Bio-identical Hormone Replacement Therapy
Hormone Optimization with Bio-identical Hormones
Why optimize hormones and what do hormones have to do with my arthritis (or other musculoskeletal problem)?
You may have been given this booklet because you desire to optimize your health. Or perhaps you came for evaluation of your arthritis, a rotator cuff tear or other musculoskeletal condition. In either case, optimal hormone levels have many health benefits and may greatly assist in the healing process. They can optimize your health and be true preventive medicine. In addition, they can assist in the healing process. Smaller, simpler and less-advanced injuries may not require hormone optimization in addition to other methods of treatment, such as the biologic agents (Platelet Rich Plasma, Bone Marrow and Adipose). However, when the condition is harder to treat or more advanced, the healing environment benefits from this optimization. When growing plants, fertilizer is used. For healing injuries or degenerative conditions, hormones provide this same benefit and “fertilize the soil” of the body.
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What’s a hormone?
A hormone is molecule that is made and secreted by specialized cells, often in endocrine glands. They are released into the bloodstream and produce effects on distant target cells. They serve as messengers from your brain, telling your internal organs how to function. Examples are thyroid (T3 and T4), testosterone, DHEA, estrogen and progesterone, to name a few.
I’m not 20 anymore! What’s happening?
As we age, a lower amount of a specific hormone may be produced. The ones that are produced no longer have the same effect as they did 20 years ago due to desensitization of the hormone receptors. Essentially, you don’t make it and what you do have, doesn’t work as well.
“Normal” is not optimal!
Hormone levels are checked with blood tests initially then rechecked at 4-12 weeks and then yearly. Re-tests are done 5 hours after taking the morning dose of medication. Some hormones have normal values that are the same for younger and older people. Other hormones have a “normal” value based on age. For example, a 55 year old will have a lower “normal” value of testosterone than a 20 year old. However, normal is NOT optimal. Who wants the levels of an 80 year old? The basic principle of hormone optimization involves raising the level of the hormone to that of a younger age. It is not the goal to create a physique like an ex-governor of California.
What is the difference between bioidentical and synthetic hormones?
A bioidentical hormone is a natural one that is structurally identical to the hormone that God made and placed in your body. It may be derived from soy or yams and cannot be patented. (Translation: a pharmaceutical company does not make big dollars.) A synthetic hormone is one that is not identical to our natural hormones and can be patented. Because it is not identical to our own God-given natural hormones, it produces effects that are different from the bioidentical hormones.
How do I take the hormones?
Depending on the hormone, one delivery method may be preferable over another based on how well it is absorbed. The options are topical (creams, gels, alcohol-based formulas), oral (tablets, pills, troches), under the tongue (sublingual), injections, or implantable via a minor surgical procedure. The most commonly used are the first three options. It is necessary to ensure consistency by using the medication precisely as prescribed, i.e., at the same time every day, in the proper amount, and with the correct application.
Where can I get these natural hormones?
These hormones are prescribed by a physician (or other provider) and made by a special type of pharmacy, called a compounding pharmacy. This pharmacy can provide you with any medication made by a pharmaceutical company. In addition, they can obtain a pure pharmaceutical grade hormone and compound it into the dose and form ordered specifically for you. The compounding pharmacy specializes in creating these custom medications specifically for you. The compounding pharmacies recommended by our office are only of the highest quality.
When can I stop the hormones and what happens when I do?
You can stop the hormones when you decide you would no longer like the protective effects. The hormone levels will return to baseline (the low level prior to starting hormones) over a period of several months.
What about follow up labs?
Labs are typically repeated until an appropriate level is achieved. Then they are repeated at less frequent intervals. It is important to draw follow up labs 5 hours after the morning dose of medication.
Vitamin D3 Hormone
Vitamin D is not actually a vitamin, but a hormone. Vitamins are not able to be made but must be obtained from the diet 90-100% of Vitamin D Hormone is made in the skin from cholesterol under the influence of UVB radiation. If you go out in the summer sun in your bathing suit until your skin just begins to turn pink, you make an average of 20,000 international units (IU) of Vitamin D in your skin. Translation: a few minutes in the midday summer sun produces 100 times more vitamin D than the government says you need!
