Presentation on theme: "Bioidentical Hormone Restoration Best Medical Practice"— Presentation transcript:
1Bioidentical Hormone Restoration Best Medical Practice This presentation available online
2Topics Hormone Loss with Age Estradiol and Progesterone for Menopause Progesterone vs. Breast CancerPharmaceutical Hormone SubstitutionTestosterone for Women and MenHypometabolism: Cortisol and ThyroidCompounding PharmaciesPractical Issues
3Hormones Parts of our integrated neuro-endocrine- immune system Travel via blood to all cellsControl 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 TestosteroneEstradiolDHEAProgesteroneAldosteroneCortisolDrug companies have patented ~5 to 100 variations of each molecule.
6Bioidentical Hormones are not Drugs Same molecule—functions properly at receptors, normal metabolism/eliminationNon-toxic:No side effects, only effectsNo interactions with drugsNo allergic reactionsSafe in youthful physiological levels/balanceBad effects if dose is excessive, delivery route is wrong, or lack of balance with other hormones
7Bioidentical Hormone Restoration is Good Medical Practice If a hormone is missing, replace it!If present but insufficient, optimize it!Type 1 Diabetes: bioidentical insulinHypothyroidism: bioidentical T4Growth hormone def.: bioidentical GHAdrenal insufficiency: bioidentical cortisolWhat do we do about mild-moderate deficiencies and deficiencies due to aging?
13Common 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 (!?!)
14Against the Common View Aging is a 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!!
15Why Docs Don’t Get It: “Reference Range Endocrinology” “Normal” ranges are misunderstood:95% of all persons tested (only 2.5% low)95% of tested persons of same ageOptimal 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/rxdrugsEither
16Reference Range Endocrinology Thyroid Hormone Testing95/5 population rangeHormone EffectToo LittleDisease“Everything is Normal”Too muchDiseaseNo Disease12FT4 ng/dLHormone Level
17Intelligent Endocrinology 80/20 range based on carefully screened young healthy populationIndividualized Diagnosis and Treatment80/20 rangeHormone EffectToo Little?Too much?Optimal??12FT4 ng/dLHormone Level
18New 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!
19Not 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 sensitivityReduce blood pressure—improve endothelial functionPrevent atherosclerosis (plaques in arteries)
20Women 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.
21Coronary Heart Disease vs. Age FemaleAIHW Heart, stroke and vascular diseases - Australian facts 2004.
22Breast Cancer Rate vs. Age Loss of ovarian functionhigher risk of breast cancerMenopauseOvarian functionNational Cancer Institute. SEER cancer statistics review Table IV-3.
23Estrogen Replacement Prevents Alzheimer’s Disease 72% used Premarin onlyZandi 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:
2430Speroff L, Fritz M Clinical Gynecologic Endocrinology and Fertility, 7th Ed.
25OsteoporosisIn 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.
26Osteoporosis 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; 81:37-43Barrett-Connor E, J Reprod Med Dec;44(12):Hormone restoration increases measured bone density better than bisphosphonates and preserves normal bone remodelingBisphosphonate drugs cause Ca++, esophageal inflammation and cancer, and suppression of normal bone formationpoor fracture healing, late non-traumatic fractures, and “rotting jaw”.
27Female EndocrinologyNature makes special demands on the female body for reproduction.More complex hormonal system than menBreast, uterine and ovarian tissues undergo a monthly cycle of proliferation, differentiation, and breakdownDefects in this cycle can lead to cancers in female organs and to many medical disorders.
28Estradiol—Progesterone Complementarity Estradiol (human estrogen) promotes breast/uterine proliferation and growth.Progesterone stops proliferation and promotes maturation and differentiation.Differentiated cells can’t become cancers.Progesterone withdrawalsloughing and necrosis of uterine lining and breast duct epithelium Longacre TA, Am J Surg Pathol Jun;10(6):382-93High progesterone/estradiol ratio suppresses proliferation and prevents cancersEstradiol is safe if opposed by progesterone.
29Progesterone’s Anti-Estrogenic Actions in Uterus and Breast Decreases synthesis of estradiol receptorsIncreases conversion of estradiol to estrone (weak estrogen) by inducing 17β- hydroxysteroid dehydrogenase Type 2Reduces conversion of estrone to estradiol by inhibiting 17β-HSD Type 1Increases sulfation (inactivation) of estrogensWilliams Text. of Endocrinology, 10th Ed., p. 612
30Progesterone Deficiency Estrogen Dominance AllergiesAutoimmune diseasesAnxiety, irritabilityInsomniaDecreased sex driveDepressionBloating and edemaFibrocystic breastsUterine fibroidsBreast cancerOvarian cancerUterine cancerThyroid dysfunctionGallbladder diseaseHeavy periodsMigrainesSeizuresEndometriosisProgesterone restoration is the only effective treatment for estrogen dominance
31Aging OvariesFemales born with a fixed no. of oocytes which are continually lostWith aging, fewer oocytes of lower quality are leftreduced estradiol and progesterone production beginning as early as age 30Lower progesteroneestrogen dominanceNo ovulation=no progesterone
36Menopause=Estradiol Deficiency Hot flashesIrritability, insomnia, depressionFatigue, aches and painsPoor memory, ’d risk of Alzheimer’s dementiaOsteoporosisspine and hip fractures, loss of teethGenital atrophy, vaginal drynessAtrophy of skin and connective tissueEndothelial dysfunction, blood pressureIncreased blood sugarAtherosclerosis, heart disease
37Estradiol Restoration Eliminates hot flashes, restores sleepProtects cognitive function, improves moodMaintains thickness, fullness of skin and hairProtects against colon cancer and macular degenerationProtects against dementiaPrevents atherosclerosis, hypertensionMaintains genital/pelvic healthImproves insulin sensitivity—prevents diabetesPrevents osteoporosis and osteoarthritisMaintains gynecoid fat distribution
38Q: But won’t estradiol restoration increase the risk of breast cancer? A: No, not if given with progesterone.
39E3N-EPIC Study E2 plus progesterone decreased risk of breast cancer! Cohort 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 decreased risk of breast cancer!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.
40Progesterone vs. Breast Cancer in menstruating women Ordet Study: Int. J. Cancer 112 (2004) (2), pp. 312–318.Progesterone vs. Breast Cancerin menstruating women6,000 women5 yr. F/URisk of breast cancerHigher progesterone=lower risk of breast cancer
41Progesterone 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):963-9Estradiol is carcinogenic in breast cell cultures unless progesterone is present.Russo J, J Steroid Biochem Mol Biol Oct;87(1):1-25Normal breast cells proliferate after E2 treatment, but become quiescent when P is added Malet C, J Steroid Biochem Mol Biol Jun;73(3-4):171-81Foidart JM, Fertil Steril.1998 May;69(5):963-9Estrogen upregulates cancer-promoting gene bcl-2, progesterone downregulates it.Formby B, Ann Clin Lab Sci Nov-Dec;28(6):360-9
42Progesterone vs. Breast Cancer Premenopausal women with low progesterone levels had 5.4x risk of early breast cancerCowan LD, Am J Epidem 1981;114:209-17Breast cancer victims have progesterone resistance Simpson HW, Br J Obstet Gynaecol Mar;105(3):345-51Progesterone decreases proliferation and induces apoptosis in breast cancer cell lines.Ansquer Y, Anticancer Res Jan-Feb;25(1A): Groshong SD, Mol Endocrinol Oct;11(11):Progesterone receptor positivity predicts better long-term survival with breast cancerCosta SD, Eur J Cancer Jul;38(10):Lamy PJ, Breast Cancer Res Treat Nov;76(1):65-71
43Key: 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 concentrationChatterton 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):39-44In peri-menopause/menopause: No progesterone estrogen dominance in the breastsbreast cancer.
44Top 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.
45So why are most doctors saying that hormone replacement for menopause is dangerous?
46Pharmaceutical “Hormone Replacement Therapy” Horse-urine Premarin approved in 1942Synthesis of first human steroid hormone, progesterone, in Poorly absorbed orallyProgesterone altered to make “progestins”— among the first drugs to be patented.“HRT”= alien molecules with hormone effectsDrug Co.s became dependent on HRT profits1942 to present—Drug Co.s push doctors to use hormone substitutes and to ignore or fear natural hormone restoration!
47Conventional 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: methyltestosteronePatented drugs—not human hormones!Most docs don’t know the difference!
48EE in Birth Control Pills EstradiolEthinyl EstradiolAcetyleneEE 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 thrombogenicDVTs, pulmonary emboli
49Contraceptive Hormone Substitution is Dangerous EE with alien progestin, shuts down ovariesLowers testosterone and DHEAS levels’d risk of blood clots, stroke, heart attack1-3x risk of breast cancer’d blood sugar, blood pressureLiver tumorsDiagnose and fix the hormonal disorderUse a copper IUD for contraception!!UpToDate 2006Instead of using BCPs::
50Premarin Conjugated Equine Estrogens Human Horse HorseEstrone Equilin EquileninCEE 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
51Oral Estrogen Replacement is Dangerous First-pass effect on the liverIGF-1, SHBG, CRP, clotting factors blood clots, strokes, heart attacks in the first yearTransdermal 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):840-5Transdermal estradiol improves insulin sensitivity, oral estrogens do not.
52Progestins Progesterone Progesterone Provera DrospirenonePremproYasminProgestins are often called “progesterone”, even in scientific papers!
53Progestin Zoo progesterone Kuhl, Climacteric 2005;8(Suppl 1)Every progestin has a different spectrum of androgenic, estrogenic, glucocorticoid, and progestational effects!
54Provera Progesterone Scientific studies show that:Provera ProgesteroneCauses birth defectsCan cause depressionInsomnia, irritabilityFluid retentionRaises blood sugarCounteracts estrogen-induced arterial dilationWorsens lipid profileCauses heart attacksIncreases estrogenic stimulation of breastsCauses breast cancerMaintains pregnancyImproves moodImproves sleepDiureticNo effect on blood sugarMaintains estrogen-induced arterial dilationImproves lipid profileNo evidence of CVDReduces estrogenic stimulation of breastsPrevents breast cancer
552002 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!
56As 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 TherapyWashington, 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.ACOG’s physicians individually receive money from these same Pharm. Corps.
57Common Sense Substitutes are alien molecules! Problems caused by hormone substitutes cannot be attributed to human hormones until proven otherwise.Problems caused by oral estrogens don’t apply to transdermal estradiol.Bioidentical hormone restoration to restore the youthful hormonal milieu must be considered safe until proven otherwise!
58Menopausal Hormone Restoration Daily transdermal estradiol combined with progesterone (sublingual, transdermal, or oral). May stop for 5 days each month.No need to cycle and bleed—uterine lining remains thin.No need to stop hormones, everMost women need testosterone and DHEA for optimal results.
59Menopause: Bioidentical Estradiol and Progesterone vs Menopause: Bioidentical Estradiol and Progesterone vs. Hormone SubstitutesAny Questions?
60Female 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
61Testosterone 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):
62Andropause 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.
63Testosterone 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 (X)
64Testosterone 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
65Testosterone 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.
67Hypometabolism: 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, painUsual blood tests are insensitiveDocs have an irrational fear of cortisol and thyroid supplementation unless a lab is low (L)Underdiagnosed, undertreated—Docs prescribe pharmaceuticals (SSRIs) instead.
69Cortisol Made in the adrenal glands Maintains blood sugar (delivers the fuel)Modulates the immune systemWe need higher levels with stress, diseaseToo muchDiabetes, HTN, osteoporosisToo littlefatigue, depression, anxiety, autoimmune diseases, hypoglycemia, allergies, aches & painsWomen have lower cortisol levels/effects and much more low-cortisol-related problems than men.
70Mild-to-Moderate Cortisol Insufficiency Blood tests are insensitive, need diurnal salivary cortisol profileUndiagnosed: Docs only taught to recognize Addison’s Disease (total adrenal gland failure)Common cause of chronic fatigue, painCommon cause of thyroid hormone intoleranceClue: Felt better on prednisone, often needs steroids
73Cortisol RestorationMild deficiency can resolve with stress, rest, adrenal supplementsModerate-to-severe deficiency—needs cortisol restorationPhysiological doses of 15-40mg daily do not cause hypertension, osteoporosis, diabetesDocs’ fear of low-dose cortisol unfoundedSee Dr. William Jeffries’ Safe Uses of Cortisol
74DHEA—The Other Adrenal Hormone Most abundant steroid hormone; yet ignoredCells make testosterone and estradiol with itAnabolic—builds tissues, improves immunityReduces abdominal fatReduces pain—restores natural endorphinsReduces inflammation (IL-6, TNF-, IL-2)Anti-cancer effect in animal, in vitro studies
76Hypothyroidism Mental fog, poor concentration Depression Fatigue, need for excessive sleepCold extremitiesAches and painsThinning scalp hairWeight gainConstipationAnkle swelling, puffy face
77Thyroid 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 T4 but rarely measure free T3 levels!Need free T4 and free T3 levelsHypothyroidism 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.
78We Need Optimal T3 Levels Incidence of severe atherosclerosis doubled with lower T3 levels within the reference 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 clotsPrevents weight gain
79Fatigue, Fibromyalgia and Depression Epidemic Pre-1970s: Treat the patient’s symptoms with T4 and T3 (desiccated porcine thyroid--Armour )Post-1970s: Treat TSH test using T4 only!Doctors lowered doses by 30-50%!TSH-normalizing T4 dose oftenlower free T3 levels, weight gain, persistence of symptomsThyroid optimization helps many symptomatic patients with “low- normal” thyroid levels, especially those with fatigue, fibromyalgia, and depression
80Rational 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):808-10Give T4 plus T3 (Armour, Cytomel+T4)Increase dose until symptoms are gone or S/S of excess dosing appearSafe:No bone loss if Vit. D and hormones are restoredNo cardiac abnormalities J Clin Endo Metab Jan;85(1):159-64No muscle wasting Am J Phys Endol Metab Jun;288(6):E
82Growth 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:reduces abdominal fatlowers blood sugar, cholesterol, and BPImproves cognition, mood, sleep, energy, staminaIncreases muscle, decreases fatImproves bone density, skin thicknessDownside: at least $185/mo., daily injections
84Where Do They Come From?All steroid hormones (including substitutes) are chemically synthesized from diosgenin (wild Mexican yams, soy, and other plants).
85Compounding Pharmacies USP-certified bioidentical hormones mixed into creams, sublingual tablets, capsules. Inexpensive!Winola Pharmacy—Rt. 307 at Lake Winola,Harrold’s Pharmacy—W-B,Fino’s Pharmacy—Dallas,Hazle Drugs Apothecary—Hazelton
86Controversies Best delivery methods Ideal doses Variations between compounding pharmaciesWhen/how to measure levels and effectsTo cycle or not to cycle estradiol and progesteroneEstriol?Bioidenticals, especially compounded, not well studied—no money.
87Doing 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 errorFollow-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.
88Costs Physician time only as required @ $4/min No Medicare or insurance billing; may submit claim for recognized diagnosesHormones—$10 to $80/month from compounding pharmacy, often covered by insuranceDiurnal salivary cortisol test—$138, or insuranceBlood tests—insurance usually covers, or pay for discount labs ~$50 to $300Out-of-pocket professional fees and prescription hormones are tax-deductible
89For 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: