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The two main principles of Bio-identical Hormone Therapy ( BHRT):

Bioidentical Hormone Replacement Therapy: Myth vs Fact What you really need to know Mark D Filidei, D.O. Director of Integrative Medicine Amen Clinics. The two main principles of Bio-identical Hormone Therapy ( BHRT):.

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The two main principles of Bio-identical Hormone Therapy ( BHRT):

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  1. Bioidentical Hormone Replacement Therapy:Myth vs FactWhat you really need to knowMark D Filidei, D.O.Director of Integrative MedicineAmen Clinics

  2. The two main principles of Bio-identical Hormone Therapy (BHRT): 1) Use of natural (human bio-identical) hormones: exactly like those produced in the body 2) Physiological replacement to levels of a young adult

  3. Many doctors are unaware they are prescribing BHRT! • Vivelle • Estrace • Estraderm • Femring • Femtrace • Climara • Alora • Prometrium

  4. BHRT-The main players • Thyroid • Estrogen • Testosterone • Progesterone • Dhea • Growth Hormone

  5. Hypothyroidism is an epidemic The Colorado thyroid disease prevalence study: 25,000+ participants CONCLUSIONS: “The prevalence of abnormal biochemical thyroid function reported here is substantial and confirms previous reports in smaller populations. Among patients taking thyroid medication, only 60% were within the normal range of TSH. Modest elevations of TSH corresponded to changes in lipid levels that may affect cardiovascular health. Individual symptoms were not very sensitive, but patients who report multiple thyroid symptoms warrant serum thyroid testing. These results confirm that thyroid dysfunction is common, may often go undetected, and may be associated with adverse health outcomes that can be avoided by serum TSH measurement.”

  6. Signs and Symptoms of Low Thyroid • Fatigue • Increased sensitivity to cold • Constipation • Dry skin • Unexplained weight gain • Puffy face • Hoarseness • Muscle weakness • Elevated blood cholesterol level • Muscle aches, tenderness and stiffness • Pain, stiffness or swelling in your joints • Heavier than normal or irregular menstrual periods • Thinning hair • Slowed heart rate • Depression • Impaired memory

  7. Standard ranges for thyroid testing (Labcorp): Free T4 0.82-1.77 Free T3 2.0-4.4 >3.50 TSH0.45-4.50 <1.50 With co-morbidities use: fT3/rT3 >20

  8. D1 (but not D2!) is suppressed and down-regulated by: Physiologic and emotional stress Depression Dieting Weight gain/Weight Loss Insulin resistance and Diabetes Obesity Inflammation Autoimmune disease Systemic illness Chronic fatigue syndrome Fibromyalgia Chronic pain Exposure to toxins, mold, heavy metals, and plastics

  9. Thyroid hormone replacement • T4 only (most common) Synthroid, levothyroxine • Natural thyroid (Armour, Westhroid, NP thyroid) contains natural ratios of T4 and T3 • T3 only (Cytomel, compounded T3)

  10. The Three Forms of Estrogen • Estrone: Produced in peripheral tissues; implicated in some cancers (breast, uterine) • Estradiol: Secreted by ovaries; most active form, supports cognitive function and mood, higher levels associated with youthful appearance. Deficiencies associates with osteoporsis, dementia, heart desease • Estriol: safest and weakest form of estrogen; may have anti-cancer effects, useful for vaginal dryness and MS (reverses brain lesions)

  11. Signs of Low Estrogen (From Unleash the Power of the Female Brain) • Weight gain • Bladder incontinence and infection • Mood changes/depression • Insomnia • Low libido • Heart palpitations • Osteoporosis • Painful intercourse • Foggy headedness • Irritability • Fatigue • Weepiness • Hot flashes • Pain

  12. Signs of Excess Estrogen (From Unleash the Power of the Female Brain) • Puffiness • Heavy bleeding • Fibrocystic breasts • Low libido • Cravings for carbohydrates • Weight gain around the hips • Vaginal or oral yeast (thrush) • Mood swings/easy to tear • Tender breasts • Headaches or migraines

  13. Benefits of Estrogen replacement • Helps reduce/eliminate menopausal symptoms • Can help maintain bone density • Anti-Aging benefits • May decrease risk of Alzheimer’s and and other brain related problems • Supports cognitive function and mood (serotonin function)