Increased muscle strength by up to 20%, analgesic effect in acute and chronic pain, decreased fracture incidence with osteoporosis and osteomalacia, prevention of rickets, protection against cancers (colorectal, renal cell, breast, prostate, ovarian and others, including leukemia and retinoblastoma), fewer infections, improved glucose tolerance (protection against type I and II Diabetes), may protect against Multiple Sclerosis and Rheumatoid Arthritis. If vitamin D3 is too low, it may cause coronary artery disease, heart failure, hypertension and atrial fibrillation.
Taking more than 40,000 iu per day can result in calcium levels that are too high. (American Journal of Clinical Nutrition, Vol. 69, No. 5, 842-856, May, 1999) These symptoms include anorexia, nausea, and vomiting, frequently followed by polyuria a lot), polydipsia (drinking a lot), weakness, nervousness, pruritus, and ultimately, renal failure. If vitamin D3 is too high (>100 ng/dL), it may cause atrial fibrillation (Circulation, 2011; 124:A14699). Monitoring Vitamin D levels and adjusting the dose as required to avoid these potential side effects.
Those who have hyperparathyroidism, granulomatous diseases (such as sarcoidosis, granulomatous TB), and some cancers (oat cell carcinoma of the lung, non-Hodgkin’s lymphoma) should only take Vitamin D under the direction of a knowledgeable physician.
Anyone who would like the benefits noted above and anyone with low or suboptimal Vitamin D levels.
Vitamin D3 is available as an oral pill.
Thyroid hormone is produced by the thyroid gland. T4 (tetraiodothyronine) is normally converted into T3 (triiodothyronine) in the peripheral tissues. Much of the T3 is bound with thyroid binding globulin. The T3 that is not bound, is the free T3, and is the active hormone with a very short half-life. (It doesn’t stick around very long.) Low T3 at the cellular level is responsible for the symptoms of hypothyroidism (low thyroid). T4 crosses from the blood to the central nervous system more easily than T3. So, both T3 and T4 are required. Many physicians, however, will only replace T4 with commercial preparations, such as levothyroxine. Compounded preparations or Armour thyroid have both T3 and T4.
Thyroid hormones will become low due to decreased production, decreased conversion of T4 to T3, or decreased receptor site sensitivity. Essentially, you don’t make it. You don’t convert what you have and what you do have, doesn’t work as well.
Fatigue, weakness, weight gain, increased body fat, lack of motivation, lack of energy, memory loss, difficulty thinking, confusion, depression, feeling cold, hair loss, thin hair/skin/nails and poor sense of well-being.
Increased fat breakdown (leading to weight loss) and decreased cholesterol. Protection against heart disease, memory loss, fatigue, weight gain, vertebral fractures and increased mortality.
If you get too much thyroid: sweaty, rapid heart rate and atrial fibrillation (at 3x normal levels). If Too low or too high: osteoporosis or hair loss.
Anyone with cardiac sensitivity with rapid heart beats (supraventricular tachycardia or atrial fibrillation).
Anyone who would like any of the benefits noted above or anyone with low or suboptimal T3/T4 or elevated TSH levels.
A common form of thyroid replacement is dried and comes from pigs. This is Armour thyroid and is measured in grains (one grain contains a standard 9 micrograms of T3 and 38 micrograms of T4). A synthetic version is derived from duck feathers in the same ratio. A compounded version is also available, which can have customized doses of T3 and T4.
It is important to know that thyroid is different from most of the other medications in that it must be taken with water only. Do not have coffee, breakfast, vitamins, other medication or anything else until 30 minutes later. The best time to take it is when you first wake up.
DHEA is secreted by the adrenal gland, is a precursor to other hormones and is derived from cholesterol. It is a necessary building block to make estrogen, progesterone and testosterone. Remember that any hormone derived from cholesterol or sterols is called a steroid. DHEA, estrogen, progesterone and testosterone are all beneficial natural steroids. DHEA raises testosterone slightly in women, but not men.
Increased antioxidant activity, immunity (thereby acting to fight cancer), mood (anti depressant), insulin sensitivity (protects against diabetes), energy, bone density, memory/brain function and lifespan.
