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Medical Aesthetic Treatments > Biote HRT > Flashcards

Biote HRT Flashcards

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USMLE® Step 1 flashcards
1
Q

dr. charles brown- sequared self injected what into himself and what year

A

self injected testicular extracts from animals in 1889

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2
Q

what did Dr. charles brown start to notice an increase of when self injecting with testicular extracts

A

increased energy, muscular strength, stamina, and mental agility

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3
Q

who developed isolated Ts for injection and won a noble prize

A

in 1891 leopold ruzicka

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4
Q

in 1942 what was testosterone used to prevent

A

peripheral vascular disease (PVD)

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5
Q

in 1953 what was testosterone used to treat

A

angina pectoris in both males and females (vasodilator)
91% of patients showed improvement

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6
Q

what age range do women lose 50% of their testosterone production

A

age 20-40

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7
Q

what age range do men lose 1-3% of total testosterone production per year

A

30-70

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8
Q

what are bioidentical hormones

A

structurally identical to those made by the body

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9
Q

what is the most biologically active estrogen

A

estradiol

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10
Q

what e’s are present in the body

A

estriol and estrone

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11
Q

don’t get progesterone confused with progestin because

A

progestin is synthetic and are bad

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12
Q

what is a bioidentical molecule

A

exact molecular structure of hormones that the body produces

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13
Q

what is a synthetic molecule

A

different molecular structure than what body produces

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14
Q

what are bioidentical molecules made from

A

soy or yams (but not an issue with food allergy)

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15
Q

what are the bioidenetical molecules (E2)

A

17b estradiol-estrace, climara, vivelle, minivelle, estrogel, estring

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16
Q

what are synthetic molecules made from

A

animal parts or urine

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17
Q

what are the synthetic molecules (E2)

A

estradiol valerate or cypionate, Premarin (CEE), enjuvia, cenestin, menest

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18
Q

what are the bioidentical molecules of testosterone

A

testosterone

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19
Q

what are the synthetic molecule of testosterone

A

testosterone cypionate, enanthate, undecanoate

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20
Q

what are the different routes of administration of testosterone

A

oral
transdermal/vaginal
injectable
pellot

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21
Q

what are the cons of oral delivery

A

1st pass is effective but GI upset is common
daily administration
testosterone itself given orally is not effective
TID very short half life

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22
Q

what are the cons of injectable delivery

A

levels fluctuate like a roller coaster
weekly/biweekly shots
allergies to oil suspension
higher level of erythrocytosis and aromatization
may increase platelet stickiness

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23
Q

what are the cons of transdermal/vaginal/ scrotal delivery

A

skin irritation
possible transfer to others
45% of people do not absorb
blood levels very
administer daily or BID

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24
Q

what are the cons of pellet delivery

A

some pain with insertion
possibility of extrusion
activity restrictions after procedure

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25
Q

what delivery route is the superior option

A

pellets

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26
Q

why is pellets the best option for delivery

A

avoids unnecessary risk of platelet aggregation
unlimited dosing options
steady levels
predictable absorption
convenient and improved patient satisfaction and compliance

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27
Q

how often do men and women get pelleted

A

3-4x/ yr for women (3-4 months)
2-3x/ yr for men (5-6 months)

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28
Q

**when does testosterone kick in

A

7-10 days

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29
Q

if a client is taking testosterone and then wants to get pellet when do you tell the patient to stop taking their testosterone

A

a week after pelleting

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30
Q

20 years ago what kind of implant was used for testosterone for androgen replacement therapy

A

fused, crystalline implants for a 13 year study of 221 men

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31
Q

testosterone use in women dates back to

A

1937 very effective for vaginal atrophy and other climacteric symptoms

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32
Q

despite overwhelming evidence in support for testosterone supplementation in women, there is no…

A

fda approved product

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33
Q

despite any lack of clear rationale, what was assumed to be the hormone of choice for “replacemet therapy” in women

A

estrogen (premarin)

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34
Q

when was testosterone reported to effectively treat symptoms of menopause

A

as early as 1937

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35
Q

what is the consensus on female use of testosterone

A

testosterone is not a male exclusive hormone
it is most abundant gonadal hormone throughout a womans life
female testosterone insufficiency is a clinical syndrome
testosterone therapy may be breast protective
testosterone insufficiency in women negatively impact sexuality, general health, and quality of life
test insufficiency may be linked to increased risk for CVD
may be brain protective and enhance cognitive function
may be improved bone health

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36
Q

testosterone is not a male exclusive hormone and production is how much more production than estrogen

A

3-4x

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37
Q

when do androgen levels peak in women

A

their twenties with symptoms preset both in pre and post menopausal women

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38
Q

what are the 3 sources testosterone production in women

A

overies, adrenal glands, and peripheral conversion from other circulating androgens

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39
Q

by age 4 in women how much testosterone is lost

A

half of their testosterone production

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40
Q

in women, the androgen production from adrenals decline but testosterone production from _________ remain somewhat intact after menopause

A

overies ( women with BSO have 50% further incline)

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41
Q

what are the benefits of people hormones being optimized with HRT

A

energy increase
better sleep and mental clarity
ability to lose weight
sex drive increases
breast, bone, and heart health

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42
Q

as hormone levels drop, what is seen

A

low energy
mood swings
weight gain
joint pain
difficulty sleeping
brain fog
low sex drive
risk of age related illness

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43
Q

with testosterone replacement therapy in women what are the two symptoms with high percentages of complete relief after receiving

A

hot flashes 90.8%
depression 75.8%

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44
Q

testosterone was superior for relief of energy, well being, somatic complaints, and psyichological symptoms but what was the worst during studies

A

estrogen alone and placebo

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45
Q

what are the top 10 myths about testosterone use in women

A

testosterone is a male hormone
the only role of T in women is sex drive and libido
T masculinizes women
T causes hair loss
T has adverse effects on the heart
T causes liver damage
causes aggression
may increase risk of breast cancer
the safety of T use in women has not been established

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46
Q

what are women at increased risk for if they have low T

A

alzheimers
cardiovascular disease
osteoporosis related fractures
diabetes mellitus
sarcopenia
possibly an increased risk for breast cancer

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47
Q

what are positive effects of bioidentical testosterone in women

A

enhanced libido
heart protection
lower cholesterol/LDL
increased HDL
increased energy
enhanced sleep
feeling of overall well being
reduction of body fat
stonger bones an muscles
relief of anxiety/depression
reduced “brain fog”, memory and cognition

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48
Q

when do testosterone levels start to decline in men

A

after age 30 they will decline 1-3% every year after 30

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49
Q

total ______ _________ is most commonly used measurement of __________ __________, though it is a poor indicator of tissue activity

A

serum testosterone, androgen activity

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50
Q

age related decline in testosterone is associated with increased all cause…

A

mortality in aging men

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51
Q

in men there is increased mortality with…

A

low testosterone levels
(cardiovascular related, cancer related)
*men in the highest quartile T levels were found to have 30% reduction in mortality compared to those in the lower quartile

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52
Q

free T measurements are equally inaccurate in the clinical setting and normal ranges very widely between laboratories and bear little correlation to clinical finding so….

