Presentation on theme: "Bioidentical Hormone Restoration Best Medical Practice"— Presentation transcript:
1Bioidentical Hormone Restoration Best Medical Practice Relax: this presentation is available online
2Topics Introduction Reference Range Endocrinology Hormone Loss with AgeHypometabolism: Thyroid and Cortisol DeficiencySteroids and DHEA in Rheumatic DiseasesVitamin D and Fish oilSex hormone replacement for Women and Men
3Hormones Parts of our integrated neuro-endocrine- immune system Travel via blood to all cellsControl cells’ proliferation, differentiation, protein synthesis, metabolic rate, etc.The most powerful molecules in biologyOptimal levels and effects are essential for health and quality of life
4Estradiol, Progesterone Central ControlMaster GlandTSHT3, T4ACTHCortisol, DHEAAldosteroneLH/FSHEstradiol, ProgesteroneTestosteroneTestosterone
5Human Steroid Hormones Bioidentical Molecules TestosteroneEstradiolDHEAProgesteroneAldosteroneCortisolDrug companies have patented ~5 to 200 variations of each molecule.
6Bioidentical Hormones are not Drugs Correct molecular structure—same action at receptors, same metabolism and eliminationNon-toxic:No side effects, only effectsNo interactions with drugsNo allergic reactionsSafe in youthful physiological levels/balanceNegative effects: Due to excessive dose, wrong delivery method, or imbalance with other hormones
7Pharmaceutical ModelFunding all schools, journals, organizations, researchNaturally-occurring molecules cannot be patentedFDA-approve s any drug that works better than placebo in two short-term trials.Symptoms labeled as syndromes, treated with drugs (depression, fatigue, fibromyalgia, anxiety, etc.)Misinformation about hormones is rampant.Hormone and nutrient deficiencies underdiagnosed and undertreated.
8Bioidentical Hormone Restoration is Good Medical Practice If a hormone is missing, replace it!; if present but deficient, optimize it!Type 1 Diabetes: bioidentical insulinHypothyroidism: bioidentical T4Growth hormone def.: bioidentical GHAdrenal insufficiency: bioidentical cortisolThe Controversies:How do we diagnose deficiency?How do we decide which dose is right?What do we do about deficiencies due to aging?
9Why Docs Don’t Get It: Reference Range Endocrinology “Normal” ranges on reports are misunderstood:95% of all persons tested (only 2.5% low)95% of tested persons of same ageadjudicated diagnostic values (glucose, cholesterol)Docs assume that all ranges are diagnostic!Male free testosterone: x!Female free testosterone: !Thyroid - Free T4: x!AM serum cortisol x!“Normal” resultno hormonal dx/rxdrugsMay mean
10Reference Range Endocrinology One size fits all95% population range“Everything is Normal”Hormone Effect“No Thyroid Disease”Too muchDiseaseToo littleDiseaseBut Hormone Effects vary continuously with concentration!0.611.82Thyroid Free T4 ng/dLHormone Level
11Intelligent Endocrinology Tighter range based on healthy persons and on physiological researchIndividualized Diagnosis and TreatmentHormone EffectOptimal??0.611.31.62FT4 ng/dLHormone Level
12What should we do about hormones that are lost to normal aging?
17Steroid Loss in Women>>Men Men WomenTestosteroneProgesteroneaverage50% loss90% Losspg/mlLessestrogenthanold men!♂♂♀♀DHEA-S 5,000,000pg/ml Cortisol 100,000 pg/ml
18Common ViewThe loss of hormones is adaptive–helps us to live longer (?)Persistence of youthful levels of hormones would cause more heart attacks and cancers as we age (?)Fits the Pharmaceutical Agenda: Take drugs for every symptom and disorder caused by hormone loss (!?!)
19Against the Common View Aging is a natural self-destruct program that kicks in around age 25 in humansObesity, high blood pressure, heart attacks, autoimmune diseases, and many cancers increase years after hormone deficiencies set in, and occur more often in those with lower hormone levels!Studies of balanced hormone restoration show the expected benefits and no proof of harm!!