Decreased cardiovascular risk (by increasing breakdown of lipids), cholesterol, abdominal body fat, osteoporosis, insulin requirements (in diabetics, as does testosterone), fatigue and muscle weakness.
Protects against cardiovascular disease, cancer, diabetes, sleep loss and progression of the aging process (in lab animals). DHEA has been shown to have a significant effect in treating connective tissue disorders such as Systemic Lupus Erythematosus (SLE). Pharmaceutical DHEA will soon be available as an FDA-approved medication to treat Lupus.
Acne is the primary side effect. Hair growth in unwanted areas may also occur. Younger women may not tolerate these side effects. If acne occurs, discontinue the medication until the acne clears, Then restart the medication at the same dose. If the acne recurs, stop the medication. When the acne clears, restart the DHEA, but take it every other day. If the acne recurs yet again, you may need a lower dose. Testosterone should be continued, however.
Anyone with sex hormone responsive cancers (such as breast, ovarian, uterine and prostate).
Anyone who would like any of the benefits noted above, anyone with low levels, anyone over 40 years old, anyone with chronic disease or Systemic
FDA approval is pending for a DHEA medication (prasterone) for use in treating SLE.
DHEA is available over-the-counter (OTC). Unfortunately, many of the OTC products come from foreign countries and contain contaminants and preservatives. They have a short half-life of approximately 6 hours, which means that it needs to be taken 3 times daily. DHEA is available as a prescription of a sustained release oral capsule in a micronized form. This form allows complete absorption and a sustained level over 24 hours. This pure pharmaceutical grade product is available only by prescription from a compounding pharmacy. Typical dosage for men is 50-100 mg and for women is 10-25 mg taken once daily.
Testosterone for Men AND Women
Effects of low testosterone for Men and women: Decreased energy (fatigue), muscle strength and mass, sexual desire/function; slower exercise recovery; decreased exercise tolerance, sense of well being, quality of life; irritability and depression.
Women: Decreased vaginal lubrication, sexual arousal and sexual orgasmic ability.
Benefits of Testosterone replacement for Men AND Women:
Increased HEALING, lean muscle mass, strength, aerobic endurance, exercise tolerance, desire for exercise, energy, memory, concentration, cognition (thus may protect against Alzheimer’s through aromatization of estrogen), bone density, insulin sensitivity, sexual affect, quality of life, skin quality increased collagen & thickness, improved texture, decreased wrinkles and fat deposition) and length of life.
Decreased fat, fasting glucose, cholesterol, triglycerides, diastolic blood pressure, cardiovascular risk (decreased total cholesterol and increased good HDL with natural testosterone) and pro-inflammatory cytokines (TNF alpha, IL-6, C-Reactive Protein).
Protects against tendon degeneration, joint degeneration (osteoarthritis), osteoporosis, diabetes, cardiovascular disease, dementia, Alzheimer’s and depressed mood.
Testosterone for Women
In addition to the above-mentioned benefits, women should take special note of the following. Estrogen helps protect against bone loss (osteoporosis) but testosterone is much better. Testosterone is the best hormone for the skin to prevent thinning and wrinkles (increased collagen and elastin). Testosterone helps alleviate the symptoms of menopause and increases sexual desire and responsiveness.
Lowering the dose, stopping for a while, or adding other medications can treat these side effects. Weight gain (muscle weighs more than fat) or weight loss (due to decreased fat), increased PSA in men (by 0.5, but without increased size of prostate, and without symptoms), hair loss (men), hair growth (women) where the topical medication is applied, increased libido (sexual desire), decreased testicular size (men), acne, fluid retention and edema, sleep apnea (rare) and elevated estrogen.
Testosterone does NOT increase the risk of prostate cancer. If you have prostate cancer, testosterone will be not be initiated and may be discontinued if you get prostate cancer. If you happen to develop prostate cancer while on testosterone, tumor growth may be accelerated. Therefore, PSA levels will be monitored on a regular basis in men.
Testosterone does NOT cause Benign Prostatic Hypertrophy (BPH).