A

treat the patient not the lab

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53
Q

low T in men are increased risk for

A

alzheimers disease
CVD
osteoporosis related fractures
prostate cancer
DM
sarcopenia

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54
Q

what do hormones protect

A

bones
brain
breast
prostate tissue
heart

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55
Q

what is the normal physiology of estrogen in normal menstrual cycle

A

follicular phase starts day 1 of cycle
gonadaptropin releasing hormone pulse frequency increases causing 30% rise in FSH which recruits follicles which causes granulose cell hypertrophy which forms serum E2
serum E2 make proliferation of endometrium
serum E2 lessens FSH but GnRH pulse increases which makes the LH surge (start of luteal phase)
estradiol peaks 1day prior to ovulation
luteal phase starts- egg is released from ovary through fallopian tube and to the uterus
the granulose cell produces progesterone which further suppresses LH
progesterone then prepares endometrium by thickening

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56
Q

what are the phases of menstrual cycles

A

follicular-proliferative (1 through 14)
ovulation (day 14)
luteal phase-secretory (15-28)

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57
Q

what are the physiologic effects of estrogen

A

actions mostly on reproductive organs but also act on
cardiovascular
skeletal
immune
gastrointestinal
brain

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58
Q

what is menopause

A

cessation of menses for over a year
significant decline in estrogen as well as testosterone and progesterone and increases FH (>23)
multiple symptoms associated: vasomotor, urogenital atrophy, bone loss
traditionally treated with HRT
treated with individualized bioidentical HRT or BHRT ideally

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59
Q

what are symptoms of estrogen deficiency

A

irregular absent periods
hot flashes
vaginal dryness
poor sleep
breast tenderness
HA or worsening pre existing migraines
depression/anxiety
frequent UTIs

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60
Q

what to know about FSH

A

gives overall status of estrogen
fluctuates through cycle in pre and perimenopause
increases consistently once E2 declines at menopause
cannot be measured by saliva
is supressed by estrogen therapy, including combination OCPs
may be >23 in perimenopause BUT E2 is HIGH
higher the FSH the more deficient E2

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61
Q

premenopausal patients make their own…

A

estradiol and progesterone

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62
Q

postmenopausal replacement estrogen replacement therapy (ERT) is

A

no longer menstrating
no longer able to make estradiol OR progesterone
**if patient has uterus and gets replacement dose E2, MUST give progesterone

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63
Q

if patient has intact uterus postmenopausal do they get a replacement dose of estrogen?

A

NO!!
because they still have their uterus

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64
Q

what is the patient screening of BHRT

A

prevention of adverse events (improves results and compliance)
BHRT must be individualized
dosages and combinations are fairly unique to each patient
patient history very important (may need to change dose, regimen)

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65
Q

between transdermal and oral estrogen what is the main takeaway

A

oral estrogen is more associated with an increased VTE risk

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66
Q

transdermal estrogen may improve the benefit/risl ratio of postmenopausal HT and should be considered a safer option for

A

women at high risk for VTE

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67
Q

what is the BHRT climacteric 2012

A

transdermal E2 showed no increase of VTE or CVA
P4 (unlike progestins) showed no increase risk of VTE or Breast Cancer

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68
Q

why is HRT in young post menopausal women safe and effective

A

to counteract climacteric symptoms and prevent long term degenerative diseases
non oral estrogens= NO VTE and better BP
natural progesterone = positive

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69
Q

non oral estrogens=

A

NO VTE and better BP

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70
Q

natural progesterone =

A

positive cognitive effects and no increase in breast cancer

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71
Q

transdermal E2=

A

no increased risk of stroke, VTE
no adverse cardioavascular effects
no effects on gallbladder function

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72
Q

can you use BHRT indefinitely?

A

yes

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73
Q

implant therapy for HRT

A

no increase in thrombotic activity with pellet therapy
reduces cardiovascular risk compared to oral therapy
does not increase the risk of breast cancer

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74
Q

does HRT increase the risk for breast cancer

A

no
80,377 post menopausal women study

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75
Q

does HRT increase risk of heart attack?

A

no
it is cardioprotective

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76
Q

transdermal estradiol (E2) does not…

A

increase risk of VTE (unlike oral)
it is cardioprotective and decreases risk of AMI
decreases risk of T2DM

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77
Q

micronized progesterone (P4)

A

reduces risk of T2DM
does not increase risk of VTE
reduces BP

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78
Q

what are the 6 “complex watches” of biotechs method optimal health and longevity

A

Testosterone
Estrogen
diet
thyroid
HGH
V&M

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79
Q

when compared to oral and patch for E2 what is seen with pellets

A

steady, consistent serum levels

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80
Q

what are the symptom reduction over time with pellets

A

men 4-5 months
women 3-4 months

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81
Q

what are potential and unnecessary effects of ORAL estrogen therapy

A

breast tenderness
vaginal bleeding
headaches
gallbladder dysfunction
nausea and vomiting
fluid retention
blood clots
leg cramps
gallstones

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82
Q

in women and med, “physiologic” replacement therapy needs to have relatively constant blood levels without daily spikes.. what is the only thing that does this

A

pellets

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83
Q

how are pellets made and absorbed

A

pure estradiol and testosterone
compressed into pellets using thousands of pounds of pressure
E-beam for sterilization- not autoclave
absorbed based on cardiac output, not time released
not depot
503B facility

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84
Q

how are pellets absorbed based on..

A

cardiac output, not time released

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85
Q

what are advantages of pellet therapy

A

steady state of hormones no roller coaster effect
2-4 insertions per year (improves patient compliance)
improves lipid sensitivity and body composition
no significant weight gain
best method to increase bone density
no increase in inflammatory markers
no increase in SHBG
in increased risk of breast or prostate cancer
no increase in blood clots, heart attack or stroke

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86
Q

what is progesterone

A

steroid hormone derived from cholesterol
involved in menstrual cycle, pregnancy, and embryogenesis
progesterone receptor sites in the uterus, breast, vagina, blood vessels and brain.

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87
Q

what hormone is important in menopausal women, perimenopausal women, premenopausal women, and pregnant women

A

progesterone

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88
Q

what is the source of E2 (estradiol)

A

ovary

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89
Q

what is the source of progesterone

A

ovary/ corpus luteum/ adrenals

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90
Q

what are the levels of E2 post menopausal

A

<20 pg/ml

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91
Q

what are levels of progesterone post menopausal

A

0.1-1 ng/ml

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92
Q

if progesterone is produced primary by the ovary then what would progesterone levels during menopause bee

A

zero
progesterone drops more drastically than estrogen does do to the limited areas of production

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93
Q

why bioidentical progesterone over synthetic?

A

because synthetic is increased risk for breast ca, cad, dvt/PE/ dementia, and diabetes
side effects are MULTIPLE

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94
Q

why no progesterone in pellets??

A

molecule is too large-> variable absorption
unpredicted duration -> leaves endometrium unprotected
cannot change dose if bleeding

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95
Q

what are the formulations of bioidentical progesterone

A

oral, SL, SL RDT, RX cream, OTC cream

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96
Q

what to know about progesterone cream

A

cream is NOT recommend in post menopausal patientsWITH a uterus

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97
Q

why is progesterone cream not recommended in post menopausal patients with a uterus

A

it does not protect the uterus adequately

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98
Q

what are the common dosing for post menopausal patients WITH a uterus for progesterone

A

generic capsules 200mg every night
compounded capsule 225mg every night
RDT or SL 100mg every day
cream- not recommended in its with a uterus

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99
Q

what are the 5 steps of progesterone dosage adjustment

A

if patient has side effects or abnormal bleeding
confirm proper use of progesterone
taking in EVENING at SAME TIME? half life is only 12 hrs
taking with food
if on sublingual or RDT, make sure it is dissolving not bittne or chewed

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100
Q

premenopausal women will not get progesterone unless

A

for another indication

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101
Q

if a women is menopausal ON ESTROGEN and with a uterus

A

absolutely MUST take progesterone

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102
Q

does biotechs method include use of progesterone in men?

