Hormone balance

DHEA in Females

December 30, 2011

A new study in Climacteric, the Journal of the International Menopause Society has found evidence that the hormone DHEA can help with menopausal symptoms and female sexual function. The study found both HRT (estradiol and a synthetic progesterone) and DHEA to be effective at improving symptoms.
For those of us who recommend DHEA regularly this is no surprise, and it is not the first study to show similar benefits.
DHEA is secreted primarily by the adrenal glands, and levels can vary significantly with stress, hormonal imbalance, and other issues.
In females, DHEA may assist with:
–Mental clarity
–Vaginal dryness
–Strength and muscle mass
–Bone density
–Menopausal symptoms
However, like all hormones DHEA needs to be used with respect, only under the correct circumstances, and with appropriate monitoring. Some women are quite sensitive to DHEA and side effects can include:
–Acne/oily skin
–Increased facial/body hair
–Hair loss
Whenever DHEA is used, it is imperative to use a compounded or Pharmaceutical grade product. I have found over the counter DHEA to extremely variable in its quality and effectiveness, something which can’t be tolerated when balancing hormones.
In addition, the majority of over the counter products out there are formulated at strengths which are too high for most women, markedly increasing the risk of side effects.
So DHEA can be a very effective and important tool in maintaing hormone balance and long term health, but levels need to be checked before and during therapy to maintain effectiveness and minimize the risk of side effects.

Men's health

Testosterone and Metabolic Syndrome

December 22, 2011

Here is yet more evidence of the profound beneficial effects of testosterone on the male body.

According to a research paper presented this month at the International Diabetes Federation World Diabetes Congress, replacing testosterone to normal levels in middle aged and elderly men significantly improved all components of metabolic syndrome in 24 months. Positive benefits were maintained for 5 years, making this one of the longest disease focused studies out there. In addition researchers noted that at 60 months, improvement in some areas was still continuing.

Metabolic Syndrome is defined by the presence of a group of symptoms including central obesity, abnormal cholesterol/triglyceride levels, elevated blood pressure, and insulin/glucose abnormalities.

Highlights of the study included:
-After 48 months there was a substantial decrease in waist circumference (over 3 inches) and a consistent and progressive decline as far out as 60 months in some cases.
-Average body weight was decreased from 234.5 to 206 lbs. Subjects lost about 5% of their original body weight after 15 months, and 10% after 3.5-4 years.
-Average systolic and diastolic blood pressures dropped fro 155/94 to 140/80 at 48 months.
-Total cholesterol dropped from 297.7 to 194.5, LDL cholesterol dropped from 160.4 to 118.3, and triglycerides dropped from 290.4 to 194.2
-Average blood glucose declined from 105.8 to 97.
Additional non-metabolic syndrome improvements included:
-A “marked reduction” in C-reactive protein, a marker for systemic inflammation.
-A significant decrease in liver function enzymes, likely indicating an improvement in fatty liver disease.
-No rise in PSA (prostate)
-A decline in the International Prostate Symptom Score, indicating an improvement in urinary function with testosterone use.

To see see this much improvement in so many critical areas is quite impressive, and indicates the importance of testosterone in males in maintaining optimal health.

Healthy living


December 17, 2011

Well, it is now the time of year when many of us look at where we are at in our lives, and see the need to change something for the better.
I have to admit that I have mixed feelings about resolutions.
On the positive side:
-It is never a bad thing to try to improve ourselves
-Making a resolution can provide us with a definitive start date to begin our improvement
-Making a resolution can allow us to focus on a particular aspect of our lives that we want to change.
On the negative side:
-Resolutions are frequently started out of frustration with little thought as to how to approach the problem.
-When we fail to follow through with the resolution or don’t achieve our goal, it fosters a sense of “I might as well not even try–I won’t be able to do it anyway” when we think about trying things again in the future.

So when considering whether or not to make a New Year’s Resolution, I would encourage you to think about a few things:
-Be realistic about your goal and your ability to reach it.
-Have a plan about how to reach that goal with specific actions (“I will exercise more” is not a specific enough plan).
-Recruit others to help you, or at least support you and follow your progress. You are more likely to succeed if you are working with others, or if you are getting some positive feedback from others for your efforts.
-Resolutions do not have to be about improving ourselves. By deciding to do something to help others, we will also make ourselves better. Remember the saying, “It is better to give than to receive”.

One of my favorite resolutions was to stop at every lemonade stand that I saw, regardless of how much of a hurry I was in, and surprise the kids by paying more than they were asking. I managed to keep that one for a whole summer with only one exception, and that was traffic related. Each time I would walk away without being sure which of us enjoyed the encounter more. Now that I think about it, I may have to try that one again this year.


