some individuals, but responses can vary from person to person.

Vaginal + Bladder Health

Current Support

  • Estradiol tablets (2x/week)
  • Estriol cream (2x/week)

Reported Improvements

  • Reduced dryness
  • Less painful during intercourse

Optimization Plan

Use estriol daily x 10 days to fully “saturate” receptors

Understanding the Goal

Think of this like rehydrating tissue that has been dry for years.

Yeast Risk

More estrogen = more moisture → possible yeast flare

If Symptoms Occur

  • Itching
  • Irritation

Treatment Option

Fluconazole (Diflucan)

  • 1 pill
  • Repeat in 3 days if needed

No drug interactions were noted with current medications. Hydration was also encouraged.

Heart Health

Current statin use suggests cardiovascular risk factors are present, but additional information is still needed.

Question Being Evaluated

Is plaque already developing in the arteries?

Order: CT Coronary Calcium Score

This imaging test may help:

  • Detect early plaque buildup
  • Evaluate cardiovascular risk
  • Determine how aggressive prevention strategies should be

Labs

Timing

Complete after approximately 1 month on estrogen therapy.

Tests Ordered

  • Testosterone
  • DHEA
  • Thyroid panel

Notes

Standard laboratory testing may not always accurately measure female testosterone levels. Quest uses a more appropriate assay for this evaluation.

Gut Health

Constipation and digestive health may affect:

  • Estrogen detoxification
  • Hormone balance
  • Bloating and inflammation

Plan

  • Daily fiber supplementation
  • Consistency over perfection

Medications Summary

Sent to Walgreens

  • Estradiol patch
  • Progesterone 100 mg

Continue

  • Estriol (temporary increase)
  • Minoxidil
  • Rosuvastatin
  • Nutrafol

Follow-Up

Next visit scheduled for Monday, August 10th at 10:00 AM.

Big Picture

You are doing exactly what this phase of life asks:

- Evaluating risks thoughtfully
-Staying proactive
- Not rushing into anything blindly

This is not about “yes or no” to hormones.

It's about:

  • Trying
  • Observing
  • Adjusting 
  • and building something that works for your body.

If anything comes up—side effects, questions, even just uncertainty—reach out. You don't have to figure it out alone