A

NOO

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103
Q

when patient is on progesterone are monitoring levels required?

A

no, measurements are mainly with post menpausal bleeding

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104
Q

what are blood levels of progesterone

A

normal range= 4-25ng/ml
optimal range= 10-20ng/ml midluteal levels

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105
Q

are saliva levels taken for progesterone?

A

no they are inaccurate and dangerous to relay on saliva test because if used while taking transdermal RX it will read high but serum levels will be low

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106
Q

contraindications for progesterone in women

A

ER/PR positive breast cancers
allergy to peanuts

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107
Q

if a patient is allergic to peanuts and is needing progesterone (females only but not all)

A

cannot use generic or brand name, must be compounded
*write RX “peanut free base”
compounded capsules do not contain peanut oil

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108
Q

do i use progesterone in women receivign E2 for menstrual migranes

A

no
premanopausal women make their own progesterone
E2 6mg is NOT a replacement dose
additional progesterone is NOT recommended for these patients

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109
Q

if a woman is bleeding after pellets what could it be

A

if there is a uterine problem, the pellets will expose it. (uterine fibroids, endometrial polyps, adenomyosis, endometrial hyper plasia or even carcinoma)
may occur soon after 1st insertion if pt has underlying pathology OR if misses progesterone dose

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110
Q

what is considered abnormal bleeding in women

A

premenopausal patients- any change in “normal” menstrual pattern

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111
Q

what is polymenorrhea

A

more frequent bleeding

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112
Q

what is oligomenorrhea

A

less frequent bleeding

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113
Q

what is amenorrhea

A

missed period for >3 months

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114
Q

what is post menopausal bleeding

A

bleeding that occurs after > 1 year of no period (in association with low E2 and high FSH)
can be light spotting or even just one day/ one time
can be red, pink, brown, may be heavy like true period

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115
Q

we do NOT use full, replacement dose of ____ in perimenopausal patients who have had a period in the last _____ months to avoid bleeding

A

E2, 12 months

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116
Q

for progesterone therapy we should rule out anatomical cause THEN consider hormonal cause

A
  1. was progesterone taken correctly
  2. exam and vag ultrasound +- EMB
  3. if normal anatomy, 4 causes of bleeding : too much E2, too little E2, too much P, too little P
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117
Q

what is the HPT axis and process

A

the hypothalamus sends TRH (thyroid releasing hormone) to the pituitary gland which then sends TSH (thyroid stimulating hormone) to the thyroid gland which then sends out T3 and T4

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118
Q

what is total T3 and T4

A

form of thyroid hormone that is bound to a protein carrier in order to be transported throughout the body (thyroid binding globulin)
T3/T4 hormone have to be separated from TBG to become metabolically active and bind to cells receptor and perform their respective function.
*key concept, its possible to have normal amounts of total T4 and total T3 but have low amounts of free T3/T4

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119
Q

what is reverse T3

A

chemically similar to T3, completely inactive, it lowers the amount of active thyroid hormone (T3) available, “emergency brake” on the system
*RT3 reverses T3

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120
Q

what causes elevated RT3

A

nutrient deficiency (selenium)
excess physical/mental/ environmental stress, adrenal compromise, high toxic burden, dysbiosis

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121
Q

what is elevated RT3 called

A

low T3 syndrome or sick euthyroid

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122
Q

what are 4 thyroid myths

A

1.T4 is good, T3 is bad (negative clinical effects)
*T3 iss present at birth and is essential to life
2. T3 will cause atrophy to the gland causing permanent dependence on thyroid hormone replacement
3. suppressing TSH will cause osteoporosis
*hyperthyroid disease (graves) from too much endogenous production of thyroid hormone IS linked to bone loss
4. once you start thyroid, you will need it the rest of your life

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123
Q

what is regulated by the thyroid hormones

A

regulate:
temperature
metabolism
cerebral function
energy

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124
Q

how is our metabolism regulated by the thyroid hormones

A

increase fat breakdown resulting in weight loss as well as lower cholesterol
help fix leptin resistance (increase hunger, slowed metabolism)

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125
Q

what does the thyroid hormones protect against

A

cardiovascular disease
cognitive impairment
fatigue and weight gain
memory loss

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126
Q

what is the enzyme that serves as essential control points of thyroid activity

A

deiodinases

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127
Q

what does the deiodinase enzyme do

A

determines intracellular activation and deactivation of thyroid hormones dependent of serum hormone levels

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128
Q

what are the 3 diodinases present in different tissues of our bodies

A

D1= converts T4 to T3
D2= converts T4-T3
D3= converts T4- reverse T3

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129
Q

where does D1 work

A

in the liver and kidney

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130
Q

what is the key enzyme that controls intracellular T3

A

D2

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131
Q

what surpresses D1 and D2

A

stress, depression, dieting, insulin resistance, obesity, DM, inflammation, systemic illness, chronic fatigue syndrome, chronic pain, exposure to toxins

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132
Q

what are symptoms related to thyroid deficiency (not enough)

A

weak, cold, tired, fatigued
thin hair, thin nails, thin skin
weight gain, increased body fat
loss of energy and motivation
loss of cognitive, memory, mood
poor sense of well being, depression
infertility, loss of libido, menstrual irregularities
constipation/compromised gut motility

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133
Q

how many americans are hypothyroid

A

30-40%

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134
Q

what are reasons for thyroid deficiency

A

decreased production by the gland
decreased conversion of T4 to T3
less effectiveness at the receptor sites causing low thyroid symptoms in spite of “normal” blood levels

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135
Q

what are the 3 types of hypothyroidism

A

primary
secondary
tertiary

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136
Q

primary thyroidism

A

decreased production of thyroid hormones
TSH elevates, T3 and T4 will be normal or low depending on severity

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137
Q

secondary thyroidism

A

poor conversion of T4 to T3 in peripheral tissue
conversion of T4 to reverse T3 (rT3)
euthyroid sick syndrom = low T3 syndrome

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138
Q

tertiary hypothyroidism

A

receptor site insensitivity
symptoms of low thyroid persist despite normal labs

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139
Q

what are causes of decrease thyroid production

A

autoimmune thyroiditis
surgical removal of gland
iodine deficiency
failure of the hypothalamus or pituitary gland
inflammatory cytokines involved in stress response
gastrointestinal lipopolysaccharides, an endotoxin produced from bacterial overgrowth aka leaky gut

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140
Q

free T3 lab range

A

2.3-4.3
*optimal is 4.0-4.3

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141
Q

TSH lab range

A

0.3-5.0
* optimal .3

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142
Q

what are treatment options for hypothyroidism

A

levothyroxine/ synthroid/ tirosint (T4)
cytomel/liothyronine (T3)
desiccated thyroid (T4/T3/T1/T2)
no desiccated compound (T4/T3)

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143
Q

what medication for hypothyroid is more readily available and well absorbed

A

NP thyroid

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144
Q

what is treatment of choice for hypothyroid

A

NP thyroid

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145
Q

what is therecommendation for thyroid screening

A

the thyroid can affect many of your bodily functions and is an important regulator of your metabolism… you should get it checked stating at age 50 and every 5 years after that

146
Q

if the patient is asymptomatic, why do we care about treating their thyroid deficiency

A

T3 is needed for fat loss, and 40% of americans are obese
T3 protects against arrhythmia and heart disease
T3 decreases with stress or dieting, prolonged hypothyroidism results in elevated cortisol levels resulting in decreased conversion on T4 to T3 and increases the amounts of rT3
risk increase for anemia and other immunology changes with low thyroid