Hormone balance

“My Wife Told Me I Had To Come To See You”

December 4, 2011

This is something I hear frequently from my new male patients.
Now it is natural when a guy has just been told by his significant other that he should consider hormone replacement to assume that the reason for this suggestion is because of libido/performance issues.
In reality though, she is probably looking at a completely different set of symptoms.
ED/libido issues are what the media has latched on to, and are something that guys tend to pay attention to. However there are a whole host of symptoms which are linked to suboptimal testosterone levels which we as guys we find easy to ignore, or we are simply not aware that they are associated with our testosterone level.
So what other “symptoms” may be associated with suboptimal testosterone levels? Some of the most common include:
-Poor sleep
-Weight gain
-Muscle loss
-Aches and pains
-Hot flashes and night sweats
-Lack of focus and motivation
-Lack of interest in things you used to like to do
While ED/libido issues are certainly important to my patients, fixing the other things on this list are what can really improve overall quality of life and general health.
So when she brings this up, remember that she really does have your best interests in mind. Also, if she is feeling good, she probably wants you along for the ride as well.


Hormone balance

Progesterone: Cream vs Capsule, Which Is Right For Me?

November 24, 2011

When I recommend using progesterone to a patient, the topic of whether to use cream or the oral form always comes up. The question “Which one is better?” invariably is asked, and my answer is almost always, “That depends.”
My impression is that while both the cream and oral form are equally effective across the entire population, when you consider an individual patient, there may be a good reason to choose one over the other.
In support of the equal effectiveness is a study in the Journal of Clinical Pharmacology which showed no difference in drug exposure when oral and cream forms of progesterone were compared.
The main difference stems from the fact that when any medication is taken by mouth, the liver becomes a major factor, standing there with open arms to try and do what it thinks is right–metabolize it and prepare for removal from the body. This can be a good thing (ridding the body of a toxic substance, or turning a medication into a more active form), or a bad thing (inactivating a helpful substance or creating a toxic metabolite).
When progesterone is applied to the skin, it is dispersed through the body in a more uniform fashion. Thus the liver is not exposed to the high concentration of progesterone that occurs immediately after ingesting the hormone orally.

A few important things to know about the two forms of progesterone are that:
1) Because of the differences in absorption and metabolism, the doses of oral and cream progesterone are quite different. Generally a higher “dose” of progesterone is required when it is used orally. There is also no standard formula for converting between forms as everyone’s absorption and metabolism are different.
2) Oral progesterone is not hard on the liver, does not create any systemic issues (as opposed to oral estrogen), and the metabolites are not harmful. In fact in some individuals the metabolites may improve sleep.
3) Some patients simply “feel better” on one form or the other.

So what are some of the things that I consider when deciding with the patient which form to use?

Oral progesterone:
-Some patients find it easier to remember to take a capsule than to rub on a cream, and it can’t help if you keep forgetting to use it.
-Oral progesterone may worsen reflux symptoms in sensitive individuals, and can also cause a feeling of intestinal bloating. These may be dose dependent.
-Oral progesterone may improve sleep better than cream in some individuals, but may cause grogginess in others.
Topical progesterone:
-May be easier to adjust the dose as changes can be made in smaller increments than you can with capsules.
-High or low cortisol states may make more of a difference with the cream than with the oral form.
-In patients with liver issues, or in those who are using multiple medications or substances which are processed by the liver, the cream may be a better option.

So, like all things in hormone replacement, there is no “one” answer, but there is a “right” answer, and it is up to both of us to find it.