  14. Estrogen enhances brain function • “Authors suggested this study supports previous results showing that the effect of estrogen therapy on mood may be independent of antidepressant effects mediated by alleviation of vasomotor symptoms and that estrogen therapy may be of benefit to perimenopausal women experiencing moderately severe depression.” Short-term use of estradiol for depression in perimenopausal and postmenopausal women: a preliminary report. Am J Psychiatry. 2003 Aug;160(8):1519-22. • “Estrogen in a therapeutic dosage alters brain activation patterns in postmenopausal women in specific brain regions during the performance of the sorts of memory function that are called upon frequently during any given day. These results suggest that estrogen affects brain organization for memory in postmenopausal women.” Effect of estrogen on brain activation patterns in postmenopausal women during working memory tasks. JAMA. 1999 Apr 7;281(13):1197-202

  15. PremarinPregnant MareUrine • Conjugated estrogens, from the urine of pregnant mares (50% equine hormones, not found in humans) • Predominantly E1 (estrone)

  16. Natural Estrogen Replacement • Bi-Est: 80% estriol, 20% estradiol in oral or transdermal form • Estradiol only • Transdermal is recommended to avoid “first pass effect” and coagulation issues of oral use • Should always be balanced with natural progesterone in women with an intact uterus

  17. Estrogen Metabolism Estrogens convert into several metabolites. Estrone, for example, may convert into three different forms: • • 2-hydroxyestrone, protective against cancer • • 4-hydroxyestrone, promotes cancer • • 16-alpha-hydroxyestrone, promotes cancer In women on HRT, the 2/16 ratio should be >2. Lower ratios are associated with breast and ovarian cancer.

  18. March 30, 2013, 9:54 p.m “Study upholds breast cancer mortality for hormone replacement” Though it was generally agreed that woman who took the two hormones to curb their hot flashes and night sweats upped their chances of developing the disease, many studies suggested that the cancers the women developed were less likely to be deadly. A new analysis of data from the Women's Health Initiative now casts doubt on those findings. The study, published Friday by the Journal of the National Cancer Institute, concludes that the prognosis for cancers related to hormone replacement therapy is just as dire as for other breast cancers. As a result, women who turn to the treatment are more likely to die of breast cancer than their peers who don't take hormones.

  19. “The new findings apply only to women who take estrogen and progestin, a synthesized form of the natural hormone progesterone. Women who have had hysterectomies can take estrogen alone, a regimen that doesn't seem to increase breast cancer risk. But those who still have a uterus must take both estrogen and progestin to avoid developing endometrial cancer. And hidden much further down in the article we find this:

  20. Hormone therapy for Breast Cancer Survivors? “We observed lower risks of recurrence and mortality in women who used HRT after breast cancer diagnosis than women who did not” …the results suggest that HRT after breast cancer has no adverse impact on recurrence and mortality” J NatlCnacerInst 2001 May “Continuous combined HRT was associated with reduced risk of death from primary tumour and all cause mortality.” Med H Aus 2002 Oct “Over a mean follow up of 30 months 17 of 214 users experienced recurrence (4.2% per year), compared with 66 of 623 controls (5.4% per year). HRT did not seem to affect breast cancer recurrence risk” J Clin Oncology 2001 April “Estrogen replacement therapy apparently does not increase either recurrences or mortality rates. Adding progesterone may even decrease recurrences. Women with early breast cancer should be offered hormone replacement therapy… Am J Obstet Gynecol. 1999

  21. Hormone replacement therapy after breast cancer: 10 year follow up of the Stockholm randomised trial. “The number of new events did not differ significantly between groups, in contrast to previous reports. The increased recurrence in HABITS has been attributed to higher progestogen exposure. As both trials were prematurely closed, data do not allow firm conclusions. Both studies found no increased mortality from breast cancer or other causes from HRT. Current guidelines typically consider HRT contraindicated in breast cancer survivors. Findings suggest that, in some women symptom relief may outweigh the potential risks of HRT.” Eur J Cancer 2013 Jan

  22. Synthetic Progestins • Provera (medroxyprogesterone acetate) most popular “progesterone” drug • Dozens of adverse effects: decreases blood flow to heart, lowers HDL, and causes edema, weight gain, insulin resistance, insomnia, and, if taken in early pregnancy, birth defects