20New Paradigm: Restorative Endocrinology Endocrine glands and their feedback control systems deteriorate with age.Our bodies cease to regulate our hormones for optimal health.Partial hormone deficiencies are harmful.The restoration of youthful/optimal nutrient and hormone levels is:Essential to preventative medicineEssential to the treatment of diseaseEssential to our quality of Life!
21Hypometabolism: Thyroid and Cortisol Insufficiency Thyroid sets throttle, cortisol delivers the fuelOur health and quality of life require optimal levels of both hormones!Deficiencyreduced metabolic ratefatigue, brain dysfunction, depression, painConventional tests are insensitive to deficienciesIrrational fear of thyroid and cortisol supplementationUnderdiagnosed, undertreated—Docs prescribe pharmaceuticals instead (SSRIs, amphetamines, anti-seizure drugs, anti-psychotics, sedatives, etc.)
22Hypothyroidism Mental fog, poor concentration Depression Fatigue, need for excessive sleepCold extremitiesAches and painsThinning scalp hairWeight gainConstipationAnkle swelling, puffy face
23Thyroid Testing Doctors often order only a TSH test--Inadequate Thyroid stimulating hormone (TSH) is NOT a thyroid hormone, it is an indirect and fallible indicator of thyroid hormone levels.Must measure free T4 and free T3 levels—for both diagnosis and monitoring therapy.Hypothyroidism: symptoms plus one or both hormone levels below middle of population rangesSevere hypothyroidism: signs and symptoms plus both hormones in lower third of ranges.
24We Need Optimal T4/T3 Levels Incidence of severe atherosclerosis cut in half with higher T3 levels within the laboratory range Clin Cardiol Dec;26(12):569-73Lowers cardiac risk factors: cholesterol, triglycerides, C-reactive protein, homocysteine and lipoprotein(a)Lowers blood pressure, dilates arteriesReduces tendency to form blood clotsHelps prevent weight gain
25Fatigue, Fibromyalgia and Depression Epidemic Chronic fatigue, fibromyalgia, and depression: low thyroid and/or low cortisol until proven otherwisePre-1970s: Treat the patient’s signs and symptoms with T4 and T3 (desiccated thyroid-- Armour )Post-1970s: Treat TSH test using T4 only!Doctors often lowered doses by 30-50%!TSH-normalizing T4 dose oftenlower free T3 levels weight gain, persistence of symptomsThyroid optimization helps most patients with symptoms and “low-normal” thyroid levels.
26Restorative Thyroidology Do Not Rely on TSH test for diagnosis or treatment Fraser WD, Are biochemical tests of thyroid function of any value in monitoring patients receiving thyroxine replacement? Br Med J (Clin Res Ed) Sep 27;293(6550):808-10Give T4 plus T3 (Armour, Cytomel+levothyroxine)Adjust dose according to symptoms and free T4 and free T3 levelsOptimizing hormone levels within physiological ranges is safe:No bone loss if Vit. D and hormones are restoredNo cardiac dysfunction J Clin Endo Metab Jan;85(1):159-64No muscle wasting Am J Phys Endo Metab Jun;288(6):E
27Cortisol Made in the adrenal glands The body’s natural “steroid”--↑’d levels needed in stress, inflammationMaintains blood sugar (delivers the fuel)Too muchDiabetes, HTN, belly fat, osteoporosisToo littlefatigue, depression, aches & pains, anxiety, hypoglycemia, insomnia, inflammationModulates the immune system—prevents and treats allergies and autoimmune diseasesWe need higher levels with stress and disease
29Mild-to-Moderate Cortisol Insufficiency Common cause of chronic fatigue, painCommon cause of thyroid hormone intoleranceUnrecognized: Docs taught to recognize only Addison’s Disease (total adrenal gland failure)Serum cortisol and ACTH stimulation tests are insensitive Reimondo G, Pituitary. 2008;11(2): Streeten DH, J Clin Endocrinol Metab Jan;81(1):Best test is saliva cortisol levels throughout day Gozansky WS, Clin Endocrinol (Oxf) Sep;63(3):Clues: Feels much better on prednisone, often needs steroids for allergies, illnesses, etc.