Healthy living

Blood Sugar Tsunami

November 19, 2011

Any way you look at them, the statistics and predictions are impressive.
In 2010 there were an estimated 18.8 million people in the US with diabetes, and another 7 million who have the disease but have not been diagnosed. Among US residents 65 and older, almost 27% have diabetes.
Even more alarming is the prediction recently published in the journal “Population Health Metrics” which estimates that if current trends continue, by 2050 up to 1/3 of the US population will be diabetic. Think about it in this way. Look at the person to your left, and then the one on your right. One of you will be diabetic. With numbers like this, the personal, societal, and financial costs are unimaginable.
Just as distressing is the fact that it does not have to be this way. Type 2 diabetes is largely preventable. The Diabetes Prevention Program, a large study of people at high risk for diabetes found that PREVENTION or delay of diabetes is feasible, cost effective, and can persist for at least 10 years.
So why should you worry about your blood sugar being “a little bit high”?
–Diabetes is the leading cause if kidney failure, non-traumatic lower limb amputations, and new cases of blindness in the US
–Diabetes is a major cause of heart disease and stroke
–Diabetes itself is the seventh leading cause of death in the US, and increases the risk of dying from from many other illnesses.
–It simply decreases long term quality of life.
These are not small issues, and personally if I can prevent them, I am willing to put a little work into it.
So what kind of “work” is required?
Studies show that for every 500 calories burned per week through exercise there is a 6% decrease in relative risk for developing diabetes. The effect is greater for those who were heavier at the start of the study.
Weight Loss
Weight loss can improve insulin sensitivity, improve blood sugar control, and delay or even prevent progression to Type 2 diabetes.
It should be noted that when exercise and weight loss are combined, the benefits increase significantly.
Dietary changes
Reduce or eliminate your intake of sugar. Be a label reader. Check for sugar content in things you consume. You would be surprised how much sugar is added to commercial or processed foods.
Lower your intake of carbohydrates (starches) as these are just sugar in a different form.
Increase your fiber intake. Having more fiber in your diet helps stabilize blood sugars, and increases the feeling of fullness so you eat less.
Eat a good breakfast containing protein and fiber as this will help stabilize blood sugar and insulin levels throughout your day.
Eat meals on a regular basis. Skipping meals (especially breakfast) increases insulin resistance
Balance your hormones
Hormone imbalance can contribute to insulin resistance and weight gain.
Check your numbers
Talk to your health care provider about getting testing to see if you are at risk for developing diabetes. These tests should include fasting blood sugar, insulin, hemoglobin A1C, or a more comprehensive and predictive test such as the PreDx test.

So in essence, this really is a case where “prevention is the best medicine”.


Hormone balance

Progesterone And The Brain–Think About It

November 2, 2011

“I was told that since I don’t have a uterus I don’t need to take progesterone.”

This is something that my new patients tell me on a fairly regular basis. While I would agree that progesterone is needed to balance the effect of estrogen on the uterus, I would disagree that this is it’s one and only function in the body. Having had a hysterectomy does not knock you out of contention for the “I love what progesterone does for me” fan club.

For those who need convincing that progesterone works on more than the uterus, one needs only to look at the brain, and specifically, brain injury. The fact that the brain responds positively to (and in fact needs) progesterone is well supported in medical literature. While there are many studies, here are a couple of examples. Also, just as importantly, I am not aware of ANY study which shows that progesterone is harmful to the brain.

Brain Research Review 2008 Mar;57(2) “There is growing evidence that this hormone (progesterone) may be a safe and effective treatment for traumatic brain injury and other neural disorders in humans.”
Annals of Emergency Medicine 2008 Feb 51(2) “There is evidence that the hormone (progesterone) affords protection from several forms of acute central nervous system injury, including penetrating brain trauma, stroke, anoxic brain injury, and spinal cord injury.”

While this is just one small facet of what progesterone can do, when you look at the studies it is pretty easy to see that progesterone is not just a “one trick pony”.


Hormone balance

“It Wasn’t Pretty”

October 29, 2011

From time to time we all get reminders as to why we do or don’t do certain things in our lives. Call them what you will–setbacks, indiscretions, trials etc. Sometimes by losing our way, we again can see why we had been doing things like we were, and that they were actually helping. Whether it is watching our diet less closely, having a few too many drinks, not exercising, sleeping too little, or even not taking our hormones as prescribed, there comes a point when we realize we need to “get back on the wagon”.
I was reminded of this again this week after receiving an e-mail from a patient. For reasons that were for the most part out of his control he had run out of testosterone and his levels had returned back to his pre-treatment, suboptimal level. He went on to describe the return of his symptoms and the difficulties which this had created. In closing he noted, “Now that I am back with the program, my life has returned back to normal. I have had the opportunity to see again what life is like without therapy and it wasn’t pretty.”
I am glad that he is “back to normal” again.



Willy Wonka vs The Evil Multi-vitamin

October 25, 2011

Compare and contrast the headlines from two separate studies in the last few weeks. The first stating that taking a multi-vitamin will cause you to die earlier, and the second stating that people who ate chocolate five times per week had lower risk of developing cardiovascular disease and stroke. Both studies were published in reputable, conventional medical journals, yet highlight how confusing it can be to know what to believe when it comes to medical literature.

With regard to medical studies, the most reliable are those that look at one variable (drug or intervention) compared to the use of a placebo. In short—when this variable and this variable alone is looked at, with no other consistent differences between test groups, what effect did the variable (drug or intervention) have. Neither of these studies were this type. The Iowa Women’s Health Study (Archives of Internal Medicine 2011;171(18):1625-1633) was based on self reported questionnaires filled out by study participants. The Chocolate Consumption Study (BMJ Aug 29; 343:d4488) was a review of the data from seven observational studies.

