Presentation on theme: "Bioidentical Hormone Restoration Best Medical Practice This presentation available online."— Presentation transcript:
Bioidentical Hormone Restoration Best Medical Practice This presentation available online
Topics Hormone Loss with Age Estradiol and Progesterone for Menopause Progesterone vs. Breast Cancer Pharmaceutical Hormone Substitution Testosterone for Women and Men Hypometabolism: Cortisol and Thyroid Compounding Pharmacies Practical Issues
Hormones Parts of our integrated neuro-endocrine- immune system Travel via blood to all cells Control proliferation, differentiation, protein synthesis, metabolic rate, etc. The most powerful molecules in biology Optimal levels and effects are essential for health and quality of life
Master Gland Central Control TSH ACTH LH/FSH T3, T4 Cortisol, DHEA Aldosterone Estradiol, Progesterone Testosterone
Human Steroid Hormones Testosterone Estradiol Progesterone Cortisol DHEA Drug companies have patented ~5 to 100 variations of each molecule. Aldosterone
Bioidentical Hormones are not Drugs Same moleculefunctions properly at receptors, normal metabolism/elimination Non-toxic: No side effects, only effects No interactions with drugs No allergic reactions Safe in youthful physiological levels/balance Bad effects if dose is excessive, delivery route is wrong, or lack of balance with other hormones
Bioidentical Hormone Restoration is Good Medical Practice If a hormone is missing, replace it! If present but insufficient, optimize it! Type 1 Diabetes: bioidentical insulin Hypothyroidism: bioidentical T 4 Growth hormone def.: bioidentical GH Adrenal insufficiency: bioidentical cortisol What do we do about mild-moderate deficiencies and deficiencies due to aging?
Growth Hormone (GH) Somatopause Modified from Jull A et al., J. Clin. Endo. Metab. 1994; 78:
Steroid Loss in Women>>Men pg/ml DHEA-S 5,000,000pg/ml Cortisol 100,000 pg/ml Men Women Progesteron e average Testosterone 0-31 pg/ml Less estrogen than old men! (25-55 pg/ml)
Andropause Testosterone in Men
Common View The 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 (!?!)
Against the Common View Aging is a self-destruct program that kicks in around age 25 in humans Obesity, 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!!
Why Docs Dont Get It: Reference Range Endocrinology Normal ranges are misunderstood: 95% of all persons tested (only 2.5% low) 95% of tested persons of same age Optimal values (glucose, cholesterol) Docs assume that all ranges are optimals! Male free testosterone: x! Female free testosterone: ! Thyroid - Free T4: x! AM serum cortisol x! Normal no hormonal dx/rx drugs Eithe r
Hormone Effect Hormone Level /5 population range Too Little Disease Everything is Normal Too much Disease No Disease Reference Range Endocrinology FT4 ng/dL Thyroid Hormone Testing
Hormone Effect Hormone Level Too Little? Too much? Intelligent Endocrinology Optimal?? FT4 ng/dL 80/20 range 80/20 range based on carefully screened young healthy population Individualized Diagnosis and Treatment
New 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 medicine Essential to the treatment of disease Essential to our quality of Life!
Not 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 systemprogesterone and testosterone are mild immunosuppressants Maintain connective tissue: skin, hair, bone, muscle Improve insulin sensitivity Reduce blood pressureimprove endothelial function Prevent atherosclerosis (plaques in arteries)
Women Killers and Hormones Cardiovascular disease (CVD), osteoporosis, and breast cancer are all rare before menopause. All three diseases are clearly related to hormone deficiency or imbalance. Youthful estradiol/progesterone/testosterone hormonal milieu protects women from these diseases.