32Cortisol RestorationMild deficiency will improve with stress, rest, adrenal supplements, licorice rootModerate-to-severe deficiency—needs cortisol restorationPhysiological doses of 15-30mg daily do not cause hypertension, osteoporosis, diabetesTaking cortisol or any glucocorticoid depresses DHEA, must replace.Doctors fear of low-dose cortisol therapy is unfounded Dr. William Jeffries’ Safe Uses of Cortisol
33Adrenal Hormones and Rheumatic Diseases Rheumatic diseases assoc. with ↓HPA activity, lower cortisol levels, and relative adrenal insufficiency Johnson EO, Ann N Y Acad Sci Nov;1088: Demir H, Scand J Rheumatol May-Jun;35(3): Chikanza IC, Arthritis Rheum Nov;35(11): Cutolo M, J Endo Invest. 2002;25(10 Suppl): Ann N Y Acad Sci Jun;1069: Gudbjornsson B, J Rheumatol Apr;23(4): Mastorakos G, Z Rheum.2000;59 Suppl 2:II/75-9. Kebapcilar L, J Endocrinol Invest Jul 20. Shah D, Kathmandu Univ Med J (KUMJ) Jul-Sep;7(27):213-9.Cortisol receptor isoforms and polymorphisms assoc. with autoimmune disease. Tait AS J Leukoc Biol Oct;84(4):Low DHEAS found years before onset of RA, and in all rheumatic diseases. Masi AT, Ann N Y Acad Sci Jun 22;876:53-62; disc.62-3.Stress is a trigger of autoimmune disease. Stojanovich L, Autoimmun Rev Jan;7(3):Low cortisol levels in fibromyalgia , chronic pain. Gur A, Ann Rheum Dis Nov;63(11): McBeth J, Arthritis Res Ther. 2005;7(5):R992-R1000.
34The Female DilemmaWomen make 1/2 as much cortisol as men Vierhapper H, Metabolism Aug;47(8):974-6.Women release less cortisol under stress Takai N, Ann N Y Acad Sci Mar;1098:510-5.Estradiol lowers cortisol levels and opposes cortisol throughout the body. Kerdelhué B, Neuro Endocrinol Lett Oct;27(5): Ligeiro de Oliveira AP, Neuroimmunomodulation. 2004;11(1):20-7Anti-depressants increase cortisol levels and effects Sagud M, Neuropsychobiology ;45(3):139-43Female/Male ratios: Fibromyalgia 8:1, RA 3:1, SLE 9:1, PMR 2:1, Sjogrens 18:1, Chronic fatigue 4:1, Depression 2:1, Hashimotos /Graves thyroiditis 5:1, Anxiety 3:2, Mult. Sclerosis 3:1
35DHEA Most abundant steroid hormone; yet ignored Cells make testosterone and estradiol with itAnabolic—builds tissues, improves immunityReduces intra-abdominal fat Villareal DT, JAMA Nov 10;292(18):Reduces inflammationAnti-atherosclerotic effectAnti-cancer effect in animal, in vitro studiesLow levels of DHEAS found in autoimmune diseasesSteroid therapy greatly reduces DHEA, must replace
37DHEA ReplacementImproves blood sugar control, lowers insulin levels, and counteracts negative effects of diabetes Brignardello E, Diabetes Care Nov;30(11): Dhatariya K, Diabetes Mar;54(3): Lasco A, Eur J Endocrinol Oct;145(4):25mg/day improves mood, fatigue and joint pain in elderly men. Genazzani AR, Aging Male Jun;7(2):Improves fertility in older women Barad D, J Assist Reprod Genet Dec;24(12):629-34,Improves sexuality in postmenopausal women. Hackbert L, J Womens Health Gend Based Med Mar;11(2):Alleviates depression Bloch M, Biol Psychiatry Jun 15;45(12): Rabkin JG, Am J Psychiatry Jan;163(1): Schmidt PJ, Arch Gen Psychiatry Feb;62(2):Reduces pain—restores natural endorphins Stomati M, Gynecol Endocrinol Feb;13(1):15-25.