147
Q

does thyroid replacement cause osteoporosis

A

no

148
Q

does thyroid replacement increase the risk of heart disease and/or arrythmias

A

no, they help decrease the risk

149
Q

how does low thyroid lead to heart disease/arrythmias

A

ricin accumulation
increased incidence of inflammation and infection
diastolic hypertension
swelling, dyspnea
bradycardia, PVCs and AFib
Vtach is associated with low T3, low ration of T3/T4 and high reverse T3

150
Q

what is T3

A

triiodothyronine (T3)

151
Q

what is T4

A

thyroxine (T4)

152
Q

what system is the thyroid apart of

A

the endocrine system

153
Q

how to describe a normal functioning thyroid gland

A

The gland, which is tiny and butterfly-shaped, is found at the bottom front of your neck. It makes the two main thyroid hormones, triiodothyronine (T3) and thyroxine (T4)—both of which have a major hand in your energy levels, internal temperature, hair, skin, weight, and more.
The thyroid gland takes its direction from both the hypothalamus (which is in your brain) and the pituitary gland, a pea-sized gland at the base of your skull. In a complex dance, the hypothalamus releases something called thyrotropin-releasing hormone, which then triggers the pituitary gland to produce something called the thyroid stimulating hormone (TSH). The TSH is then what helps your thyroid gland release T4 and T3. Without TSH, the system would fail.When thyroid hormone levels are off, several issues can arise. You can have an overactive thyroid gland where too much thyroid hormone is produced (hyperthyroidism). An example of this is Graves’ disease. You can also have an underactive thyroid gland in which too little thyroid hormone is produced (hypothyroidism). An example of this is Hashimoto’s thyroiditis.”

154
Q

what is T3 and T4 responsible for

A

Thyroxine (T4) is responsible for your metabolism, mood, and body temperature, among other things. T3, too, is made in the thyroid gland, and it can also be made in other tissues within the body by converting T4 (in a process called deiodination) into T3. This hormone is at the center of your digestive and metabolic function, and it also oversees bone health.

So, if your T3 and T4 levels are too low, the pituitary gland will release more TSH. If they’re too high, the gland will release less TSH—but this give and take system only works if everything is functioning properly.

155
Q

When You Have Too Much T3 or T4, You Might Experience:

A

Anxiety
Feelings of irritation
Hyperactivity
Hair loss
Skipped periods
Tremors and shaking
Sweating

156
Q

When You Have Too Little T3 or T4, You Might Experience:

A

Weight gain
Memory issues
Lethargy
Fatigue
Constipation
Brain fog
Dry skin

157
Q

what is TSH

A

As mentioned above, the thyroid stimulating hormone (aka thyrotropin or thyrotrophin) is produced by the pituitary gland. It works sort of like the master of the hormones, and rules the production of T3 and T4 from its control center.

If you have too much TSH, it might mean that your thyroid gland isn’t making enough T3 or T4. Remember, the TSH is supposed to stimulate the thyroid gland—but if the gland isn’t responding, then you’ll have too much TSH in your system.

If your TSH levels are too low, it may mean that your thyroid gland is making too much thyroid hormone. This excessive thyroid production could actually suppress the TSH.

158
Q

what levels are associated with adverse outcomes in patients with ACS undergoing PCI
related to increased early and late mortality in NSTE-ACS patients
predicts worse hospital outcomes in patients with acute HF and can be useful in the risk stratification of these patients

A

low T3`

159
Q

in 1970 Dr. Broda Barnes was known for

A

placeing 1,569 patients on natural thyroid hormone, all had elevated cholesterol and high BP
based on stats, 72 of his patients should have dies from heart attacks, but only 4had done so.
this represents a 95% decrease of heart attack deaths in patients receiving natural thyroid hormone

160
Q

for inflammation, thyroid hormone lowers…

A

CRP
C-Reactive protein
*CRP is secreted by the liver and checks for inflammation in the body

161
Q

how does T3 correlate with alzheimers

A

higher serum FT3 is associated with lower risk of conversion to AD
patients in the lowest serum FT3 quartile had a twofold increased risk of AD

162
Q

what is hashimotos

A

autoimmune disease and mos tcommon cause of thyroid illness in US
often occurs in women between 3050 y/o
could be genetic
onset might be triggered by environment: iodine status, toxins, heavy metals, nutrient deficiencies, food intolerances, stress

163
Q

what is the treatment for hashimotos

A

treat with NP thyroid
*if not respnding to above, treat with synthroid 0.1mg daily and cytomel 5mcg BID
possibly iodine, but some issues with that
address nutrient deficiencies
dietary modification
gut health important!!

164
Q

why do we want to stay away from levothyroxine as treatment

A

patients on long term levothyroxine replacement show persistent impairments in both cognitive functioning and general well being

165
Q

why should we use supplements especially to optimize hormones

A

because in todays society there is
poor food quality
poor food choices
stress
health conditions
excess alcohol intake
drug nutrient depletion

166
Q

why use biote supplements instead of over the counter supplements

A

cheap and poorly absorbed or used in the body
dosage on the label may not match the dosage in the pill
additives, colors, fillers, allergens
raw materials may not be tested for toxins
low manufacturing standards

167
Q

food for thought: what could be said about spinach

A

you would need to eat a dozen bowls of spinach today to equal the iron content of one bowl of spinach in the 1930s

168
Q

what are the top patient health goals

A

lose weight
build muscle
boost energy
increase performance
improve mental health
balance hormones
improve overall health
build up immunity

169
Q

what are the core 4 nutraceuticals we use at pure

A

DIM, ADK, probiotics, methyl factors

170
Q

what is biotes current lineup of nutraceuticals

A

these are a custom formulation exclusive to BIOTE
DIM SGS+
ADK5
ADK10
Multistrain Probiotic 20B
Methyl Factors+
Iodine+
Bacillus Coagulans
Curcumin SF
Omega3+ CoQ10

171
Q

what components are found in DIM SGS+

A

DIM
sulforaphane
pomegranate extract

172
Q

what is DIM full of

A

cruciferous veggies
cabbage
broccoli
bo choy
brussel sprouts
cauliflower
kale
turnips

173
Q

what are benefits of DIM

A

improves estrogen metabolism in men and women (increases 2-hydroxy metabolites “healthy estrogens” decreases production of 4 hydroxy metabolites “higher risk estrogens”)
increases free or active testosterone
reduces aromatization (less conversion of testosterone to estrogen)

174
Q

additional components of DIM SGS+ are beneficial by

A

having antioxidant and anti inflammatory and detoxification properties.

175
Q

why DIM SGS+

A

improves hormone metabolism
beneficial for estrogen and testosterone balance
breast and prostate health
weight management

176
Q

what other conditions can DIM SGS+ be used for

A

women and men over 40 to aid with the clearance of estrogen (even those not on BHRT)
fibrocystic breast
migraines related to birth control pills
PMS
acne

177
Q

DIMSGS+ dosing

A

women take 1 daily with food
men take 2 daily with food
*may increase up to 2-3 daily if needed
(excess aromatization or side effects such as irregular cycles, moodiness, breast tenderness)

178
Q

what are benefits of vitamin A

A

eye health
immune support
fights inflammation
support skin health and cell growth
helps prevent cancer

179
Q

what vitamin deficiency is an epidemic in the USA

A

vitamin D

180
Q

what does vitamin D do

A

lowers risk of falls by improving balance and muscle performance
maintain bone and muscle
reduce risk of cancer
support immune system
vital for healty hair and nails
vital for healthy thyroid function

181
Q

can you really get bought vitamin D from just sun exposure

A

no, unless you are outside laying down every day with 72% of your skin exposed

182
Q

can you not just take vitamin D alone?