Coronary Heart Disease vs. Age AIHW Heart, stroke and vascular diseases - Australian facts Female
Breast Cancer Rate vs. Age National Cancer Institute. SEER cancer statistics review Table IV-3. Menopause Loss of ovarian function higher risk of breast cancer Ovarian function
Estrogen Replacement Prevents Alzheimers Disease Zandi PP, et al., Cache County Study. JAMA Nov 6;288(17): RR 0.46 in Kawas C, The Baltimore Longitudinal Study of Aging. Neurology 1997;48: RR 0.65 Paganini-Hill A, Arch Intern Med 1996;156: RR 0.4, Tang M-X, Lancet 1996;348: % used Premarin only
Speroff L, Fritz M Clinical Gynecologic Endocrinology and Fertility, 7 th Ed. 30
Osteoporosis In menopause 5% bone loss each year for first 5 years=25%due to loss of estrogen! 20 yrs. post menopause50% reduction in trabecular bone, 30% in cortical bone 50% of women >65 yrs. old have spinal compression fractures 14% lifetime risk of hip fracture for 50 yr.old woman, 30% for 80 yr. old. Speroff L, Fritz M Clinical Gynecologic Endocrinology and Fertility, 7 th Ed.
Osteoporosis Prevention and Treatment A hormone deficiency diseasethe 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; 81:37-43 Barrett-Connor E, J Reprod Med Dec;44(12): Hormone restoration increases measured bone density better than bisphosphonates and preserves normal bone remodeling Bisphosphonate drugs cause Ca ++, esophageal inflammation and cancer, and suppression of normal bone formation poor fracture healing, late non-traumatic fractures, and rotting jaw.
Female Endocrinology Nature makes special demands on the female body for reproduction. More complex hormonal system than men Breast, uterine and ovarian tissues undergo a monthly cycle of proliferation, differentiation, and breakdown Defects in this cycle can lead to cancers in female organs and to many medical disorders.
EstradiolProgesterone Complementarity Estradiol (human estrogen) promotes breast/uterine proliferation and growth. Progesterone stops proliferation and promotes maturation and differentiation. Differentiated cells cant become cancers. Progesterone withdrawal sloughing and necrosis of uterine lining and breast duct epithelium. Longacre TA, Am J Surg Pathol Jun;10(6): High progesterone/estradiol ratio suppresses proliferation and prevents cancers Estradiol is safe if opposed by progesterone.
Progesterones Anti-Estrogenic Actions in Uterus and Breast Decreases synthesis of estradiol receptors Increases conversion of estradiol to estrone (weak estrogen) by inducing 17β- hydroxysteroid dehydrogenase Type 2 Reduces conversion of estrone to estradiol by inhibiting 17β-HSD Type 1 Increases sulfation (inactivation) of estrogens Williams Text. of Endocrinology, 10 th Ed., p. 612
Progesterone Deficiency Estrogen Dominance Allergies Autoimmune diseases Anxiety, irritability Insomnia Decreased sex drive Depression Bloating and edema Fibrocystic breasts Uterine fibroids Breast cancer Ovarian cancer Uterine cancer Thyroid dysfunction Gallbladder disease Heavy periods Migraines Seizures Endometriosis Progesterone restoration is the only effective treatment for estrogen dominance
Aging Ovaries Females born with a fixed no. of oocytes which are continually lost With aging, fewer oocytes of lower quality are left reduced estradiol and progesterone production beginning as early as age 30 Lower progesterone estrogen dominance No ovulation=no progesterone
Normal Progesterone Dominance Ovulation Menstrual Cycle Ovulation
Perimenopause Luteal Insufficiency=Estrogen Dominance Menstrual Cycle Inadequate Luteal Phase shorter periods, early spotting d risk of breast cancer Ovulation
Anovulation=Estrogen Dominance Menstrual Cycle d risk of breast and uterine cancers
Menopause Estradiol and Progesterone Deficiency
Menopause=Estradiol Deficiency Hot flashes Irritability, insomnia, depression Fatigue, aches and pains Poor memory, d risk of Alzheimers dementia Osteoporosis spine and hip fractures, loss of teeth Genital atrophy, vaginal dryness Atrophy of skin and connective tissue Endothelial dysfunction, blood pressure Increased blood sugar Atherosclerosis, heart disease
Estradiol Restoration Eliminates hot flashes, restores sleep Protects cognitive function, improves mood Maintains thickness, fullness of skin and hair Protects against colon cancer and macular degeneration Protects against dementia Prevents atherosclerosis, hypertension Maintains genital/pelvic health Improves insulin sensitivityprevents diabetes Prevents osteoporosis and osteoarthritis Maintains gynecoid fat distribution
Q: But wont estradiol restoration increase the risk of breast cancer? A: No, not if given with progesterone.