Side effects are typically seen with injectable forms, but less likely with others: acne, aggression, decreased sperm production (possibly leading to infertility), gynecomastia (increase in breast size in men) and vocal cord swelling (women). SYNTHETIC injectable testosterone (but not natural compounded testosterone cream) and oral testosterone can cause liver problems and increased cholesterol. The natural compounded cream has a good effect on cholesterol.
- Physiologic erythrocytosis occurs with testosterone use. It is more prominent with injections and rare in women. This is an increased number of red blood cells and is not dangerous. It may be confused with, but is NOT polycythemia vera, a problem of increased red blood cells, white blood cells and platelets, which causes “thick blood” and possibly clotting. Those not familiar with this effect of testosterone will be mistakenly concerned about clotting.
- Transfer to others will occur if the topical forms are used improperly. With topical application, testosterone can be transferred to others by skin-to-skin contact (such as hugging/playing with children, and by “off-gassing” under the covers when sleeping if applied within 3-4 hours of bedtime.
Pregnant women or women who plan to become pregnant (as it will cause birth defects), men with active prostate cancer, men with fertility issues, men under 40 years old, women with hormone responsive cancer (such as breast cancer) and bodybuilders.
Anyone who would like the benefits noted above and anyone with low or sub optimal levels of testosterone.
How is Testosterone supplied? Topical, sublingual (under the tongue), implanted pellets, injection and for women, vaginal suppositories. Oral pills are toxic to the liver in men, but not women, due to the lower doses in women. The commercially prepared gels are not typically prescribed, as the testosterone levels do not reach high enough levels with these products. In addition, they’re much more expensive. Topical preparations are usually a good place to start.
Benefits of BIOIDENTICAL Estrogen replacement in Postmenopausal Women Protects against Cardiovascular Disease (70% lower mortality, with lowered total cholesterol and increase in HDL – the good cholesterol), stroke, Alzheimer’s disease, memory disorders, vaginal atrophy & dryness, urinary incontinence, urinary tract infections, osteoporosis, macular degeneration, cataracts and cancer (colon).
Improves muscle tone, hair quality, sex life and skin tone (fewer wrinkles and sagging).
Decreases visceral fat.
Note that we will only prescribe the BIOIDENTICAL form of estrogen. SYNTHETIC estrogen (Premarin) and synthetic progestin (Provera) increased the risk of breast cancer, heart disease and strokes in menopausal women, as shown in the 2002 Women’s Health Initiative Trial. BIOIDENTICAL estrogen (estradiol) has NO increased risk of breast cancer, heart disease and strokes. Blood clots (Deep Venous Thrombosis, or DVTs) may rarely occur with the oral form of estrogen but especially with Premarin. Again, we will only prescribe the BIOIDENTICAL form of estrogen.
Potential side effects from estrogen include breast tenderness, bleeding, bloating (fluid retention), breakout (acne), mood swings, headaches, gallstones and uterine fibroids. If progesterone is not used in conjunction with estrogen, there is a risk of breast and endometrial cancer. If oral progesterone is used with estrogen, there is no increased risk Blood clots (Deep Venous Thrombosis, or DVTs) may rarely occur only with the oral form of estrogen and especially with Premarin.
Those with uterine fibroids, headaches, gallstones or fibrocystic breast disease. However, the use of progesterone will prevent worsening of these conditions. We will only prescribe the BIOIDENTICAL form of estrogen.
If you are older than 60 years old, 10 or more years out from menopause with cardiovascular risk factors, BMI > 30 (overweight), smoke, OR have a personal or family history of DVTs (blood clots), there is an increased risk for a myocardial infarction by rupturing plaques. However, the use of transdermal estrogen (the patch) does not carry this risk. Unfortunately, transdermal estrogen does not provide the same beneficial protective effects. That’s why it would be better to be on oral estrogen than the transdermal form.
Those with active breast cancer.
Anyone who would like the benefits noted above and any post-menopausal woman.
Estrogen comes in oral and transdermal (cream or patch) forms.
Progesterone is the hormone of pregnancy and is secreted by the ovary. Progesterone receptors are found in the uterus, breast, vagina, blood vessels and brain. After menopause, the ovary stops functioning and progesterone is no longer produced.