I am going to admit my bias and give the BMJ study a bit of a free pass, as I do personally believe that chocolate may in fact have some health benefits. The only down sides that I see are: 1) those that use this as an excuse to overindulge “because it is good for me”, and 2) the inevitable “chocolate has been shown to reduce the risk of heart disease” emblazoned across my Hershey Bar wrapper (dark of course).

I do have more problems with the Iowa Women’s Health Study.

First, this study while presented (in the headlines at least) as the definitive study on Multi-vitamins, was in fact information gathered by women filling out questionnaires. There was thus no consistency in dose, quality, or reason for taking a multi-vitamin. There is no way to judge compliance (did they take it regularly, or even as recommended on the bottle). There was no one “multi-vitamin” as the report looked at individual components and blended the results (more on that in a bit). Also medication use (other than hormones) was not looked at by the authors. Not that use of medications might have any association with mortality rate.

The data was collected over 18 years, and over that time the use of supplements did increase significantly. As supplement use increased, and mortality increased, the assumption was made that the two were related in a causative fashion. More clearly stated, the intake of a multivitamin caused the increase in mortality. However, think about this. Over those same 18 years many of those same women were developing illnesses (cancer, heart disease, diabetes, etc) or seeing those diseases develop in their parents and siblings, which they knew increased their risk as well. So, if you developed an illness or saw one heading your way, would you not pull out all the stops to try to stay healthy? So the illness in some cases may have been the cause of the multi-vitamin use. Again, it is important to keep in mind that this is an “association” not “cause and effect”. To quote the authors “Supplement users were more likely to have lower intake of energy (calories), total fat…and a higher intake of whole grain products, fruits and vegetables.” To use the same reasoning which they applied to supplements, it would seem that eating a lower fat/calorie diet high in fruits and vegetables caused the women to die sooner.

It would also appear in the study that data initially showed supplementing with Vitamins C, D, E and calcium was associated with a “significantly” lower risk of mortality. However after negative results of copper and iron were factored in, and statistically adjusting the way the data was looked at, it was concluded that there was an increase in mortality with multivitamin/mineral supplementation in general. This is in contrast to a study in the European Journal of Nutrition (EPIC-Heidelberg Study) July 2011, which showed that supplement intake may decrease the risk of cancer and all cause mortality.

I do think that it is important to note that when supplements are taken, they should be very high quality (Pharmaceutical grade if possible), and used in a targeted, medically supervised setting. That however is a discussion in and of itself.

So while the dust settles, I think that I will continue to take my supplements AND have the occasional piece of chocolate. Who knows, I might even throw caution to the wind and enjoy a glass of red wine now and then as well.

As they say—“The Devil is in the details”, but I think this shows that sometimes he likes to write the headlines as well.


Hormone balance

Hormonal Spin Cycle

October 22, 2011

“What happened? I was doing so well for so long. I haven’t changed a thing and now all of a sudden my symptoms are coming back.”

This is something I hear occasionally from a patient who has indeed been doing well, and then out of the blue their symptoms return. Maybe it is hot flashes, maybe worsening sleep, maybe mood issues, but regardless of the symptom, they are distressed at the return of this unwelcome visitor.

When this happens it is time for us to take a step back and try to figure out what has changed. Often the cause is not a big thing–and whatever made them go off kilter may or may not be directly related to hormone levels.

Think about a washing machine on the spin cycle. When working perfectly, it spins around quietly at an amazing speed. However, move a hand-towel to the other side of the washer and this small change will cause the machine to start trying to walk across the floor, sounding like it is going to explode. When hormones go out of balance it is not unlike the washer in spin cycle. Our job is to find that “hand-towel” and fix the problem.

So why does this happen?

Time may be a part of the cause.

When we administer hormones, we are adding to the hormones the patient’s body is already making. No one comes to me with hormone levels of “0″. However, over time the amount that the body can make on its own may change, and thus the dose that was once perfect, may now be suboptimal, creating a return of their symptoms.
Changes in weight and exercise, increased stress, new medications, and many other factors can cause the body to 1) react differently to hormones, 2) change the need for hormones, or 3) alter metabolism of hormones.

So when something changes, a bit of detective work is in order to determine the cause of the change.
Hormone levels may also be checked to help us to determine the amount of imbalance and what needs to be done to get them back to where they were.

Also, in order to try to prevent this from occurring, I usually monitor my patient’s hormone levels every 6 months. I have found that by doing this, we can pick up on these hormonal changes and intervene before they manifest as a return of symptoms.

While this may only occur in a small number of patients, it is important to recognize when it does, and know how to re-balance them (hormonally or otherwise). This way we can get them back to humming along like a well balanced spin cycle.



Hormone balance


October 15, 2011

This week while seeing one of my patients for a follow up visit, I asked one of my standard questions–”So, has anything changed since we met last?”
“Yes” she said, “I am getting hit on again!” Cautiously, I asked her if that was ok.
“You bet” she said “it is good to be noticed”.
Now, I wish I could take all the credit for the physical changes that have occurred in her, but my role was only in making suggestions and offering guidance in lifestyle choices, and balancing her hormones. In truth, it was she who did all of the heavy lifting (both literally and figuratively) to get where she was at.
Now she may have assumed that this new attention was due to the physical changes of weight loss, toning, etc. But I think that it is much more than that.
What I see when I look at her is confidence. A confidence in knowing that she was able to make some very marked changes in diet and lifestyle, stick to them, and then see the results of her effort. A confidence that comes from sleeping well and feeling good. A confidence in knowing that although challenges in life are inevitable, she now has more physical and emotional reserve to meet them. She has changed in ways that neither of us could have anticipated.
I am also sure that her new-found smile did not hurt either.



Sunshine On My Shoulders Makes Me Happy

October 8, 2011

The signs are unmistakable. It is now the time of year again in the Upper Midwest when many of us are noticing the shortening of the days. For those who look forward to winter sports or pulling the snowmobile out of storage there can be a sense of excitement during this time. However for those who are sensitive to the sun’s departure, this time of year may seem like the entrance to a very long, dark tunnel. Among other things the shorter days mean less ability for the body to manufacture its own Vitamin D. Should you care? Absolutely!

So let’s take a minute to look at Vitamin D.

Vitamin D is a fat-soluble vitamin (or more correctly a hormone) that is essential for maintaining normal calcium metabolism. Vitamin D3 (cholecalciferol) can be synthesized by humans in the skin upon exposure to ultraviolet-B (UVB) radiation from sunlight.

There are really only 3 sources for vitamin D in our body. 1) Dietary inake 2) The Sun 3) Supplements.

1) In general, non-supplemental dietary intake is fairly low. The star of the show is Cod liver oil which sports approximately 1200 IU per tablespoon. Contrast this with a cup of fortified milk which contains about 120 IU, 3 ounces of salmon which contains about 360 IU, and an egg which contains about 20 IU.
2) Vitamin D production in the skin is affected by age, latitude, amount of sun exposure, clothing, skin pigmentation, and use of sunscreen. Just by nature of where we live (44 degrees latitude in Minneapolis) we are at higher risk for Vitamin D deficiency. My summer was full of patients insisting that they “get outside all the time during the summer” who I then found to have abysmally low levels of vitamin D.
3) Given the factors above it is pretty apparent that most of us will have to rely on some sort of supplementation to maintain healthy levels of Vitamin D.

When you think about this, it makes sense that I see vitamin D levels decreasing with age because, a) as we age our skin seems to be less efficient in making Vitamin D, b) we tend to expose less of our skin to the sun, c) we slather on the sunscreen (which completely blocks Vitamin D production) because we do not want to develop skin cancer and we know how sun exposure accelerates skin aging, and d) we become more calorie conscious or lactose intolerant so avoid dairy products which are supplemented with Vitamin D.

For millennia we have been exposed to the sun and our physiology has developed a dependence on this exposure to produce Vitamin D, and now we are trying to avoid it at all cost. So why does it matter?

Vitamin D deficiency/sub-optimal Vitamin D has been associated with countless problems including depression and Seasonal Affective Disorder (now I am sure nobody that you know suffers from the wintertime blues), and osteoporosis. Studies have also linked low Vitamin D to breast cancer, colon cancer, asthma, risk of influenza, cardiovascular disease, and insulin resistance among many other things. In addition Researchers at the University of Minnesota found that Vitamin D levels in the body at the start of a low-calorie diet predict weight loss success, suggesting a possible role for vitamin D in weight loss.

The current RDA (revised in 2010) for Vitamin D in an adult is 600-800 IU daily. While Vitamin D toxicity is a real possibility with excessive dosing, I find that for many of my patients, the recommended doses are clearly inadequate to maintain healthy levels. It is for this reason that I recommend that all of my patients get a baseline Vitamin D level, and that we adjust their dose till we reach what we feel to be an optimal level given their personal physiology and risk factors.

So get out there and wax those skis, sharpen your skates, fire up the snowmobile AND make sure that you know what your Vitamin D level is.



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