E3N-EPIC Study E2 plus progesterone decreased risk of breast cancer! Int J Cancer Apr 10;114(3): Cohort study 55,000 women 8 years f/u c/w WHI-- 16,000, 6 yr. f/u TD-E2=transdermal estradiol See also: De Lignieres B, de Vathaire F, Fournier S, et al. Combined hormone replacement therapy and risk of breast cancer in a French cohort study of 3175 women. Climacteric 2002;5:332–40. No HRT
Ordet Study: Int. J. Cancer 112 (2004) (2), pp. 312–318. Higher progesterone=lower risk of breast cancer 6,000 women 5 yr. F/U Progesterone vs. Breast Cancer in menstruating women Risk of breast cancer
Progesterone vs. Breast Cancer Progesterone cream applied to the breast reduces proliferation. Chang KJ, Fertil Steril 1995; 63: Barrat J, J Gynecol Obstet Biol Reprod (Paris). 1990;19(3): Foidart JM, Fertil Steril May;69(5):963-9 Estradiol is carcinogenic in breast cell cultures unless progesterone is present. Russo J, J Steroid Biochem Mol Biol Oct;87(1):1-25 Normal breast cells proliferate after E2 treatment, but become quiescent when P is added. Malet C, J Steroid Biochem Mol Biol Jun;73(3-4): Foidart JM, Fertil Steril.1998 May;69(5):963-9 Estrogen upregulates cancer-promoting gene bcl-2, progesterone downregulates it. Formby B, Ann Clin Lab Sci Nov- Dec;28(6):360-9
Progesterone vs. Breast Cancer Premenopausal women with low progesterone levels had 5.4x risk of early breast cancer Cowan LD, Am J Epidem 1981;114: Breast cancer victims have progesterone resistance Simpson HW, Br J Obstet Gynaecol Mar;105(3): Progesterone decreases proliferation and induces apoptosis in breast cancer cell lines. Ansquer Y, Anticancer Res Jan- Feb;25(1A):243-8 Groshong SD, Mol Endocrinol Oct;11(11): Progesterone receptor positivity predicts better long-term survival with breast cancer Costa SD, Eur J Cancer Jul;38(10): Lamy PJ, Breast Cancer Res Treat Nov;76(1):65-71
Key: Hormones within the Breasts Breast fatty tissue produces estradiol locally from adrenal androgens (DHEA, androstenedione) Compared to the premenopausal breast, postmenopausal breast nipple aspirate fluid has: Same estradiol concentration (youthful serum conc.) Much lower progesterone concentration Chatterton RT Clin Endocrinol Metab Mar;90(3): Breasts must get progesterone from blood, and they concentrate it by a factor of 3 to 4x. Gann PH, Cancer Epidemiol Biomarkers Prev Jan;15(1): In peri-menopause/menopause: No progesterone estrogen dominance in the breasts breast cancer.
Top European Researchers Agree! The hypothesis of progesterone …decreasing the proliferative effect of estradiol in the postmenopausal breast remains highly plausible and should be, until the coming of new evidences, the first choice for symptomatic postmenopausal women. Modena MG, Sismondi P, Mueck AO, Kuttenn F, Lignieres B, Verhaeghe J, Foidart JM, Caufriez A, Genazzani AR; The TREAT. Maturitas Sep 16;52(1):1-10.
So why are most doctors saying that hormone replacement for menopause is dangerous?
Pharmaceutical Hormone Replacement Therapy Horse-urine Premarin approved in 1942 Synthesis of first human steroid hormone, progesterone, in Poorly absorbed orally Progesterone altered to make progestins among the first drugs to be patented. HRT= alien molecules with hormone effects Drug Co.s became dependent on HRT profits 1942 to presentDrug Co.s push doctors to use hormone substitutes and to ignore or fear natural hormone restoration!
Conventional HRT is really HST: Hormone Substitution Therapy! Estradiol substitutes: conjugated equine estrogens (CEE-Premarin ) and ethinyl estradiol (in birth control pills)=estrogen Progesterone substitutes: medroxyprogesterone acetate (MPA- Provera ) and 30+ other progestins Testosterone substitute: methyltestosterone Patented drugsnot human hormones! Most docs dont know the difference!
Estradiol Ethinyl Estradiol EE cannot be inactivated by normal oxidation! EE does not interact with estrogen receptor ! EE is 12,000-60,000 times more potent by weight! EE is highly thrombogenic DVTs, pulmonary emboli EE in Birth Control Pills Acetylene
Contraceptive Hormone Substitution is Dangerous EE with alien progestin, shuts down ovaries Lowers testosterone and DHEAS levels d risk of blood clots, stroke, heart attack 1-3x risk of breast cancer d blood sugar, blood pressure Liver tumors Diagnose and fix the hormonal disorder Use a copper IUD for contraception!! UpToDate 2006 Instead of using BCPs::
Premarin Conjugated Equine Estrogens Estrone Equilin Equilenin CEE contains at least 10 estrogens, only 3 are human; also contains horse androgens and progestins. Klein R The Composition of Premarin Int J Fertil 43:223 Human Horse Horse
Oral Estrogen Replacement is Dangerous First-pass effect on the liver IGF-1, SHBG, CRP, clotting factors blood clots, strokes, heart attacks in the first year Transdermal estradiol has none of these effects! Oral but not transdermal estrogen is associated with an increased VTE risk. Canonico M, ESTHER study. Circulation Feb 20;115(7):840-5 Transdermal estradiol improves insulin sensitivity, oral estrogens do not.
Progestins Progesterone Progesterone Provera Drospirenone Progestins are often called progesterone, even in scientific papers! Yasmin Prempro
Progestin Zoo Kuhl, Climacteric 2005;8(Suppl 1) progesteron e Every progestin has a different spectrum of androgenic, estrogenic, glucocorticoid, and progestational effects!
Provera Progesterone Maintains pregnancy Improves mood Improves sleep Diuretic No effect on blood sugar Maintains estrogen- induced arterial dilation Improves lipid profile No evidence of CVD Reduces estrogenic stimulation of breasts Prevents breast cancer Causes birth defects Can cause depression Insomnia, irritability Fluid retention Raises blood sugar Counteracts estrogen- induced arterial dilation Worsens lipid profile Causes heart attacks Increases estrogenic stimulation of breasts Causes breast cancer Scientific studies show that:
2002 WHI Study Menopausal HST is Dangerous! Premarin alone given to older postmenopausal women had adverse effects in the first year (strokes, blood clots) (as with all oral estrogens) Adding Provera (Prempro ) caused more adverse effects (breast cancers, heart attacks) Prempro caused a large increase in dementia, probably vascular. Thousands of lawsuits pending; drug companies running a legal-protection propaganda campaign to paint all hormones as equally dangerous!
As Women Choose Bioidenticals: ACOG Caves In to Pharma Pressure October 31, 2005, ACOG NEWS RELEASE No Scientific Evidence Supporting Effectiveness or Safety of Compounded Bioidentical Hormone Therapy Washington, DC – hormone therapy does not belong to a class of drugs with an indication for individualized dosing…ACOG recommends that all of them should be considered to have the same safety issues as those hormone products that are approved by the FDA and may also have additional risks unique to the compounding process. (So…….No differences exist between any: women, estrogens, progestins, bioidentical and alien molecules, or oral vs. transdermal estrogens. All hormone therapies are the SAME! ) ACOG is funded by Pharmaceutical Corporations that make hormone substitutes. ACOGs physicians individually receive money from these same Pharm. Corps.
Common Sense Substitutes are alien molecules! Problems caused by hormone substitutes cannot be attributed to human hormones until proven otherwise. Problems caused by oral estrogens dont apply to transdermal estradiol. Bioidentical hormone restoration to restore the youthful hormonal milieu must be considered safe until proven otherwise!
Menopausal Hormone Restoration Daily transdermal estradiol combined with progesterone (sublingual, transdermal, or oral). May stop for 5 days each month. No need to cycle and bleeduterine lining remains thin. No need to stop hormones, ever Most women need testosterone and DHEA for optimal results.