38DHEA ReplacementImproves mood and energy in patients on steroid replacement Hunt PJ, Clin Endocrinol Metab Dec;85(12):4650-6Decreases platelet aggregation Jesse RL. Ann N Y Acad Sci 1995 Dec 29;774:281-90Increases bioavailable IGF Morales AJ, J Clin Endocrinol Metab Jun;78(6):1360-7Counteracts high cortisol level/effects Kroboth PD, J Clin Psychopharmacol Feb;23(1):96-9Increases natural killer cell number and activity Casson, P Am J. Obstet Gynecol 169:Reduces inflammatory markers (IL-6, TNF-) Daynes RA, J Immunol 1993 Jun 15;150(12):Beneficial in ulcerative colitis and Crohn’s disease Andus T, Aliment Pharmacol Ther :
39DHEA for SLE SLE patient have very low DHEAS levels Given by prescription as PrasteroneIncreases IL-2 and reduces SLE disease activity Petri MA, Arthritis Rheum Sep;50(9):Allows reduction in steroid dose. Petri MA, Arthritis Rheum Jul;46(7):Suppresses IL-10, a cytokine that increases autoantibody production in Lupus Chang DM, Ann Rheum Dis Dec;63(12):Improves well-being, sexuality, and cognition in women with Lupus or adrenal insufficiency Arlt W, Endocr Res Nov;26(4): Nordmark G, Autoimmunity Nov;38(7):
40TNF-α and Adrenal Hormones TNF-α is an inflammatory cytokine that is elevated in autoimmune diseases.Better cortisol and DHEAS levels suppress TNF-α levels.TNF-α suppresses cortisol and DHEAS production→more inflammation, vicious cycleAnti-TNF-α drugs increase cortisol and DHEAS levels. Straub RH, Arthritis Rheum Apr;58(4): Arthritis Rheum Jun;48(6): , Ernestam S, J Rheumatol Jul;34(7):
41Steroids in Rheumatic Disease Doctors view steroids as drugs, not hormonesLong-term , low-dose treatment is actually hormone replacement (prednisone ≤7.5mg, Medrol ≤6mg)Low-dose prednisone (≤7.5mg/d) generally safe Da Silva JA, Ann Rheum Dis Mar;65(3):Short-term, high dose treatment is pharmacological—for disease suppression.Hydrocortisone preferred, but short-acting, long- acting tablets under developmentPrednisone/prednisolone are closest in structure to cortisol, but have more negative effects.
42DHEA in Rheumatic Diseases Taking oral steroids drastically reduces DHEA levelsDHEA prevents “side effects” of steroids and reduces pain and inflammationAll patients on steroids should be given DHEA. Straub RH, Z Rheumatol. 2000;59 Suppl 2:II/Best taken sublingually 2x/day, mg/day for women, 25 to 50mg/day for men. (Life Extension, dissolve-in-the-mouth 25mg tablets)Women may experience pimples, oily skin initiallyStart with low dose and work up gradually
43Vitamin D A powerful hormone with anti-inflammatory effects Vit. D levels low in SLE patients, contributing to inflammation. Supplementation improves immune system abnormalities. Cutolo M, Lupus 2008;17(1):6-10. Kamen D, Aranow C. Curr Opin Rheumatol Sep;20(5):532-7.Higher Vit. D levels assoc. with lower TNF-α. Peterson CA, J Inflamm (Lond) Jul 24;5:10.Levels must be >30ng/ml for significant benefitOptimal levels 55-70ng/ml, usually requires 4000IU Vit. D3 daily.