A

no because vitamin D is dependent on vitamin K2 to bind to calcium

183
Q

what is the power of Vitamin K

A

improves energy during exercise
increases testosterone and fertility in males
decreases androgens in females with pcos
promotes healthy blood sugar
improves mineralization of bones and teeth resulting in lower risk of fractures and cavities
prevents atherosclerosis and kidney stones
helps turn of cancer genes and turn on the genes that make cells healthy

184
Q

ADK dosing

A

take in the morning WITH food
start with ADK10 for 3 months then maintenance dose is adk5

185
Q

key functions of methylation

A

reduces our toxic load by processing chemicals and toxins
processes and metabolises estrogen
produces energy
builds immune cells
builds neurotransmitters (dopamine, serotonin, epinephrine)

186
Q

what are the down stream effects of poor methylation

A

altered hormone metabolis
anxiety
cancer risk
cardiovascular risk
decreased cognitive function
depression
insomnia
migraines
esteoporosis
poor detoxification

187
Q

what supplement has the B vitamins

A

methylfactors+

188
Q

what are the 7 signs you need methylation support

A

brain fog after eating
red faced after exercising
low energy
mthfr or high homocysteine
stress
increased estrogen
trouble falling asleep

189
Q

why do you need methylfactors+

A

converts food to energy (atp)
mitochondrial function
DNA production
detoxification
blood vessel health and function
methylation

190
Q

methylfactors+ dosing

A

1-3 daily with food
3 daily for patients with elevated homocysteine or B12 <300
2 daily for patients with low b12 < 500
1 daily for others

191
Q

what are signs of unhealthy digestion

A

acid reflux
nasal congestions
gas
bloating
inflammation
skin disorders
digestive disorders
loose stools
depression
constipation

192
Q

what distroys good bacteria

A

antibiotics
steroids
antacids
high sugar diet
diets high in refined and processed foods
chemotherapy and radiation

193
Q

in healthy intestines what protein hold together tight junctions between the intestinal cells to establish a protective barrier

A

xonulin

194
Q

what breaks down zonulin and tight junctions making the gut more permeable (leaky gut)

A

sugar and gluten

195
Q

54% of acne sufferers have marked alterations to their

A

intestinal microflora- put on probiotic

196
Q

who should be on a probiotic

A

anyone that has a gut, because the gut infulences all major organs of our body

197
Q

what is a multi strain probiotic 20B

A

20 billion live culture at time of EXPIRATION
helps restore the microbiome
promotes digestive and immune support for travelers and athletes and for those with stressed out GI tract
protect from gut flora disruptions and diarrhea from antibiotics

198
Q

what is bacillus coagulans

A

great for acute illnesses (diarrhea)as well as for use with antibiotics
good for general use (short-term) then transition to multi strain probiotic 20B
does not completely restore the microbiome but is a great start

199
Q

bacillus coagulans dosing

A

1 capsule daily with food
*may use this when pt has acute diarrhea or other acute GI symptoms
transition back to multi strain probiotic 20B once acute illness resolved

200
Q

iodine+ dosing

A

start iodine 4-6 wks AFTER starting pellet therapy and other supplements
dose 1 capsule 2-3 times weekly and increase to 1 capsule daily

201
Q

why Iodine+

A

blend of iodine, zinc, selenium all support thyroid function
iodine is necessary to create thyroidhormone T4
zinc and selenium are nutrient cofactors in the conversion of T4 -> active T3 in peripheral tissues
important for healthy prostate

202
Q

the only glycocalyx regenerating product patented to stabilize and regress vulnerable arterial plaque

A

arterosil

203
Q

what is the endothelium

A

layer of single overlapping cells lining the interior of every artery, vein and capillary which have unique functions for vascular health

204
Q

what is the importance of our arteries, veins, and capillaries

A

delivery of oxygen, nutrients, hormones, and more to every organ and system
regulation of coagulation
inflammatory response modulation and antioxidant storage
blood pressure modulation

205
Q

what is the number 1 killer of men and women worldwide

A

cardiovascular disease

206
Q

what is the most common cause of CVD

A

atherosclerosis

207
Q

what is at the center of the initiation and progression of atherosclerosis

A

endothelial disfunction

208
Q

evidence shows the missing link of prevention of CVD suggests maintaining the integrity of

A

the endothelial glycocalyx structure

209
Q

dysfunction of the vascular endothelial glycocalyx is hallmark of

A

diseases
*normal healthy artery, endothelium intact
diseased artery (plaque build up causing blood clot, endothelium compromised

210
Q

what does arterosil do

A

the only glycocalyx regenerating product patented to stabilize and regress vulnerable plaque
helps maintain the arteries walls protective barrier
helps maintain blood pressure in the normal range
helps support erectile function in men

211
Q

who should take arterosil

A

all men who desire improved erectile function
all men and women age 45+ for prevention (promotes healthy heart)
men and women regardless of age with or at risk of:
CVD/stroke
hypertension
atherosclerotic plaque
DM/ diabetic neuropathy
erectile dysfunction

212
Q

what are the contraindications when taking arterosil

A

no known contraindications

213
Q

what nutraceutical is recommended for restfullness and awake refreshed

A

best nights sleep

214
Q

what do hormones protect

A

bones, brain, breast heart, prostate

215
Q

muscle and bones facts

A

women lose 25% of bone mass from onset of menopause until age 60 due in large part to loss of estrogen
1/2 of women over age of 50 will have osteoporosis related fracture during their lifetime
androgen therapy increases lean tissue mass and decreases fat mass

216
Q

pellets and bones

A

two year study of estradiol pellets demonstrated marked increase in bone density
testosterone= “bone builder” and pellets demonstrated 4x greater increase in bone mineral density (which is a test that evaluates bone health) than oral estrogens and 2.5 greater increase than patches

217
Q

what are the testosterone effects on bone

A

maintains and BUILDS bone
excellent therapy for prevention and treatment of osteoporosis
high endogenous levels of testosterone-> higher BMD

218
Q

testosterone effects on joints and inflammation

A

improves most forms of chronic JOINT and MUSCULAR pain

lowers inflammatory markers
most autoimmune disease patients notice improvements

219
Q

HRT effects on total knee and hip arthroplasty

A

gradual bone tissue destruction and prosthesis loosening in the most common cause of revision for TKA and THA
*HRT use is associated with almost 40% reduction in revision rates after a TKA/THA

220
Q

what to know about HRT and alzheimer’s disease

A

both E and T have neuroprotective roles
women have higher incidence of AD 8:1 over men
women with lower E2 levels have even greater risk of AD
overwhelming evidence that E and T help decrease cell death
this protective effect of both hormones decreases the beta amyloid deposition

221
Q

what else decreases the beta amyloid

A

thyroid

222
Q

HRT and particularly ERT plays a role in preventin neurodegenerative conditions like

A

alzheimers and dementia
*E2 can reduce the risk of alzheimers disease and minimize cognitive decline in otherwise healthy women

223
Q

for patients that have history of epilepsy what would you not put them on

A

estradiol lowers seizure threshold -> increase risk of seizures in patient swith epilepsy
*adjuvent E2 is not recommended in these patients when they become menopausal

224
Q

for patients that have history of seizures what should be given to them

A

pogesterone and testosterone increase seizure threshold -> lowers risk of seizures
* testosterone is great for men and women with epilepsy
progesterone may also be used

225
Q

estrogen and the breast

A

does NOT increase the risk of breast cancer when used alone
when combined with micronized progesterone does not increase risk of breast cancer

226
Q

E2 and prior breast cnacer

A

ERT does not increase either recurrence of breast cancer or mortality rates
*recurrence rates and mortality rates were doubled in non users when compared to HRT users

227
Q

for breast cancer survivors what is not recommened

A

E2
*instead testosterone and anastrozole pellets available

228
Q

summary of testosterone and prostate

A

testosterone replacement therapy does not increase prostate cancer
it does not worsen prognosis nor increase morbitity or mortality in pt with hx of prostate cancer
*androgen deprivation therapy increases risks of DM, HTN, dementia, dyslipidemia and CVD

229
Q

what was the study on testosterone and prostate cancer

A

almost 3000 men in finland, norway and sweden had blood drawn
>1/4 diagnosed with prostate CA afterwards
compared free and total testosterone
decreased risk prostate CA in HIGHER testosterone levels

230
Q

what lab is predictive of prostate cancer

A

low levels of testosterone is an independent risk factor for PCa

231
Q

what can we add to PSA (prostate specific antigen) that may improve predictive accuracy

A

testosteron

232
Q

how should we go about with treating patients with prostate cancer history

A

*patient should understand data is limited on progression and recurrence
should have recieved definitive therapy first AND undetectable or stable PSA level
T therapy NOT recommended if patient receiving androgen deprivation therapy (ADT)

233
Q

there is not now, nor has there ever been, a scientific basis for the belief that testosterone caused…

A

prostate cancer to grow

234
Q

what should the PSA level be

A

<2.5 ng/mL to pellet

235
Q

what can increase PSA

A

prostate massage
prostatitis
sex

236
Q

does testosterone therapy affect PSA levels

A

T affects PSA levels minimally in normal prostates (<0.1)

237
Q

testosterone pellet CV summary

A

NO increased risk hypercoagulability with pellets
reduced CV risk
improved lipids
improved HDL
improves insulin resistance

238
Q

summary of effects on lipids: how do testosterone pellets affect lipids

A

improved total cholesterol
increased HDL
decreased LDL
decreased triglycerides
increased lean body mass
decreased bone resorption

239
Q

what is HDL

A

high density lipoprotein
“good” cholesterol

240
Q

what is the function of HDL

A

the good cholesterol absorbs cholesterol in the blood and carries it back to the liver. the liver then flushes it from the body
*high levels of HDL can lower your risk for heart disease and stroke

241
Q

what should HDL levels be

A

women= > 55mg/dL
men= > 45 mg/dL

242
Q

what is LDL

A

low density lipoproteins
“bad cholesterol”

243
Q

what is the function of LDL

A

it is called bad cholesterol because a high LDL level leads to a build up of cholesterol in your arteries

244
Q

what should LDL levels be

A

under 130 mg/dL
*people with heart or blood vessel disease, diabetes, or high total cholesterol should be less than 70mg/dL

245
Q

what is cholesterol

A

a waxy, fat like substance that’s found in the cells in your body. your liver makes cholesterol, and it is also in some foods, such as meat and dairy

246
Q

why is cholesterol important for our body

A

we need small amounts of blood cholesterol because the body uses it to build the structure of cell membranes, make hormones like estrogen, testosterone and adrenal hormones, help your metabolism work efficiently

247
Q

how can a high LDL level raise my risk of coronary artery disease and other diseases

A

if you have a high LDL, this means that you have too much LDLcholesterol in your blood. This extra LDL, along with other substances, forms plaque. the plaque builds up in your arteries; this is a condition called atherosclerosis

248
Q

how does coronary artery disease happen

A

what the plaque build up is in the arteries of your heart. it causes your arteries to become hardened and narrowed, which slows down or blocks the flow to your heart. because your blood carries oxygen to your heart, this means that your heart may not be able to get enough oxygen. this can cause angina (chest pain), or if the blood flow is completely blocked, a heart attach.

249
Q

metabolic effects of low testosterone

A

increased insulin levels and insulin resistance
increased serum glucose
abnormal lipid profile like increased triglycerides, total, and LDL cholesterol as well as decreased ApoA1 and ApoB

250
Q

what are triglycerides

A

type of fat, called lipid, that circulate in your blood.
most common type of fat in your body.
they come from foods especially butter, oils, and other fats your eat

251
Q

what is total cholesterol

A

this is the total amount of cholesterol that’s circulating in your blood
*formula= HDL + LDL + 20% of triglycerides

252
Q

what is low testosterone associated with

A

abnormal lipids
increased insulin resistance
increased abdominal adiposity
increased pro inflammatory markers
vascular dysfunction
atherosclerosis

253
Q

what is hypogonadism

A

a failure of the gonads, testes in men and overies in women, to function properly

254
Q

what is endothelial function

A

the endothelium is a thin membrane that lines the inside of the heart and blood vessels. endothelial cells release substances that control vascular relaxation and contraction as well as enzymes that control blood clotting, immune function and platelet adhesion

255
Q

what is metabolic syndrome

A

a cluster condition that increases the risk of heart disease, stroke, and diabetes
metabolic syndrome includes; high blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol levels. this increases a persons risk for heart attack and stroke

256
Q

what are testosterones actions in the heart

A

it is a vasodilator-> increases blood flow to the coronaries (used in past to treat angina)
decreases plaque
decreases inflammation
has been shown to reduce risk of CV events in some populations

257
Q

what is aromatization

A

process that converts testosterone to estrogen. this is a natural process your body goes through to maintain homeostasis. it is named after the chief enzyme involved in the conversion, aromas. while aromatization mainly occurs in menit also occurs naturally in females as well if testosterone levels become out of balance

258
Q

what about anabolic steroids

A

they are NON aromatizable
adversely affect the myocardium in monkeys and rats (not testosterone)
anabolic andorgens have been shown to increase vasoconstriction and vasospasm in experimental models
elevate LDL, VLDL, decrease HDL

259
Q

how do men form estradiol

A

aromatase enzyme
*testosterone is aromatized to form estradiol

260
Q

does biotechs method administer estradiol in men in form of pellets?

A

it does NOT
*do not worry about baseline E2 level in men

261
Q

why do we not worry about baseline E2 in MEN

A

E2 levels improve after normalization of testosterone levels in most men
(<10% will aromatize excessively to E2)

262
Q

what nutraceutical helps normalize aromatization

A

DIM SGS+

263
Q

estradiol and CV disease in men… “its not just low T”

A

men in the lowest estradiol quintile were 217% more likely to die during a 3 year follow up
men in the highest estradiol quintile were 133% more likely to die
men in the balanced quintile had the fewest deaths
*excess estrogen contributes to the development of atherosclerosis

264
Q

what is the impact of E2 on HDL

A

physiologic levels of estradiol stimulate an increase in HDL cholesterol in men (this is good)

265
Q

what is MMP-9

A

anenzyme that degrades collagen and elastin which is the major component of the covering of the cap in arteries

266
Q

what to know about MMP and the heart

A

predisposed to cap rupture
increased risk for thrombus formation
made worse by smoking
when there is plaque build up in the artery wall, if we have a weak cap (due to high MMP) the cap could rupture and expell the plaque into the artery causeing a thrombosis

267
Q

how many women premenopausal die from heart disease

A

1 in 7
*cause= testosterone deficiency

268
Q

how many women postmenopausal die from heart disease

A

1 in 3
*cause= estrogen and testosterone deficiency

269
Q

what is the leading cause of death of american women

A

heart disease

270
Q

why is it important to get your levels checked when you hit menopause (or even before)

A

blood cholesterol can often change within 6 months of onset of menopause
*risk of HTN triples with menopause
*HRT is beneficial to heart if started early

271
Q

it is important to be clear that ____ reduces all cuase mortality, wheras ____ therapy DOES NOT in primary prevention. avoidance of ____ is associated with excess morbidity and mortality

A

Hormone therapy
statin
hormone therapy

272
Q

what is the time frame of when you first start to feel a difference from the pellets

A

3 months

273
Q

what are the body composition and strength that could change from pelleting

A

increase in muscle strength
increase in lean mass
decrease fat mass
decrease waist circumference
increase exercise capacity
increase bone mineral density
decrease waist hip ratio

274
Q

what are some unique conditions in which to consider pellet therapy

A

chronic pain patients
chronic opiod/narcotic use
PTSD/ soldiers
morbid obesity
sleep apnea
diabetes
night shift workers
high stress jobs
metabolic syndrome
lipid disorders
PCOS patients

275
Q

what 3 hormones do we balance

A

Estrogen
testosterone and thyroid

276
Q

what minimum tests should a womens biote workup include

A

FSH & estradiol
TSH, Free T4, Free T3, TPO
total testosterone
25- OH Vitamin D
comprehensive metabolic panel
CBC
B12

277
Q

what should womens follow up labs be (after 1st round)

A

FSH, estradiol and total testosterone
(6 weeks if doing well)
(4 weeks if non responder)
if thyroid labs only, can be done at 4 weeks

278
Q

after 1st round of pelleting in women what should FSH be

A

decrease by 50% or <23 if given replacement dose E2 (not the 6mg)

279
Q

how much should total testosterone be after first pellet in women

A

total testosterone levels at 6 weeks should be 150-250

280
Q

usual FHS values in women during follicular phase

A

2-10

281
Q

usual FHS values in women during mid cycle

A

15-35

282
Q

usual FHS values in women during post ovulatory (luteal)

A

5-20

283
Q

usual FHS values in women during post menopausal

A

23-195

284
Q

what is the goal for post menopausal female bite patients

A

to produce a normal premenopausal FSH level to alleviate symptoms OR to have FSH reduced by 50% to reinstate normal female physiology

285
Q

basic female postmenopausal E2 dosing on clinical DS

A

with uterus= 12.5 mg estradiol
200 mg micronized progesterone or 225mg compounded micronized progesterone
without uterus= 15mg estradiol with or without micronized progesterone

286
Q

what about premenopausal E2 dosing

A

premenopausal women make their own E2 and progesterone
*premenopausal women ONLY get E2 if they have menstrual migraines, and the dose is 6mg

287
Q

oral contraceptive users should always have a FSH of

A

<5

288
Q

women with FSH; LH ration >1 or estradiol level <20ng/dl on the last pill free day are by definition in menopause and may be transitioned to estradiol pellets and oral micronized progesterone

A

the higher the FSH, the more estrogen deficient

289
Q

don’t stop birth control pill prior to

A

lab testing

290
Q

what are the 4 main benefits of DIM

A

forces healthy estrogen metabolism
increases free testosterone
natural aromatase inhibitor
helps reduce testicular shrinkage

291
Q

signs and symptoms of testosterone deficiency (12)

A

loss of energy
loss of mental clarity
loss of muscle mass
weight gain
decreased exercise tolerance
increased recovery time exercise
anxiety
irritability
bone loss
decreased libido
loss of erectile ability
clitoral insensitivity or orgasmic dysfunction

292
Q

what is a normal testosterone in women but where do they feel the best

A

<14-80 expected lab range
70 or above is normal and where most women feel best

293
Q

at 6weeks post insertion total testosterone level in women should be

A

150-250

294
Q

*biote initial workup for men should include these minimum tests

A

CBC, CMP
PSA (age 55-69)
TSH, free T4, Free T3, TPO
testosterone-total and free
estradiol
25-OH vit D and Vit b12
prolactin if age <40 and if T <300
consider semen analysis if no children

295
Q

*if a man is on testosterone shots or cream and going to start the HRT process, what should be done prior to the lab draw

A

if on shots, test on day 4 or 5 post injection
if on creams, hold cream AM of lab draw

296
Q

what are the biote follow up labs for men

A

free and total testosterone and estradiol
thyroid if on meds

297
Q

for 4 week follow up labs what should total testosterone and free testosterone be

A

total testosterone 900-1100
free testosterone upper end of range over the mean

298
Q

what is a “normal” total testosterone in men and when do they feel the best

A

300-900 is what most labs use as normal
900-1100 men feel the best

299
Q

does testosterone replacement affect PSA

A

minimal expected change in PSA with normal prostate

300
Q

what is the suggested baseline PSA in men

A

> 40 who are to receive treatment with testosterone

301
Q

when is screening PSA required

A

ages 55-69

302
Q

what is the normal PSA level of men NOT on 5a-reductase inhibitor

A

<2.5

303
Q

what is the normal PSA level of men currently on 5a-reductase inhibitor for benign prostatic hyperplasia or balding)

A

<1.25

304
Q

if male testosterone is very low for age and no illigal anabolic sterioid use, what lab test would be important to get?

A

prolactin

305
Q

what is prolactin

A

there is no normal function for prolactin in men.
prolactin is usually measured when checking for pituitary tumors and the cause of breast milk production that is not related to childbirth, decreased sex drive in men and women (libido), erection problems in men
*when in males a high prolactin concentration interferes with the function of the testicles, resulting in decrease of testosterone and sperm production

306
Q

if male testosterone is very low for age and no anabolic steroid use, what clinical condition should be ruled out

A

sleep apnea

307
Q

how to calculate free testosterone

A

upper testosterone lab value + lower testosterone lab value divided by 2 = mean
ex: norma lab valu 5-25
5+25=30/2= 15

308
Q
  • estradiol pearls (6)*
A

NOT recommended in women with epilepsy
NEVER given to men
do NOT give men aromatase inhibitors based on PRE-pellet lab results
do NOT give estradiol to breast cancer survivors
maximum E2 given to women with uterus on FIRST dose is 12.5mg
FSH should go down by 1/2 or <23 if women gets replacement dose E2

309
Q

how and when do I use dosing site

A

1st round- based on blood panel results, age, weight, and medial history
boost dosing- done only between 4-8wks, lack of response (what symptoms persist or ar not significantly imporved), ask about response and possible side effects before boosting
2nd round dosing- any experienced side effects, was a boost needed or were post insertion labs borderline, frequency (time between procedures)

310
Q

if a patient is needing a boost when should it be given

A

MUST be given <8 weeks from insertion but not before 4 weeks
*no charge to the patient
should not be given if patient feeling well

311
Q

what is not given with a history of breast cancer

A

estradiol and progesterone

312
Q

what if after pelleting a patient and they say they forgot to tell you they are taking soemthing for hairless or BPH

A

check dosing and PSA level, if PSA over 1.25 need a urological work up before proceeding

313
Q

what if post total testosterone was 700 (male)

A

if feeling well, increase testosterone 200mg next round; if no change in symptoms, give them a boost

314
Q

what if total T was 800 and free was 15 (male)

A

if feeling well, increase testosterone 200mg next round; if no change in symptoms, give them a boost

315
Q

what if the PSA is 4.0 next year (anniversary labs) (male)