  23. Natural Progesterone • Protects against estrogen’s proliferative effects on endometrium • Helps alleviate PMS symptoms • Reduces fibrocystic breast disease • May elevate libido and mood • May promote bone formation

  24. Natural progesterone • Supports GABA - a major calming neurotransmitter • “natures Valium” • Levels drop with low thyroid, chronic stress, vitamin deficiencies and refined sugar

  25. Symptoms of low progesterone • Anxiety/depression • Poor sleep • Fibrocystic breasts • PMS • Premenstrual headaches • Postpartum depression

  26. Progesterone Replacement • Oral micronized progesterone, 100-300 mg at bedtime • Transdermal natural progesterone creams, 1/4-1/2 teaspoon daily • Available both OTC and prescription

  27. Testosterone for Women (?) • Yes! • Declines with age, just like in men • Increases libido, elevates mood and energy level • Improves ratio of fat to muscle • Replacement: Natural testosterone in transdermal cream or gel. Implanted pellets.

  28. Testosterone for Men • Levels fall gradually with age; ”Low T” syndrome • Low levels herald andropause • Symptoms include loss of libido, fatigue, depression, loss of muscle mass, osteoporosis, anhedonia, • “I lost my mojo” • Testosterone replacement can be used for men with history of prostate cancer if they are disease free.

  29. Testosterone Replacement • Injections: 200mg wk, 100mg 2x/wk SQ or IM • Topical in gel or cream: 50-100mg/day • Troche • Implanted pellets • Avoid oral testosterone • HCG injections

  30. DHEA –adrenal hormone Precursor hormone • Low levels associated with depression, weight gain, heart disease, diabetes, autoimmune disorders, immune dysfunction, obesity, cancer, osteoporosis, memory loss • Replacement improves sense of well-being, mood, memory, immune function, and in women libido

  31. DHEA • “DHEA was associated with a remarkable increase in perceived physical and psychological well-being for both men (67%) and women (84%)... • Morales, AJ et al. Effects of replacement dose of dehydroepiandrosterone in men and women of advancing age. J. Clin. Endocrinology and Metabolism, 1994; 78(6):1360-1367.

  32. DHEA • "... an increase in DHEA-S of 100 mg/dl was associated with a 36% reduction in mortality from any cause and a 48% reduction in mortality from cardiovascular disease." • Barrett-Connor, et al. A perspective study of dehydroepiandrosterone sulfate, mortality and cardiovascular disease. NEJM, Dec. 11, 1986; 315(24):1519-1524.

  33. DHEA • Average doses: • 5-25 mg women • 25-50 mg men • Check blood levels of DHEA-S to determine optimal dose • Use with caution in patients with hormone-sensitive cancers, such as breast or prostate cancer*

  34. DHEA may protect against breast cancer • Dehydroepiandrosterone (DHEA) has a protective role against cancer…These results suggest that the mechanism of DHEA actions against breast cancer involves the inhibition of cell proliferation and the suppression of migration, indicating that DHEA could be useful in the treatment of breast cancer. EurJ Pharmacol. 2011 Jun 25 • The DHEA metabolite 7β-hydroxy-epiandrosterone exerts anti-estrogenic effects on breast cancer cell lines Steroids. 2012 Apr;77(5

  35. Human Growth Hormone After 6 months of treatment: • Increase in muscle mass (8.1%) • Reduction of body fat (14.4%) • Increase in bone density (1.6%) • Rejuvenation of skin (7.1%) • Rudman, D et al. Effects of human growth hormone in men over 60 years old. New Engl J Med, July 5, 1990; 323(1): 1-6.

  36. Human Growth Hormone • “The effects of 6 months of hGH on lean body mass and adipose-tissue mass were equivalent to the changes incurred during 10 to 20 years of aging.” • Rudman, D et al. Effects of human growth hormone in men over 60 years old. New Engl J Med, July 5, 1990; 323(1).

  37. Human Growth Hormone • Speeds healing after surgery and recovery from severe illness • Excellent therapy for heart failure: increases cardiac output and exercise capacity • Given by SQ injection • Oral “Secretagogues”do not reliably increase IGF-1

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