44Fish Oils—Omega-3 Fatty Acids Decrease the production of inflammatory eicosanoids, cytokines, and reactive oxygen species. Calder PC. Am J Clin Nutr Jun;83(6 Suppl):1505S-1519S.Reduce TNF- α levels. Fetterman JW Jr, Am J Health Syst Pharm Jul 1;66(13):Improve SLE disease activity and have cardiovascular benefits. Duffy EM, J Rheumatol Aug;31(8): Wright SA, Ann Rheum Dis Jun;67(6):841-8.Proven to be beneficial in Rheumatoid Arthritis. Proudman SM, Rheum Dis Clin North Am May;34(2):Dose: 1500 to 3000mg EPA +DHA daily
45Sex Hormones in Autoimmune Diseases Low testosterone and progesterone levels seen in men and women with RA.Testosterone and progesterone have immunosupressive effects. Wilder RL. J Rheumatol Suppl Mar;44:10-2. Schust DJ, Hum Reprod May;11(5):980-5.RA and MS improve during pregnancy worsen during breast feeding (low progesterone/estrogen).Higher testosterone levels helpful in autoimmune diseases that affect women>menEstrogen and testosterone beneficial in MS. Gold SM, Prog Brain Res. 2009;175:
46Not Just “Sex Hormones” Estradiol, progesterone, testosterone and DHEA are required for the function, growth, and maintenance, of all tissues in both sexes!Maintain brain function and health— neurosteroids affect mood, cognition, memory, pain, etc.Maintain the immune system—progesterone and testosterone are mild immunosuppressantsMaintain connective tissue: skin, hair, bone, muscleImprove insulin sensitivity: prevent diabetes, fatty liverReduce blood pressure—improve endothelial functionPrevent atherosclerosis (plaques in arteries)
4730Speroff L, Fritz M Clinical Gynecologic Endocrinology and Fertility, 7th Ed.
48OsteoporosisIn menopause 5% bone loss each year for first 5 years=25%—due to loss of estrogen!20 yrs. post menopause—50% reduction in trabecular bone, 30% in cortical bone50% of women >65 yrs. old have spinal compression fractures14% lifetime risk of hip fracture for 50 yr.old woman, 30% for 80 yr. old.Speroff L, Fritz M Clinical Gynecologic Endocrinology and Fertility, 7th Ed.
49Osteoporosis Prevention and Treatment A hormone deficiency disease—the proper prevention and treatment is hormone restoration.Estradiol prevents resorption of old bone while testosterone, progesterone, DHEA and GH build new bone. Raisz LG, J Clin Endo Metab. 1996; 81: Barrett-Connor E, J Reprod Med Dec;44(12):Hormone restoration including Vit. D increases bone density better than bisphosphonates and preserves normal bone remodelingWomen on prednisone 5 to 15mg/day gained bone mass with either estradiol/progesterone or DHEA replacement. Lukert BP, J Bone Miner Res Sep;7(9): Mease PJ, J Rheumatol Apr;32(4):
50Estradiol Restoration Eliminates hot flashes, restores sleepRestores cognitive function and moodMaintains thickness, fullness of skin and hairMaintains genital/pelvic health-helps with vaginal lubrication, incontinence, bladder infectionsProtects against colon cancer and macular degenerationProtects against dementiaPrevents atherosclerosis, hypertensionImproves insulin sensitivity—prevents diabetesPrevents osteoporosis and osteoarthritisMust be accompanied by progesterone
51Female Hormone Replacement: Risks? WHI study showed that Premarin and Provera have serious risks.However, only oral estrogens (Premarin, BCPs) increase blood clotting (DVT’s, stroke), transdermal estradiol does not. Canonico M, ESTHER study. Circulation Feb 20;115(7):840-5Provera increases breast cancers and heart attacks, progesterone does not.