Menopause: Bioidentical Estradiol and Progesterone vs. Hormone Substitutes Any Questions?
Female Andropause Young womans free testosterone level is 2x her free estradiol DHEAS declines with agemain source of androgen effect in women Female testosterone levels decline 50% between age 20 and 45. Oral estrogens and birth control pills reduce free testosterone and DHEAS levels
Testosterone for Women Improves energy and mood Improves sexual desire and sensation Increases muscle and tissue strength With estradiol, increases bone density J Reprod Med Dec;44(12): Probably decreases risk of heart attack J Womens Health Sep;7(7):825-9 Opposes estradiol-induced breast stimulation and reduces risk of breast cancer Menopause Jul-Aug;10(4):292-8, Endocr Rev Jun;25(3): Menopause Sep-Oct;11(5):531-5, FASEB J Sep;14(12):
Andropause in Men
Testosterone Restoration for Men Improves mood and sociability Restores energy and ambition Improves cognition, protects against Alzheimers disease Increases libido and sexual performance Increases muscle and bone mass Reduces abdominal fat, improves insulin sensitivity, lowers blood pressure-- counteracts metabolic syndrome (X)
Testosterone and the Heart Low testosterone levels correlate with coronary artery disease and stroke Arterioscler Thromb. 1994; 14: Eur Heart J 2000; 21; 890–4 Int J Cardiol Jan 31;63(2):161-4 Arterioscler Thromb Vasc Biol Jun;16(6): Testosterone dilates coronary arteries improves angina T increases heart muscle size, strength T decreases fibrinogen levelsprevents blood clots Endocr Res. 2005;31(4):335-44
Testosterone 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: Testosterone 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 1:40-3 Low testosterone associated with more aggressive prostate cancers Slater S, Drugs Aging 2000 Dec;17(6):431-9 Testosterone promotes prostate growth to a point, but does not promote prostate cancer.
Testosterone for Women and Men Any Questions?
Hypometabolism: Thyroid and Cortisol Insufficiency Thyroid sets throttle, cortisol delivers the fuel Our health and quality of life require optimal levels of both hormones! Deficiency reduced metabolic rate fatigue, brain dysfunction, depression, pain Usual blood tests are insensitive Docs have an irrational fear of cortisol and thyroid supplementation unless a lab is low (L) Underdiagnosed, undertreatedDocs prescribe pharmaceuticals (SSRIs) instead.
Cortisol Made in the adrenal glands Maintains blood sugar (delivers the fuel) Modulates the immune system We need higher levels with stress, disease Too much Diabetes, HTN, osteoporosis Too little fatigue, depression, anxiety, autoimmune diseases, hypoglycemia, allergies, aches & pains Women have lower cortisol levels/effects and much more low-cortisol-related problems than men.
Mild-to-Moderate Cortisol Insufficiency Blood tests are insensitive, need diurnal salivary cortisol profile Undiagnosed: Docs only taught to recognize Addisons Disease (total adrenal gland failure) Common cause of chronic fatigue, pain Common cause of thyroid hormone intolerance Clue: Felt better on prednisone, often needs steroids
Normal Saliva Cortisol Profile
Cortisol Restoration Mild deficiency can resolve with stress, rest, adrenal supplements Moderate-to-severe deficiencyneeds cortisol restoration Physiological doses of 15-40mg daily do not cause hypertension, osteoporosis, diabetes Docs fear of low-dose cortisol unfounded See Dr. William Jeffries Safe Uses of Cortisol
DHEAThe Other Adrenal Hormone Most abundant steroid hormone; yet ignored Cells make testosterone and estradiol with it Anabolicbuilds tissues, improves immunity Reduces abdominal fat Reduces painrestores natural endorphins Reduces inflammation ( IL-6, TNF-, IL-2) Anti-cancer effect in animal, in vitro studies
Cortisol and DHEA Any Questions?