Benefits of Bioidentical Progesterone replacement Progesterone protects the uterus, breasts, bone and heart. It protects against cancers (uterine, breast), osteoporosis, fibrocystic breast disease, ovarian cysts and cardiovascular disease (via decreased total cholesterol and increase HDL).
SYNTHETIC progestin (medroxyprogesterone acetate, or Provera) is not the same as BIOIDENTICAL progesterone! Synthetic progestins cause breast cancer, strokes, cardiovascular heart disease, birth defects, bloating, headache, fatigue, weight gain, depression, dementia and diabetes. This is not what we will prescribe for you. BIOIDENTICAL progesterone taken orally has never been shown in any study to increase the risk of breast cancer, strokes and heart disease. In fact, bioidentical progesterone has been shown to decrease the risk of breast cancer. Bioidentical progesterone may cause drowsiness (therefore is given at night), breast/nipple tenderness, dizziness (at high doses), bleeding or spotting.
Every postmenopausal woman with or without a uterus should take progesterone. Consider progesterone use for those in perimenopause or for Pre Menstrual Syndrome (PMS).
Oral capsule, sublingual (under the tongue) as a triturate or Rapid Dissolved Tablet are absorbed the best. Creams and sublingual drops are not absorbed well and not recommended.
Fish Oil (Omega 3 Fatty Acids) Benefits of Fish Oil replacement
There is tremendous scientific evidence for the use of fish oil as a nutritional supplement. EPA and DHA are the two main omega-3 fatty acids (FA’s) in fish oil. There are many potential benefits, which may include:
- Supports circulation and healthy blood vessel function
- Promotes the metabolism of dietary fat and cholesterol
- Supports a healthy heart rhythm
- Promotes healthy triglyceride levels
- Lowers blood pressure
- Reduced risk of heart attack and stroke
- Supports healthy brain function
- Promotes positive mood and well-being
- Supports memory and learning ability
- Supports focus and attention
- May help slow the progression of age-related memory loss
- Protects nerve and brain cells from oxidative stress and damage
- Promotes healthy eyes and vision
- Can help alleviate dryness and redness
- Protects against age-related oxidative damage
- Supports the resolution of pain in the joints and back. Omega-3 fatty acids are essential if you have osteoarthritis.
- Promotes back and joint health
- Promotes joint mobility and flexibility
- Enhances cardiovascular function
- Supports optimal fat metabolism and body composition
- Enhances exercise performance, endurance and recovery
- Digestive Health
- Protects against free radicals
- Supports digestive and GI health
- 7) Kids
- May support learning
- 8) Skin, hair and nails
- Nourishes skin, hair and nails
- Protects against free radicals
- Supports a clear and healthy complexion
- Protects against age-related damage
If you get a low quality product, you max get fish burps and an upset stomach. These side effects don’t exist with a high quality product. Therefore, it’s worth a few extra dollars to purchase a better product. You may also get loose stools and an increased risk of bleeding with higher doses. Caution is advised in people with bleeding disorders or those taking medication that may increase the risk of bleeding.
Those who are allergic to fish, fish oil or omega-3 fatty acids.
Anyone who would like any of the benefits noted above.
Fish oil comes in liquid or pill form.
For 2 weeks prior to a procedure and the 3 months after, use only 1-2 g daily if you were on a higher dose.
CoQ10, or ubiquinone, is an antioxidant that is involved in the electron transport chain and participates in aerobic cellular respiration, generating energy in the form of ATP. It is necessary for basic functioning of cells and decreases with age. It may be low in some chronic disease states, such as cardiac conditions, diabetes, cancer, Parkinson’s disease and muscular dystrophies. Some medications inhibit CoQ10 function, including Beta blockers, blood pressure-lowering medications and statins. Statins are used to lower cholesterol and can decrease serum CoQ10 levels by up to 40%!
Protects against macular degeneration, Alzheimer’s disease and migraines. Decreases blood pressure (by up to 17 mm Hg systolic and 10 mm Hg diastolic) and angina. May improve exercise tolerance, asthma symptoms, chronic fatigue syndrome symptoms and exercise performance,
There have been few serious reported side effects with CoQ10 usage. It may slightly lower blood sugar levels, blood pressure and cholesterol. But these things are good!
There are no contraindications to CoQ10 use.
Anyone who would like the benefits noted above.