52Cohort study55,000 women8 years f/uc/w WHI--16,000, 6 yr. f/uE3N-EPIC StudyTD-E2=transdermal estradiolNo HRTInt J Cancer Apr 10;114(3):448-54E2 plus progesterone: no increased risk of breast cancer!Similar study: estradiol + progesterone 0.4; estradiol + synthetic progestin 0.94Espié, Gynecol Endocrinol Jul;23(7):391-7.
53Female AndropauseYoung woman’s free testosterone level is 2x her free estradiolDHEAS declines with age—main source of androgen effect in womenFemale testosterone levels decline 50% between age 20 and 45.Oral estrogens and birth control pills reduce free testosterone and DHEAS levels
54Testosterone for Women Improves energy and moodImproves sexual desire and sensationIncreases muscle and tissue strengthWith estradiol, increases bone densityJ Reprod Med Dec;44(12):Probably decreases risk of heart attackJ Womens Health Sep;7(7):825-9Opposes estradiol-induced breast stimulation and reduces risk of breast cancerMenopause Jul-Aug;10(4):292-8, Endocr Rev Jun;25(3):374-88Menopause Sep-Oct;11(5):531-5, FASEB J Sep;14(12):
55Andropause in MenTestosterone levels decline slowly in men— “just getting old.”Fatigue, reduced mental functionPassivity and moodiness—loss of drive and ambitionLoss of muscle, increased abdominal fatIncreased blood sugar and blood pressureLoss of libido, spontaneous erections, and eventually erectile function.
56Testosterone Restoration for Men Improves mood and sociabilityRestores energy and ambitionImproves cognition, protects against Alzheimer’s diseaseIncreases libido and sexual performanceIncreases muscle and bone massReduces abdominal fat, improves insulin sensitivity, lowers blood pressure-- counteracts metabolic syndrome (Syndrome X)
57Testosterone and the Heart Low testosterone levels correlate with coronary artery disease and strokeArterioscler Thromb. 1994; 14:Eur Heart J 2000; 21; 890–4Int J Cardiol Jan 31;63(2):161-4Arterioscler Thromb Vasc Biol Jun;16(6):749-54Testosterone dilates coronary arteries—improves anginaT increases heart muscle size, strengthT decreases fibrinogen levels—prevents blood clots Endocr Res. 2005;31(4):335-44
58Testosterone and the Prostate Lower testosterone levels increase the risk of prostate cancer. Endogenous sex hormones and prostate cancer: a collaborative analysis of 18 prospective studies. J Natl Cancer Inst Feb 6;100(3):170-83, also Morgenthaler A, Urology 2006;68:1263-7Testosterone supplementation does not increase the risk of prostate cancer. Morgentaler A, Testosterone replacement therapy and prostate risks: where's the beef? Can J Urol Feb;13 Suppl 1:40-3Low testosterone associated with more aggressive prostate cancers Slater S, Drugs Aging 2000 Dec;17(6):431-9Testosterone promotes prostate growth to a point, but does not promote prostate cancer.Prostate cancer growth can be temporarily slowed only by eliminating testosterone from the body.
59Growth Hormone Declines 14% per decade after age 25 IGF-1 of many adults equal to hypopituitary patients (only vs.Deficiency heart disease, frailty, depression, body fat, bone lossGH restoration for GH-deficient adults:Improves cognition, mood, sleep, energy, staminareduces abdominal fatlowers blood sugar, cholesterol, and blood pressureIncreases muscle massImproves bone density, skin thicknessDownside: $200/mo. for low dose, daily injections
60Approach to Rheumatic Diseases First, diagnose and treat adrenal, sex hormone, and thyroid deficienciesCortisol and prednisone can be taken long- term in low doses and accompanied by DHEA.Optimize Vit D and Fish oil intakePharmaceuticals as needed in consultation with rheumatologist
61For More InformationThe Hormone Solution—Stay Younger Longer Thierry Hertoghe, MDThe Miracle of Natural Hormones David Brownstein, MDHow to Achieve Healthy Aging—Look, Live, and Feel Fantastic After 40 Neal Rouzier, MDLife Extension Foundation (www.lef.org)Information and hundreds of abstracts atContact me: