1. Bioidentical Hormone Restoration Best Medical Practice Relax: this presentation is available online

2. Topics Introduction Why Doctors Don’t Get It Hypometabolism: Cortisol and Thyroid Hormone Loss with Age Estradiol and Progesterone for Menopause Progesterone prevents Breast Cancer Pharmaceutical Hormone Substitution Testosterone for Women and Men Compounding Pharmacies Practical Issues

3. Hormones Parts of our integrated neuro-endocrine- immune system Travel via blood to all cells Control cells’ 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

4. Master Gland Central Control TSH ACTH LH/FSH T3, T4 Cortisol, DHEA Aldosterone Estradiol, Progesterone Testosterone

5. Human Steroid Hormones Testosterone Estradiol Progesterone Cortisol DHEA Drug companies have patented ~5 to 100 variations of each molecule. Aldosterone

6. Bioidentical Hormones are not Drugs Correct molecular structure—same action at receptors, same metabolism and elimination Non-toxic: No side effects, only effects No interactions with drugs No allergic reactions Safe in youthful physiological levels/balance Negative effects: excessive dose, wrong delivery method, or imbalance with other hormones

7. Bioidentical Hormone Restoration is Good Medical Practice If a hormone is missing, replace it!; if present but deficient, optimize it! Type 1 Diabetes: bioidentical insulin Hypothyroidism: bioidentical T 4 Growth hormone def.: bioidentical GH Adrenal insufficiency: bioidentical cortisol The Controversies: How do we diagnose deficiency? How do we decide which dose is right? What do we do about deficiencies due to aging?

8. Why 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 age Optimal values (glucose, cholesterol) Docs assume that all ranges are optimals! Male free testosterone: 35-155 5x! Female free testosterone: 0.0-2.2  ! Thyroid - Free T4: 0.6-1.8 3x! AM serum cortisol 5-25 5x! “Normal” result  no hormonal dx/rx  drugs May mean

9. Hormone Effect Hormone Level 0 1 2 95/5% population range Disease “Everything is Normal” Disease No Disease Reference Range Endocrinology FT4 ng/dL But hormone effects work on a continuum—no cut-offs in Nature

10. Hormone Effect Hormone Level 0 1 2 Intelligent Endocrinology Optimal?? FT4 ng/dL Tighter range based on carefully screened young healthy persons Individualized Diagnosis and Treatment

11. 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 Conventional tests are insensitive to most deficiencies Irrational fear of thyroid and cortisol supplementation Underdiagnosed, undertreated—Docs prescribe pharmaceuticals instead (SSRIs, amphetamines, anti-seizure drugs, anti-psychotics, sedatives, etc.)

12. Cortisol (hydrocortisone) Dexamethasone (70x) Decadron® Methylprednisolone (5x) Medrol® Glucocorticoids (“Steroids”) Prednisone (4x)

13. 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 than men.

14. Mild-to-Moderate Cortisol Insufficiency Blood cortisol and ACTH stimulation tests are insensitive, need to do 24 hr. saliva testing Undiagnosed: Docs only taught to recognize Addison’s Disease (total adrenal gland failure) Common cause of chronic fatigue, pain Common cause of thyroid hormone intolerance Clues: Feels better on prednisone, often needs steroids for allergies, illnesses, etc.

15. Normal Saliva Cortisol Profile

16. Cortisol Deficiency

17. Cortisol Restoration Mild deficiency can resolve with  stress,  rest, adrenal supplements Moderate-to-severe deficiency—needs cortisol restoration Physiological doses of 15-40mg daily do not cause hypertension, osteoporosis, diabetes Doctors fear of low-dose cortisol unfounded See Dr. William Jeffries’ Safe Uses of Cortisol

18. DHEA—The Other Adrenal Hormone Most abundant steroid hormone; yet ignored Cells make testosterone and estradiol with it Anabolic—builds tissues, improves immunity Reduces abdominal fat Reduces pain—restores natural endorphins Reduces inflammation (  IL-6, TNF- ,  IL-2) Anti-cancer effect in animal, in vitro studies

19. Cortisol and DHEA Any Questions?

20. 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

21. Thyroid Testing Doctors often order only a TSH test--Inadequate Thyroid stimulating hormone (TSH) is a pituitary hormone. It is NOT a thyroid hormone, it is not a measure of thyroid hormone levels. Must test free T 4 and free T 3 levels Hypothyroidism: symptoms plus one or both hormone levels below middle of reference ranges Severe hypothyroidism: signs and symptoms plus both hormones in lower third of ranges.