CoQ10 is available as an oral pill.
As with the other hormones, melatonin levels will decrease with age. Melatonin is secreted by the pineal gland and affects circadian rhythms, sleep patterns and quality of sleep. The cells of the body rejuvenate and repair during the deeper stages of sleep by producing natural killer cells or CD4 cells. Melatonin increases the deep stage of sleep (stage 4), thereby enhancing immunity and subsequently producing anti-cancer effects. Increased energy may be felt due to improved sleep patterns and improved mood. Melatonin has powerful antioxidant effects accounting for disease prevention,
The proper dose of melatonin may help you STAY asleep, increase stage 4 (REM) sleep, feel more energized, enhance your mood, increase immune function, protect against wat night), lower night-time blood pressure and decrease migraine headaches (if you awake with headaches). Gray hair may resolve a bit.
Increased dreams (which can be quite vivid and may be interpreted as good or bad), drowsiness upon waking (with too high of a dose), hair color change the gray may resolve a bit), headache, nightmares (avoided by starting with a small dose and gradually increasing), stimulation in 1% and no effect in 10%.
Melatonin is not very effective for those habitually taking sleeping pills. These people will need to taper off the medication very slowly and then start a high dose of melatonin.
Anyone who would like any of the benefits noted above. I like to add this to help the regenerative process. The most common mistakes people make when using melatonin is 1) taking a poor quality product, and 2) not taking a high enough dose,
Melatonin is available over-the-counter (OTC). Many of these preparations are from foreign countries and may contain contaminants. The pharmaceutical grade from a compounding pharmacy is 100% pure. Melatonin is a capsule taken orally. The typical dosage for women is 1-30 mg and for men is 9-30 mg. The most beneficial effects will be obtained from the highest dose that is tolerated without side effects.
There’s no substitute for a good healthy diet rich in fruits, vegetables, whole grains, healthy fats (nuts and oils), and low in red meat and unhealthy fats. This good eating pattern is most important for your health. But let’s face it. Many people don’t eat the ideal diet. A multivitamin can provide some insurance against nutritional deficiencies. It’s an inexpensive nutritional insurance policy. For example, it will provide folic acid to help lower the risk of heart disease, colon and breast cancer, and neural tube defects in newborns if taken by pregnant women. It may have iodine, which can help with thyroid issues. It will also have vitamin C to prevent scurvy on your next long cruise!
Pregnenolone is a precursor to all other hormones. It is involved in cellular repair, especially in the brain and nervous system. Pregnenolone protects cerebral function and protects against neuronal injury.
There are no contraindications to pregnenolone use.
Anyone who would like to protect neuronal function or has memory problems, especially if they are already on the other hormones.
Pregnenolone is a sustained release capsule in a micronized form taken orally. The typical dosage is 100mg daily.
Yes. You can, However, these medications may have several problems.
1) The dose available Over-The-Counter (OTC) is often much lower than that of the prescribed variety. That’s why they don’t require a prescription and are available OTC. These lower doses don’t produce a measurable difference in blood tests.
2) The OTC medications may be larger in size and not absorbed as well. The pure pharmaceutical grade ingredients from the compounding pharmacy are micronized, which is a fine grain and are well absorbed.
3) The OTC products may be quick-release, quick acting and/or poorly absorbed. These tiple times per day. The natural hormones from a compounding pharmacy can be prescribed as a long acting, or Sustained Release version, which gives a steady release over the course of 24 hours.
4) The quality of the OTC medications may be substandard as the base ingredients are often obtained overseas.
5) The actual amount of the OTC ingredients may vary considerably from the amount stated on the label.
6) The OTC products come in standard dosages, while those from a compounding pharmacy can be customized to your specific needs.
This is a simplified and brief explanation of the topic of hormone optimization. For a more detailed explanation, Dr. Neal Rouzier’s 48-page pamphlet is available in our office. For an even more detailed explanation, Dr. Rouzier’s paperback book, How to Achieve Healthy Aging, is available through Medquest Pharmacy for $15 (www.mgrx.com).
I hope this ‘brief” explanation helps you understand how to truly practice preventive medicine, live life to its fullest and get you back doing the things you love to do!
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