A

need urologic workup

316
Q

what if post estradiol is 72 without symptoms (male)

A

make sure patient is taking DIM SGS+

317
Q

what if post estradiol is >70 with symptoms and taking DIM SGS+ (male)

A

needs oral aromatase inhibitor

318
Q

what if patient is anxious and not sleeping well at 4 weeks (male)

A

needs 5-HTP (sleep supplement)

319
Q

dosing pearls for females (3)

A

labs done at baseline, weeks, then annually
if non responder, repeat labs 4 weeks and boost if levels below expected or in low range of expected
annual labs may be done prior to 4 round of pellets to make sure patient not “stacking”; can do 6 weeks post insertion, also, if desired

320
Q

dosing pearls for meales(6)

A

labs done at baseline, 4 weeks then annually
boost if levels below expected or in low range og expected
consider boost if free T in lower end of expected AND pt still symptomatic
encourage DIM SGS+ 2 caps daily
annual labs may be done prior to 3rd round of pellets to make sure patient not “stacking”; can do 4 weeks post insertion, also, if desired
avoid aggressive aromatase inhibitor use to where E2 < 30

321
Q

if a patient is sensitive to meds what do you do

A

lower dose

322
Q

if patient has pre existing uterine fibroids

A

use only low dose E2 (if any) 12.5 or less. always use prometrium or progesterone 200mg

323
Q

if patient has pre existing ED how long does it take to improve after HRT

A

may take up to 6 months to improve
*consider writing Cialis daily 2.5mg or 5mg

324
Q

if patient still complaining of not staying erect what should you screen for

A

DM and may beed to reduce aromatase inhibitors

325
Q

if you have a BPH patient what should you do with testosterone

A

use normal dose of testosterone unless BPH is not treated
*testosterone does not cause symptomatic BPH

326
Q

how should you treat a patient with hx of prostate cancer and what lab should be checked

A

treat with pellets ONLY if has had definitive therapy AND negligible/stable PSA

327
Q

what lab should we obtain on all asymptomatic, low risk males age prior to pelleting

A

PSH

328
Q

when should female labs be drawn

A

at 6 weeks, unless NO symptom relief then pull at 4 weeks

329
Q

post pellet expected female labs at 6 weeks: total testosterone

A

150-250

330
Q

post pellet expected female labs at 6 weeks: FSH

A

should decrease by approximately 50% (or <23) IF patient given replacement dose of E2

331
Q

post pellet womens boost should be done

A

before 8 weeks since last pellet
(37.5-50mg)

332
Q

when should male labs be drawn

A

4 weeks

333
Q

post pellet expected male lab alue: total testosterone

A

900-1100

334
Q

post pellet mens boost should be done

A

before 8 weeks since last pellet
200-400mg

335
Q

what are possible side effects

A

acne 2%-10%
mild facial hair growth 2%-10%
hair thinning <1%

336
Q

if patient is having hair thinning what should be done

A

reversing insulin resistance and addressing thyroid and low vitamin D will significantly lower risk of hair loss

337
Q

is maternal testosterone therapy safe for the breast fed infant?

A

yes

338
Q

what is erythrocytosis

A

not a blood cancer
HIGH erythropoietin
NO platelet stickiness
NO increase in thrombosis
hgb > 18 at low altitude
more common with injections
more common in men (dose dependent)
routine phlebotomy not recommended (can also lead to iron deficiency)

339
Q

what is polycythemia vera (PCV)

A

myeloproligerative blood cancer
LOW erythropoietin
platelet stickiness
INCREASE thrombosis
blood volume can increase 2x normal
median age 70-79

340
Q

having problems with swelling or fluid retention while pelleting?
what causes this, for how long, and what can be prescribed

A

testosterone can cause fluid retention
most common in 1st round, usually does not occur or is uch less problematic w/ subsequent rounds, will resolve after few weeks
*Rx: HCTZ 25mg, lasix 10mg or Maxide 37.5 mg

341
Q

having problems with acne?
what causes this, for how long, what can be prescribed

A

testosterone causes this
most common in 1st round; will resolve after few weeks; reduce dose next round if persistent or severe
*Rx: (females) spironolactone 50mg QD or BID
(males) doxy or minocycline 100mg 1PO BID x 30 days

342
Q

what acne prescription is not recommended in pregnancy or in patients trying to conceive

A

spironolactone

343
Q

if acne is severe what should be done next pelleting

A

reduce testosterone by 10%-20% next round

344
Q

what to consider if patient has hair growth post pellet

A

this can be an issue that arises
decrease testosterone by 10-20% next round
laser hair removal ( we give discount)
consider spironolactone QD or BID
start at 1/2 tab dauly x1 week and increase to desired results, as tolerated
not recomended in pregnant or trying to conceive

345
Q

if patient is having hair loss what shoul dbe done

A

rule out telogen effluvium vs alopecia areata vs tinea vs other labs
optimize thyroid
RX finasteride 5mg BIW (post menopausal) or spironolactone
REDUCE TESTOSTERONE NEXT ROUND
compound hair solutions

346
Q

what are the compounding hair solutions for thinning hair

A

hair rescue: activate (PTD-DBM + methyl vanillateours)
hair rescue: repair (GHK- CU- Zn- thymulin)

347
Q

if a patient is experiencing hair loss and you are thinking about giving finasteride, what should you make sure prior to prescribing to a female

A

cannot use if patient is childbearing age and not on contraceptive
*teratogenic category x

348
Q

if patients hair is thinning and begin RX when can they expect hair growth

A

6-8 weeks for new hair growth

349
Q

what if patient says they are still very tired post pellet

A

ask more to degree of fatigue
review labs, was does correct, room to increase? was thyroid treated?
other labs or prescriptions needed?
*some patients feel best after 2nd round

350
Q

post pellet issue sstill tired what should be given

A

was thyroid optimized
methylfactors + daily (b12 injection needed?)
good multivitamin
labs for chrinic fatigue?

351
Q

when too much testosterone is converted to estradiol

A

male aromatizer

352
Q

what medication can help the male aromatizers? (too much testosterone converted to estradiol)

A

aromatase inhibitor
femara 2.5mg- 1/2 tab q week or q 2 weeks
arimidex 1mg q week or q 2 weeks
DIM SGS+ 150mg - 1PO BID

353
Q

when determining aromatization what should you do regarding labs

A

dont get tricked on initial labs, wait for follow up labs to determine aromatization

354
Q

post insertion wound concerns: when will you see histamine reactions

A

most common with 1st insertion

355
Q

when is pellet extrusion usually seen

A

seen after 2-3 months of pelleting

356
Q

if post pellet gets infected, red/cellulitis what should be done

A

clindamycin 30mg TID x 7 days OR Bactrim DS BID x 7 days
apply heat

357
Q

how to treat etrusions

A

apply heat
keep clean
will come to surface and easily removed
if very painful or patient not wanting to wait…
cleanse area
inject local anesthetic
small superficial incision -> pellet will extrude easily

358
Q

for a localized histamine reaction what should be done

A

is it limited to area of pellet insertion (not whole body)
treat with non dedating antihistamine during day time: claritin, allegra
at night time: benadryl

359
Q

what are alternatives to lidocaine 1% with epi

A

lidocaine 2% with or without epi
lido 1% plain

360
Q

if patient has lidocaine allergy what should be given for insertion

A

marcaine 0.5% with or without epi
only use 1/2 cc of bicarb as it will precipitate

361
Q
A

Medical Aesthetic Treatments (8 decks)

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