22. We Need Optimal T 3 Levels Incidence of severe atherosclerosis doubled with lower T 3 levels within the reference range Clin Cardiol. 2003 Dec;26(12):569-73 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

23. Fatigue, Fibromyalgia and Depression Epidemic Fatigue, fibromyalgia, and depression are due to low cortisol and/or low thyroid until proven otherwise Pre-1970s: Treat the patient’s signs and symptoms with T 4 and T 3 (desiccated thyroid-- Armour  ) Post-1970s: Treat TSH test using T 4 only! Doctors often lowered doses by 30-50%! TSH-normalizing T 4 dose often  lower free T 3 levels  weight gain, persistence of symptoms Thyroid optimization helps most patients with symptoms and “low-normal” thyroid levels

24. Rational Thyroid Restoration If sign/symptoms of hypothyroidism: Restore! 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). 1986 Sep 27;293(6550):808-10 Give T 4 plus T 3 (Armour , Cytomel  +T4) Adjust dose according to symptoms and free hormone levels Safe: No bone loss if Vit. D and hormones are restored No cardiac abnormalities J Clin Endo Metab. 2000 Jan;85(1):159-64 No muscle wasting Am J Phys Endol Metab. 2005 Jun;288(6):E1067-73

25. Thyroid Restoration Any Questions?

26. What should we do about hormones that are lost to normal aging?

27. DHEA  DHEA-S J Clin Endocrinol Metab. 1997 Aug;82(8):2396- 402 Adrenopause

28. Endocr Rev. 1995 Dec;16(6):686- 715 Thyropause TSH response to low T4 (2.7-3.2  g/dL) Carle, Thyroid. 2007 Feb;17(2):139- 44

29. Growth Hormone (GH) Somatopause Clinical Chemistry 48, No. 12, 2002

30. Andropause Testosterone in Men

31. Steroid Loss in Women>>Men pg/ml DHEA-S 5,000,000pg/ml Cortisol 100,000 pg/ml ♀ ♀ ♂ ♂ Men Women Progesteron e average Testosterone Less estrogen than old men! 90% Loss50% loss

32. 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 (!!)

33. Against the Common View Aging is a natural 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!!

34. 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!

35. 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 system—progesterone and testosterone are mild immunosuppressants Maintain connective tissue: skin, hair, bone, muscle Improve insulin sensitivity: prevent diabetes Reduce blood pressure—improve endothelial function Prevent atherosclerosis (plaques in arteries)

36. 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.

37. Coronary Heart Disease vs. Age AIHW Heart, stroke and vascular diseases - Australian facts 2004. Female

38. Estrogen Replacement Prevents Alzheimer’s Disease Zandi PP, et al., Cache County Study. JAMA. 2002 Nov 6;288(17):2123-9. RR 0.46 in Kawas C, The Baltimore Longitudinal Study of Aging. Neurology 1997;48:1517-1521 RR 0.65 Paganini-Hill A, Arch Intern Med 1996;156:2213-2217. RR 0.4, Tang M-X, Lancet 1996;348:429-432. 72% used Premarin  only

39. Speroff L, Fritz M Clinical Gynecologic Endocrinology and Fertility, 7 th Ed. 30

40. Osteoporosis In 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 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.

41. Osteoporosis 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; 81:37-43 Barrett-Connor E, J Reprod Med. 1999 Dec;44(12):1012-20 Hormone restoration including Vit. D increases bone density better than bisphosphonates and preserves normal bone remodeling Bisphosphonate drugs cause  Ca ++, esophageal inflammation and cancer, pain, and suppression of normal bone formation  poor fracture healing, late non-traumatic fractures, and “rotting jaw”.

42. Female Endocrinology Nature makes special demands on the female body for reproduction. Much 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.

43. Estradiol—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 withdrawal  sloughing and necrosis of uterine lining and breast duct epithelium. Longacre TA, Am J Surg Pathol. 1986 Jun;10(6):382-93 High progesterone/estradiol ratio suppresses proliferation and prevents cancers Estradiol is safe if opposed by progesterone.

44. Progesterone’s 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

45. 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

46. 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

47. Normal Progesterone Dominance Ovulation Menstrual Cycle Ovulation

48. Perimenopause Luteal Insufficiency=Estrogen Dominance Menstrual Cycle Inadequate Luteal Phase shorter periods, early spotting  ’d risk of breast cancer Ovulation

49. Anovulation=Estrogen Dominance Menstrual Cycle  ’d risk of breast and uterine cancers

50. Menopause Estradiol and Progesterone Deficiency

51. Estradiol Deficiency Hot flashes Irritability, insomnia, depression Fatigue, aches and pains Poor memory,  ’d risk of Alzheimer’s 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

52. 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 sensitivity—prevents diabetes Prevents osteoporosis and osteoarthritis Maintains gynecoid fat distribution

53. Q: OK, estradiol restoration has many benefits, but won’t it increase the risk of breast cancer? A: Not if progesterone is also restored.

54. E3N-EPIC Study E2 plus progesterone: no increased risk of breast cancer! Int J Cancer. 2005 Apr 10;114(3):448-54 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

55. 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

56. Progesterone vs. Breast Cancer Progesterone cream applied to the breast reduces proliferation. Chang KJ, Fertil Steril 1995; 63:785-91 Barrat J, J Gynecol Obstet Biol Reprod (Paris). 1990;19(3):269-74 Foidart JM, Fertil Steril. 1998 May;69(5):963-9 Estradiol is carcinogenic in breast cell cultures unless progesterone is present. Russo J, J Steroid Biochem Mol Biol. 2003 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. 2000 Jun;73(3-4):171-81 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. 1998 Nov- Dec;28(6):360-9

57. Progesterone vs. Breast Cancer Premenopausal women with low progesterone levels had 5.4x risk of early breast cancer Cowan LD, Am J Epidem 1981;114:209- 17 Breast cancer victims have progesterone resistance Simpson HW, Br J Obstet Gynaecol. 1998 Mar;105(3):345-51 Progesterone decreases proliferation and induces apoptosis in breast cancer cell lines. Ansquer Y, Anticancer Res. 2005 Jan- Feb;25(1A):243-8 Groshong SD, Mol Endocrinol. 1997 Oct;11(11):1593-607 Progesterone receptor positivity predicts better long-term survival with breast cancer Costa SD, Eur J Cancer. 2002 Jul;38(10):1329-34 Lamy PJ, Breast Cancer Res Treat. 2002 Nov;76(1):65-71

58. Key: Hormones within the Breasts 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. 2005 Mar;90(3):1686-91 Breasts produce estradiol locally from adrenal androgens (DHEA, androstenedione) Breasts must get progesterone from blood, and they concentrate it by a factor of 3 to 4x. Gann PH, Cancer Epidemiol Biomarkers Prev. 2006 Jan;15(1):39- 44 In peri-menopause/menopause: No progesterone  estrogen dominance in the breasts  breast cancer.

59. Breast Cancer Rate vs. Age National Cancer Institute. SEER cancer statistics review 1975-2002. Table IV-3. Menopause Loss of ovarian function  higher risk of breast cancer Ovarian function

60. 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. 2005 Sep 16;52(1):1-10.

61. So why are most doctors saying that hormone replacement for menopause is dangerous?

62. 2002 WHI Study—“HRT” 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!

63. Pharmaceutical “Hormone Replacement Therapy” Horse-urine Premarin  approved in 1942 Synthesis of first human steroid hormone, progesterone, in 1942. 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 present—Pharm. Corps. pushed doctors to use hormone substitutes and to ignore or fear natural hormone restoration!

64. 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 drugs—not human hormones! Most docs don’t know the difference!

65. 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

66. 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::

67. 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. 1998 Int J Fertil 43:223 Human Horse Horse

68. 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. 2007 Feb 20;115(7):840-5 Transdermal estradiol improves insulin sensitivity, oral estrogens do not.

69. Progestins  Progesterone Progesterone Provera  Drospirenone  Progestins are often called “progesterone”, even in scientific papers! Yasmin  Prempro 

70. Progestin Zoo Kuhl, Climacteric 2005;8(Suppl 1) progesteron e Every progestin has a different spectrum of androgenic, estrogenic, glucocorticoid, and progestational effects!

71. 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:

72. 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. ACOG’s physicians individually receive money from these same Pharm. Corps.

73. 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 don’t apply to transdermal estradiol. Bioidentical hormone restoration to restore the youthful hormonal milieu must be considered safe until proven otherwise!

74. Menopausal Hormone Restoration Daily transdermal estradiol combined with progesterone (sublingual, transdermal). May stop for 5 days each month. No need to cycle and bleed—uterine lining remains thin. No need to stop hormones, ever. Most women need testosterone and DHEA for optimal results.

75. Estradiol and Progesterone Restoration for Menopause Any Questions?

76. Female Andropause Young woman’s free testosterone level is 2x her free estradiol DHEAS declines with age—main 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

77. 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. 1999 Dec;44(12):1012-20 Probably decreases risk of heart attack J Womens Health. 1998 Sep;7(7):825-9 Opposes estradiol-induced breast stimulation and reduces risk of breast cancer Menopause. 2003 Jul-Aug;10(4):292-8, Endocr Rev. 2004 Jun;25(3):374-88 Menopause. 2004 Sep-Oct;11(5):531-5, FASEB J. 2000 Sep;14(12):1725-30

78. Andropause in Men

79. Testosterone Restoration for Men Improves mood and sociability Restores energy and ambition Improves cognition, protects against Alzheimer’s disease Increases libido and sexual performance Increases muscle and bone mass Reduces abdominal fat, improves insulin sensitivity, lowers blood pressure-- counteracts metabolic syndrome (X)

80. Testosterone and the Heart Low testosterone levels correlate with coronary artery disease and stroke Arterioscler Thromb. 1994; 14:701-706 Eur Heart J 2000; 21; 890–4 Int J Cardiol. 1998 Jan 31;63(2):161-4 Arterioscler Thromb Vasc Biol. 1996 Jun;16(6):749- 54 Testosterone dilates coronary arteries— improves angina T increases heart muscle size, strength T decreases fibrinogen levels—prevents blood clots Endocr Res. 2005;31(4):335-44

81. 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. 2008 Feb 6;100(3):170-83, also Morgenthaler A, Urology 2006;68:1263-7 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. 2006 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, compared to no testosterone, but does not promote prostate cancer.

82. Testosterone for Women and Men Any Questions?

83. Growth Hormone Declines 14% per decade after age 25 IGF-1 of many adults equal to hypopituitary patients (only 80-110 vs. 300 @25yrs.old) 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

84. What Else Can Hormone Restoration Help? Infertility, PMS, heavy bleeding, endometriosis Insomnia—almost always Heart failure, Angina Mood/Anxiety/Cognitive disorders Autoimmune diseases (Systemic Lupus Erythematosis, Rheumatoid Arthritis, Ulcerative Colitis, Crohn’s Disease, etc.) Allergies, skin diseases Every disease/disorder!!

85. Where Do They Come From? All steroid hormones (including substitutes) are chemically synthesized from diosgenin (wild Mexican yams, soy, and other plants).

86. Compounding Pharmacies USP-certified bioidentical hormones mixed into creams, sublingual tablets, capsules. Convenient, low cost, locally made Winola Pharmacy—Rt. 307 at Lake Winola, 378-2885 Harrold’s Pharmacy—W-B, 822-5794 Fino’s Pharmacy—Dallas, 675-1141 Hazle Drugs Apothecary—Hazelton 1- 800-439-2026

87. 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 studied—no money.

88. 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.

89. Costs Physician time only as required @ $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 tests—insurance usually covers, or pay for discount labs ~$50 to $300 Out-of-pocket professional fees and prescription hormones are tax-deductible

90. For More Information The Hormone Solution—Stay Younger Longer Thierry Hertoghe, MD The Miracle of Natural Hormones David Brownstein, MD How to Achieve Healthy Aging—Look, Live, and Feel Fantastic After 40 Neal Rouzier, MD Life Extension Foundation (www.lef.org) Information and hundreds of abstracts at www.hormonerestoration.com. Contact me: Henry@hormonerestoration.com