Hypothyroidism Mental fog, poor concentration Depression Fatigue, need for excessive sleep Cold extremities Aches and pains Thinning scalp hair Weight gain Constipation Ankle swelling, puffy face
Thyroid Testing Doctors often order only a TSH test-- Inadequate. Thyroid stimulating hormone (TSH) is a pituitary hormone. It is NOT a thyroid hormone. Docs sometimes measure free T 4 but rarely measure free T 3 levels! Need free T 4 and free T 3 levels Hypothyroidism present if symptoms exist and one or both hormones are below middle of reference ranges; severe hypothyroidism when both are in lower third of ranges.
We Need Optimal T 3 Levels Incidence of severe atherosclerosis doubled with lower T 3 levels within the reference range Clin Cardiol Dec;26(12): Lowers cardiac risk factors: cholesterol, triglycerides, C-reactive protein, homocysteine and lipoprotein(a) Lowers blood pressure, dilates arteries Reduces tendency to form blood clots Prevents weight gain
Fatigue, Fibromyalgia and Depression Epidemic Pre-1970s: Treat the patients symptoms with T 4 and T 3 (desiccated porcine thyroid--Armour ) Post-1970s: Treat TSH test using T 4 only! Doctors lowered doses by 30-50%! TSH-normalizing T 4 dose often lower free T 3 levels, weight gain, persistence of symptoms Thyroid optimization helps many symptomatic patients with low- normal thyroid levels, especially those with fatigue, fibromyalgia, and depression
Rational Thyroid Restoration If sign/symptoms of hypothyroidism: Restore! Do not rely on TSH test to diagnose or to guide 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): Give T 4 plus T 3 (Armour, Cytomel +T4) Increase dose until symptoms are gone or S/S of excess dosing appear Safe: No bone loss if Vit. D and hormones are restored No cardiac abnormalities J Clin Endo Metab Jan;85(1): No muscle wasting Am J Phys Endol Metab Jun;288(6):E
Thyroid Restoration Any Questions?
Growth 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 loss GH restoration for GH-deficient adults: reduces abdominal fat lowers blood sugar, cholesterol, and BP Improves cognition, mood, sleep, energy, stamina Increases muscle, decreases fat Improves bone density, skin thickness Downside: at least $185/mo., daily injections
What Else Can Hormone Restoration Help? Infertility, PMS, heavy bleeding, endometriosis Insomniaalmost always Heart failure, Angina Mood/Anxiety/Cognitive disorders Autoimmune diseases (Systemic Lupus Erythematosis, Rheumatoid Arthritis, Ulcerative Colitis, Crohns Disease, etc.) Allergies, skin diseases Every disease/disorder!!
Where Do They Come From? All steroid hormones (including substitutes) are chemically synthesized from diosgenin (wild Mexican yams, soy, and other plants).
Compounding Pharmacies USP-certified bioidentical hormones mixed into creams, sublingual tablets, capsules. Inexpensive! Winola PharmacyRt. 307 at Lake Winola, Harrolds PharmacyW-B, Finos PharmacyDallas, Hazle Drugs ApothecaryHazelton
Controversies Best delivery methods Ideal doses Variations between compounding pharmacies When/how to measure levels and effects To cycle or not to cycle estradiol and progesterone Estriol? Bioidenticals, especially compounded, not well studiedno money.
Doing HR History, consent, contract forms online Get saliva and blood tests before visit, or Dr. Lindner can order tests at initial visit. Individualized adjustment, trial and error Follow-up office visits as needed; at least every 6 months initially, once/year when stable. Telephone follow-ups as needed. Brief e- mail responses are free.
Costs Physician time only as $4/min No Medicare or insurance billing; may submit claim for recognized diagnoses Hormones$10 to $80/month from compounding pharmacy, often covered by insurance Diurnal salivary cortisol test$138, or insurance Blood testsinsurance usually covers, or pay for discount labs ~$50 to $300 Out-of-pocket professional fees and prescription hormones are tax-deductible
For More Information The Hormone SolutionStay Younger Longer Thierry Hertoghe, MD The Miracle of Natural Hormones David Brownstein, MD How to Achieve Healthy AgingLook, Live, and Feel Fantastic After 40 Neal Rouzier, MD Life Extension Foundation (www.lef.org) Information and hundreds of abstracts at Contact me: