Biote HRT Flashcards
dr. charles brown- sequared self injected what into himself and what year
self injected testicular extracts from animals in 1889
what did Dr. charles brown start to notice an increase of when self injecting with testicular extracts
increased energy, muscular strength, stamina, and mental agility
who developed isolated Ts for injection and won a noble prize
in 1891 leopold ruzicka
in 1942 what was testosterone used to prevent
peripheral vascular disease (PVD)
in 1953 what was testosterone used to treat
angina pectoris in both males and females (vasodilator)
91% of patients showed improvement
what age range do women lose 50% of their testosterone production
age 20-40
what age range do men lose 1-3% of total testosterone production per year
30-70
what are bioidentical hormones
structurally identical to those made by the body
what is the most biologically active estrogen
estradiol
what e’s are present in the body
estriol and estrone
don’t get progesterone confused with progestin because
progestin is synthetic and are bad
what is a bioidentical molecule
exact molecular structure of hormones that the body produces
what is a synthetic molecule
different molecular structure than what body produces
what are bioidentical molecules made from
soy or yams (but not an issue with food allergy)
what are the bioidenetical molecules (E2)
17b estradiol-estrace, climara, vivelle, minivelle, estrogel, estring
what are synthetic molecules made from
animal parts or urine
what are the synthetic molecules (E2)
estradiol valerate or cypionate, Premarin (CEE), enjuvia, cenestin, menest
what are the bioidentical molecules of testosterone
testosterone
what are the synthetic molecule of testosterone
testosterone cypionate, enanthate, undecanoate
what are the different routes of administration of testosterone
oral
transdermal/vaginal
injectable
pellot
what are the cons of oral delivery
1st pass is effective but GI upset is common
daily administration
testosterone itself given orally is not effective
TID very short half life
what are the cons of injectable delivery
levels fluctuate like a roller coaster
weekly/biweekly shots
allergies to oil suspension
higher level of erythrocytosis and aromatization
may increase platelet stickiness
what are the cons of transdermal/vaginal/ scrotal delivery
skin irritation
possible transfer to others
45% of people do not absorb
blood levels very
administer daily or BID
what are the cons of pellet delivery
some pain with insertion
possibility of extrusion
activity restrictions after procedure
what delivery route is the superior option
pellets
why is pellets the best option for delivery
avoids unnecessary risk of platelet aggregation
unlimited dosing options
steady levels
predictable absorption
convenient and improved patient satisfaction and compliance
how often do men and women get pelleted
3-4x/ yr for women (3-4 months)
2-3x/ yr for men (5-6 months)
**when does testosterone kick in
7-10 days
if a client is taking testosterone and then wants to get pellet when do you tell the patient to stop taking their testosterone
a week after pelleting
20 years ago what kind of implant was used for testosterone for androgen replacement therapy
fused, crystalline implants for a 13 year study of 221 men
testosterone use in women dates back to
1937 very effective for vaginal atrophy and other climacteric symptoms
despite overwhelming evidence in support for testosterone supplementation in women, there is no…
fda approved product
despite any lack of clear rationale, what was assumed to be the hormone of choice for “replacemet therapy” in women
estrogen (premarin)
when was testosterone reported to effectively treat symptoms of menopause
as early as 1937
what is the consensus on female use of testosterone
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
testosterone is not a male exclusive hormone and production is how much more production than estrogen
3-4x
when do androgen levels peak in women
their twenties with symptoms preset both in pre and post menopausal women
what are the 3 sources testosterone production in women
overies, adrenal glands, and peripheral conversion from other circulating androgens
by age 4 in women how much testosterone is lost
half of their testosterone production
in women, the androgen production from adrenals decline but testosterone production from _________ remain somewhat intact after menopause
overies ( women with BSO have 50% further incline)
what are the benefits of people hormones being optimized with HRT
energy increase
better sleep and mental clarity
ability to lose weight
sex drive increases
breast, bone, and heart health
as hormone levels drop, what is seen
low energy
mood swings
weight gain
joint pain
difficulty sleeping
brain fog
low sex drive
risk of age related illness
with testosterone replacement therapy in women what are the two symptoms with high percentages of complete relief after receiving
hot flashes 90.8%
depression 75.8%
testosterone was superior for relief of energy, well being, somatic complaints, and psyichological symptoms but what was the worst during studies
estrogen alone and placebo
what are the top 10 myths about testosterone use in women
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
what are women at increased risk for if they have low T
alzheimers
cardiovascular disease
osteoporosis related fractures
diabetes mellitus
sarcopenia
possibly an increased risk for breast cancer
what are positive effects of bioidentical testosterone in women
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
when do testosterone levels start to decline in men
after age 30 they will decline 1-3% every year after 30
total ______ _________ is most commonly used measurement of __________ __________, though it is a poor indicator of tissue activity
serum testosterone, androgen activity
age related decline in testosterone is associated with increased all cause…
mortality in aging men
in men there is increased mortality with…
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
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….
treat the patient not the lab
low T in men are increased risk for
alzheimers disease
CVD
osteoporosis related fractures
prostate cancer
DM
sarcopenia
what do hormones protect
bones
brain
breast
prostate tissue
heart
what is the normal physiology of estrogen in normal menstrual cycle
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
what are the phases of menstrual cycles
follicular-proliferative (1 through 14)
ovulation (day 14)
luteal phase-secretory (15-28)
what are the physiologic effects of estrogen
actions mostly on reproductive organs but also act on
cardiovascular
skeletal
immune
gastrointestinal
brain
what is menopause
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
what are symptoms of estrogen deficiency
irregular absent periods
hot flashes
vaginal dryness
poor sleep
breast tenderness
HA or worsening pre existing migraines
depression/anxiety
frequent UTIs
what to know about FSH
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
premenopausal patients make their own…
estradiol and progesterone
postmenopausal replacement estrogen replacement therapy (ERT) is
no longer menstrating
no longer able to make estradiol OR progesterone
**if patient has uterus and gets replacement dose E2, MUST give progesterone
if patient has intact uterus postmenopausal do they get a replacement dose of estrogen?
NO!!
because they still have their uterus
what is the patient screening of BHRT
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)
between transdermal and oral estrogen what is the main takeaway
oral estrogen is more associated with an increased VTE risk
transdermal estrogen may improve the benefit/risl ratio of postmenopausal HT and should be considered a safer option for
women at high risk for VTE
what is the BHRT climacteric 2012
transdermal E2 showed no increase of VTE or CVA
P4 (unlike progestins) showed no increase risk of VTE or Breast Cancer
why is HRT in young post menopausal women safe and effective
to counteract climacteric symptoms and prevent long term degenerative diseases
non oral estrogens= NO VTE and better BP
natural progesterone = positive
non oral estrogens=
NO VTE and better BP
natural progesterone =
positive cognitive effects and no increase in breast cancer
transdermal E2=
no increased risk of stroke, VTE
no adverse cardioavascular effects
no effects on gallbladder function
can you use BHRT indefinitely?
yes
implant therapy for HRT
no increase in thrombotic activity with pellet therapy
reduces cardiovascular risk compared to oral therapy
does not increase the risk of breast cancer
does HRT increase the risk for breast cancer
no
80,377 post menopausal women study
does HRT increase risk of heart attack?
no
it is cardioprotective
transdermal estradiol (E2) does not…
increase risk of VTE (unlike oral)
it is cardioprotective and decreases risk of AMI
decreases risk of T2DM
micronized progesterone (P4)
reduces risk of T2DM
does not increase risk of VTE
reduces BP
what are the 6 “complex watches” of biotechs method optimal health and longevity
Testosterone
Estrogen
diet
thyroid
HGH
V&M
when compared to oral and patch for E2 what is seen with pellets
steady, consistent serum levels
what are the symptom reduction over time with pellets
men 4-5 months
women 3-4 months
what are potential and unnecessary effects of ORAL estrogen therapy
breast tenderness
vaginal bleeding
headaches
gallbladder dysfunction
nausea and vomiting
fluid retention
blood clots
leg cramps
gallstones
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
pellets
how are pellets made and absorbed
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
how are pellets absorbed based on..
cardiac output, not time released
what are advantages of pellet therapy
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
what is progesterone
steroid hormone derived from cholesterol
involved in menstrual cycle, pregnancy, and embryogenesis
progesterone receptor sites in the uterus, breast, vagina, blood vessels and brain.
what hormone is important in menopausal women, perimenopausal women, premenopausal women, and pregnant women
progesterone
what is the source of E2 (estradiol)
ovary
what is the source of progesterone
ovary/ corpus luteum/ adrenals
what are the levels of E2 post menopausal
<20 pg/ml
what are levels of progesterone post menopausal
0.1-1 ng/ml
if progesterone is produced primary by the ovary then what would progesterone levels during menopause bee
zero
progesterone drops more drastically than estrogen does do to the limited areas of production
why bioidentical progesterone over synthetic?
because synthetic is increased risk for breast ca, cad, dvt/PE/ dementia, and diabetes
side effects are MULTIPLE
why no progesterone in pellets??
molecule is too large-> variable absorption
unpredicted duration -> leaves endometrium unprotected
cannot change dose if bleeding
what are the formulations of bioidentical progesterone
oral, SL, SL RDT, RX cream, OTC cream
what to know about progesterone cream
cream is NOT recommend in post menopausal patientsWITH a uterus
why is progesterone cream not recommended in post menopausal patients with a uterus
it does not protect the uterus adequately
what are the common dosing for post menopausal patients WITH a uterus for progesterone
generic capsules 200mg every night
compounded capsule 225mg every night
RDT or SL 100mg every day
cream- not recommended in its with a uterus
what are the 5 steps of progesterone dosage adjustment
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
premenopausal women will not get progesterone unless
for another indication
if a women is menopausal ON ESTROGEN and with a uterus
absolutely MUST take progesterone
does biotechs method include use of progesterone in men?
NOO
when patient is on progesterone are monitoring levels required?
no, measurements are mainly with post menpausal bleeding
what are blood levels of progesterone
normal range= 4-25ng/ml
optimal range= 10-20ng/ml midluteal levels
are saliva levels taken for progesterone?
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
contraindications for progesterone in women
ER/PR positive breast cancers
allergy to peanuts
if a patient is allergic to peanuts and is needing progesterone (females only but not all)
cannot use generic or brand name, must be compounded
*write RX “peanut free base”
compounded capsules do not contain peanut oil
do i use progesterone in women receivign E2 for menstrual migranes
no
premanopausal women make their own progesterone
E2 6mg is NOT a replacement dose
additional progesterone is NOT recommended for these patients
if a woman is bleeding after pellets what could it be
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
what is considered abnormal bleeding in women
premenopausal patients- any change in “normal” menstrual pattern
what is polymenorrhea
more frequent bleeding
what is oligomenorrhea
less frequent bleeding
what is amenorrhea
missed period for >3 months
what is post menopausal bleeding
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
we do NOT use full, replacement dose of ____ in perimenopausal patients who have had a period in the last _____ months to avoid bleeding
E2, 12 months
for progesterone therapy we should rule out anatomical cause THEN consider hormonal cause
- was progesterone taken correctly
- exam and vag ultrasound +- EMB
- if normal anatomy, 4 causes of bleeding : too much E2, too little E2, too much P, too little P
what is the HPT axis and process
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
what is total T3 and T4
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
what is reverse T3
chemically similar to T3, completely inactive, it lowers the amount of active thyroid hormone (T3) available, “emergency brake” on the system
*RT3 reverses T3
what causes elevated RT3
nutrient deficiency (selenium)
excess physical/mental/ environmental stress, adrenal compromise, high toxic burden, dysbiosis
what is elevated RT3 called
low T3 syndrome or sick euthyroid
what are 4 thyroid myths
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
what is regulated by the thyroid hormones
regulate:
temperature
metabolism
cerebral function
energy
how is our metabolism regulated by the thyroid hormones
increase fat breakdown resulting in weight loss as well as lower cholesterol
help fix leptin resistance (increase hunger, slowed metabolism)
what does the thyroid hormones protect against
cardiovascular disease
cognitive impairment
fatigue and weight gain
memory loss
what is the enzyme that serves as essential control points of thyroid activity
deiodinases
what does the deiodinase enzyme do
determines intracellular activation and deactivation of thyroid hormones dependent of serum hormone levels
what are the 3 diodinases present in different tissues of our bodies
D1= converts T4 to T3
D2= converts T4-T3
D3= converts T4- reverse T3
where does D1 work
in the liver and kidney
what is the key enzyme that controls intracellular T3
D2
what surpresses D1 and D2
stress, depression, dieting, insulin resistance, obesity, DM, inflammation, systemic illness, chronic fatigue syndrome, chronic pain, exposure to toxins
what are symptoms related to thyroid deficiency (not enough)
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
how many americans are hypothyroid
30-40%
what are reasons for thyroid deficiency
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
what are the 3 types of hypothyroidism
primary
secondary
tertiary
primary thyroidism
decreased production of thyroid hormones
TSH elevates, T3 and T4 will be normal or low depending on severity
secondary thyroidism
poor conversion of T4 to T3 in peripheral tissue
conversion of T4 to reverse T3 (rT3)
euthyroid sick syndrom = low T3 syndrome
tertiary hypothyroidism
receptor site insensitivity
symptoms of low thyroid persist despite normal labs
what are causes of decrease thyroid production
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
free T3 lab range
2.3-4.3
*optimal is 4.0-4.3
TSH lab range
0.3-5.0
* optimal .3
what are treatment options for hypothyroidism
levothyroxine/ synthroid/ tirosint (T4)
cytomel/liothyronine (T3)
desiccated thyroid (T4/T3/T1/T2)
no desiccated compound (T4/T3)
what medication for hypothyroid is more readily available and well absorbed
NP thyroid
what is treatment of choice for hypothyroid
NP thyroid
what is therecommendation for thyroid screening
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
if the patient is asymptomatic, why do we care about treating their thyroid deficiency
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
does thyroid replacement cause osteoporosis
no
does thyroid replacement increase the risk of heart disease and/or arrythmias
no, they help decrease the risk
how does low thyroid lead to heart disease/arrythmias
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
what is T3
triiodothyronine (T3)
what is T4
thyroxine (T4)
what system is the thyroid apart of
the endocrine system
how to describe a normal functioning thyroid gland
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.”
what is T3 and T4 responsible for
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.
When You Have Too Much T3 or T4, You Might Experience:
Anxiety
Feelings of irritation
Hyperactivity
Hair loss
Skipped periods
Tremors and shaking
Sweating
When You Have Too Little T3 or T4, You Might Experience:
Weight gain
Memory issues
Lethargy
Fatigue
Constipation
Brain fog
Dry skin
what is TSH
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.
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
low T3`
in 1970 Dr. Broda Barnes was known for
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
for inflammation, thyroid hormone lowers…
CRP
C-Reactive protein
*CRP is secreted by the liver and checks for inflammation in the body
how does T3 correlate with alzheimers
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
what is hashimotos
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
what is the treatment for hashimotos
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!!
why do we want to stay away from levothyroxine as treatment
patients on long term levothyroxine replacement show persistent impairments in both cognitive functioning and general well being
why should we use supplements especially to optimize hormones
because in todays society there is
poor food quality
poor food choices
stress
health conditions
excess alcohol intake
drug nutrient depletion
why use biote supplements instead of over the counter supplements
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
food for thought: what could be said about spinach
you would need to eat a dozen bowls of spinach today to equal the iron content of one bowl of spinach in the 1930s
what are the top patient health goals
lose weight
build muscle
boost energy
increase performance
improve mental health
balance hormones
improve overall health
build up immunity
what are the core 4 nutraceuticals we use at pure
DIM, ADK, probiotics, methyl factors
what is biotes current lineup of nutraceuticals
these are a custom formulation exclusive to BIOTE
DIM SGS+
ADK5
ADK10
Multistrain Probiotic 20B
Methyl Factors+
Iodine+
Bacillus Coagulans
Curcumin SF
Omega3+ CoQ10
what components are found in DIM SGS+
DIM
sulforaphane
pomegranate extract
what is DIM full of
cruciferous veggies
cabbage
broccoli
bo choy
brussel sprouts
cauliflower
kale
turnips
what are benefits of DIM
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)
additional components of DIM SGS+ are beneficial by
having antioxidant and anti inflammatory and detoxification properties.
why DIM SGS+
improves hormone metabolism
beneficial for estrogen and testosterone balance
breast and prostate health
weight management
what other conditions can DIM SGS+ be used for
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
DIMSGS+ dosing
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)
what are benefits of vitamin A
eye health
immune support
fights inflammation
support skin health and cell growth
helps prevent cancer
what vitamin deficiency is an epidemic in the USA
vitamin D
what does vitamin D do
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
can you really get bought vitamin D from just sun exposure
no, unless you are outside laying down every day with 72% of your skin exposed
can you not just take vitamin D alone?
no because vitamin D is dependent on vitamin K2 to bind to calcium
what is the power of Vitamin K
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
ADK dosing
take in the morning WITH food
start with ADK10 for 3 months then maintenance dose is adk5
key functions of methylation
reduces our toxic load by processing chemicals and toxins
processes and metabolises estrogen
produces energy
builds immune cells
builds neurotransmitters (dopamine, serotonin, epinephrine)
what are the down stream effects of poor methylation
altered hormone metabolis
anxiety
cancer risk
cardiovascular risk
decreased cognitive function
depression
insomnia
migraines
esteoporosis
poor detoxification
what supplement has the B vitamins
methylfactors+
what are the 7 signs you need methylation support
brain fog after eating
red faced after exercising
low energy
mthfr or high homocysteine
stress
increased estrogen
trouble falling asleep
why do you need methylfactors+
converts food to energy (atp)
mitochondrial function
DNA production
detoxification
blood vessel health and function
methylation
methylfactors+ dosing
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
what are signs of unhealthy digestion
acid reflux
nasal congestions
gas
bloating
inflammation
skin disorders
digestive disorders
loose stools
depression
constipation
what distroys good bacteria
antibiotics
steroids
antacids
high sugar diet
diets high in refined and processed foods
chemotherapy and radiation
in healthy intestines what protein hold together tight junctions between the intestinal cells to establish a protective barrier
xonulin
what breaks down zonulin and tight junctions making the gut more permeable (leaky gut)
sugar and gluten
54% of acne sufferers have marked alterations to their
intestinal microflora- put on probiotic
who should be on a probiotic
anyone that has a gut, because the gut infulences all major organs of our body
what is a multi strain probiotic 20B
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
what is bacillus coagulans
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
bacillus coagulans dosing
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
iodine+ dosing
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
why Iodine+
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
the only glycocalyx regenerating product patented to stabilize and regress vulnerable arterial plaque
arterosil
what is the endothelium
layer of single overlapping cells lining the interior of every artery, vein and capillary which have unique functions for vascular health
what is the importance of our arteries, veins, and capillaries
delivery of oxygen, nutrients, hormones, and more to every organ and system
regulation of coagulation
inflammatory response modulation and antioxidant storage
blood pressure modulation
what is the number 1 killer of men and women worldwide
cardiovascular disease
what is the most common cause of CVD
atherosclerosis
what is at the center of the initiation and progression of atherosclerosis
endothelial disfunction
evidence shows the missing link of prevention of CVD suggests maintaining the integrity of
the endothelial glycocalyx structure
dysfunction of the vascular endothelial glycocalyx is hallmark of
diseases
*normal healthy artery, endothelium intact
diseased artery (plaque build up causing blood clot, endothelium compromised
what does arterosil do
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
who should take arterosil
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
what are the contraindications when taking arterosil
no known contraindications
what nutraceutical is recommended for restfullness and awake refreshed
best nights sleep
what do hormones protect
bones, brain, breast heart, prostate
muscle and bones facts
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
pellets and bones
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
what are the testosterone effects on bone
maintains and BUILDS bone
excellent therapy for prevention and treatment of osteoporosis
high endogenous levels of testosterone-> higher BMD
testosterone effects on joints and inflammation
improves most forms of chronic JOINT and MUSCULAR pain
lowers inflammatory markers
most autoimmune disease patients notice improvements
HRT effects on total knee and hip arthroplasty
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
what to know about HRT and alzheimer’s disease
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
what else decreases the beta amyloid
thyroid
HRT and particularly ERT plays a role in preventin neurodegenerative conditions like
alzheimers and dementia
*E2 can reduce the risk of alzheimers disease and minimize cognitive decline in otherwise healthy women
for patients that have history of epilepsy what would you not put them on
estradiol lowers seizure threshold -> increase risk of seizures in patient swith epilepsy
*adjuvent E2 is not recommended in these patients when they become menopausal
for patients that have history of seizures what should be given to them
pogesterone and testosterone increase seizure threshold -> lowers risk of seizures
* testosterone is great for men and women with epilepsy
progesterone may also be used
estrogen and the breast
does NOT increase the risk of breast cancer when used alone
when combined with micronized progesterone does not increase risk of breast cancer
E2 and prior breast cnacer
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
for breast cancer survivors what is not recommened
E2
*instead testosterone and anastrozole pellets available
summary of testosterone and prostate
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
what was the study on testosterone and prostate cancer
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
what lab is predictive of prostate cancer
low levels of testosterone is an independent risk factor for PCa
what can we add to PSA (prostate specific antigen) that may improve predictive accuracy
testosteron
how should we go about with treating patients with prostate cancer history
*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)
there is not now, nor has there ever been, a scientific basis for the belief that testosterone caused…
prostate cancer to grow
what should the PSA level be
<2.5 ng/mL to pellet
what can increase PSA
prostate massage
prostatitis
sex
does testosterone therapy affect PSA levels
T affects PSA levels minimally in normal prostates (<0.1)
testosterone pellet CV summary
NO increased risk hypercoagulability with pellets
reduced CV risk
improved lipids
improved HDL
improves insulin resistance
summary of effects on lipids: how do testosterone pellets affect lipids
improved total cholesterol
increased HDL
decreased LDL
decreased triglycerides
increased lean body mass
decreased bone resorption
what is HDL
high density lipoprotein
“good” cholesterol
what is the function of HDL
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
what should HDL levels be
women= > 55mg/dL
men= > 45 mg/dL
what is LDL
low density lipoproteins
“bad cholesterol”
what is the function of LDL
it is called bad cholesterol because a high LDL level leads to a build up of cholesterol in your arteries
what should LDL levels be
under 130 mg/dL
*people with heart or blood vessel disease, diabetes, or high total cholesterol should be less than 70mg/dL
what is cholesterol
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
why is cholesterol important for our body
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
how can a high LDL level raise my risk of coronary artery disease and other diseases
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
how does coronary artery disease happen
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.
metabolic effects of low testosterone
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
what are triglycerides
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
what is total cholesterol
this is the total amount of cholesterol that’s circulating in your blood
*formula= HDL + LDL + 20% of triglycerides
what is low testosterone associated with
abnormal lipids
increased insulin resistance
increased abdominal adiposity
increased pro inflammatory markers
vascular dysfunction
atherosclerosis
what is hypogonadism
a failure of the gonads, testes in men and overies in women, to function properly
what is endothelial function
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
what is metabolic syndrome
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
what are testosterones actions in the heart
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
what is aromatization
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
what about anabolic steroids
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
how do men form estradiol
aromatase enzyme
*testosterone is aromatized to form estradiol
does biotechs method administer estradiol in men in form of pellets?
it does NOT
*do not worry about baseline E2 level in men
why do we not worry about baseline E2 in MEN
E2 levels improve after normalization of testosterone levels in most men
(<10% will aromatize excessively to E2)
what nutraceutical helps normalize aromatization
DIM SGS+
estradiol and CV disease in men… “its not just low T”
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
what is the impact of E2 on HDL
physiologic levels of estradiol stimulate an increase in HDL cholesterol in men (this is good)
what is MMP-9
anenzyme that degrades collagen and elastin which is the major component of the covering of the cap in arteries
what to know about MMP and the heart
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
how many women premenopausal die from heart disease
1 in 7
*cause= testosterone deficiency
how many women postmenopausal die from heart disease
1 in 3
*cause= estrogen and testosterone deficiency
what is the leading cause of death of american women
heart disease
why is it important to get your levels checked when you hit menopause (or even before)
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
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
Hormone therapy
statin
hormone therapy
what is the time frame of when you first start to feel a difference from the pellets
3 months
what are the body composition and strength that could change from pelleting
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
what are some unique conditions in which to consider pellet therapy
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
what 3 hormones do we balance
Estrogen
testosterone and thyroid
what minimum tests should a womens biote workup include
FSH & estradiol
TSH, Free T4, Free T3, TPO
total testosterone
25- OH Vitamin D
comprehensive metabolic panel
CBC
B12
what should womens follow up labs be (after 1st round)
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
after 1st round of pelleting in women what should FSH be
decrease by 50% or <23 if given replacement dose E2 (not the 6mg)
how much should total testosterone be after first pellet in women
total testosterone levels at 6 weeks should be 150-250
usual FHS values in women during follicular phase
2-10
usual FHS values in women during mid cycle
15-35
usual FHS values in women during post ovulatory (luteal)
5-20
usual FHS values in women during post menopausal
23-195
what is the goal for post menopausal female bite patients
to produce a normal premenopausal FSH level to alleviate symptoms OR to have FSH reduced by 50% to reinstate normal female physiology
basic female postmenopausal E2 dosing on clinical DS
with uterus= 12.5 mg estradiol
200 mg micronized progesterone or 225mg compounded micronized progesterone
without uterus= 15mg estradiol with or without micronized progesterone
what about premenopausal E2 dosing
premenopausal women make their own E2 and progesterone
*premenopausal women ONLY get E2 if they have menstrual migraines, and the dose is 6mg
oral contraceptive users should always have a FSH of
<5
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
the higher the FSH, the more estrogen deficient
don’t stop birth control pill prior to
lab testing
what are the 4 main benefits of DIM
forces healthy estrogen metabolism
increases free testosterone
natural aromatase inhibitor
helps reduce testicular shrinkage
signs and symptoms of testosterone deficiency (12)
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
what is a normal testosterone in women but where do they feel the best
<14-80 expected lab range
70 or above is normal and where most women feel best
at 6weeks post insertion total testosterone level in women should be
150-250
*biote initial workup for men should include these minimum tests
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
*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
if on shots, test on day 4 or 5 post injection
if on creams, hold cream AM of lab draw
what are the biote follow up labs for men
free and total testosterone and estradiol
thyroid if on meds
for 4 week follow up labs what should total testosterone and free testosterone be
total testosterone 900-1100
free testosterone upper end of range over the mean
what is a “normal” total testosterone in men and when do they feel the best
300-900 is what most labs use as normal
900-1100 men feel the best
does testosterone replacement affect PSA
minimal expected change in PSA with normal prostate
what is the suggested baseline PSA in men
> 40 who are to receive treatment with testosterone
when is screening PSA required
ages 55-69
what is the normal PSA level of men NOT on 5a-reductase inhibitor
<2.5
what is the normal PSA level of men currently on 5a-reductase inhibitor for benign prostatic hyperplasia or balding)
<1.25
if male testosterone is very low for age and no illigal anabolic sterioid use, what lab test would be important to get?
prolactin
what is prolactin
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
if male testosterone is very low for age and no anabolic steroid use, what clinical condition should be ruled out
sleep apnea
how to calculate free testosterone
upper testosterone lab value + lower testosterone lab value divided by 2 = mean
ex: norma lab valu 5-25
5+25=30/2= 15
- estradiol pearls (6)*
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
how and when do I use dosing site
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)
if a patient is needing a boost when should it be given
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
what is not given with a history of breast cancer
estradiol and progesterone
what if after pelleting a patient and they say they forgot to tell you they are taking soemthing for hairless or BPH
check dosing and PSA level, if PSA over 1.25 need a urological work up before proceeding
what if post total testosterone was 700 (male)
if feeling well, increase testosterone 200mg next round; if no change in symptoms, give them a boost
what if total T was 800 and free was 15 (male)
if feeling well, increase testosterone 200mg next round; if no change in symptoms, give them a boost
what if the PSA is 4.0 next year (anniversary labs) (male)
need urologic workup
what if post estradiol is 72 without symptoms (male)
make sure patient is taking DIM SGS+
what if post estradiol is >70 with symptoms and taking DIM SGS+ (male)
needs oral aromatase inhibitor
what if patient is anxious and not sleeping well at 4 weeks (male)
needs 5-HTP (sleep supplement)
dosing pearls for females (3)
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
dosing pearls for meales(6)
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
if a patient is sensitive to meds what do you do
lower dose
if patient has pre existing uterine fibroids
use only low dose E2 (if any) 12.5 or less. always use prometrium or progesterone 200mg
if patient has pre existing ED how long does it take to improve after HRT
may take up to 6 months to improve
*consider writing Cialis daily 2.5mg or 5mg
if patient still complaining of not staying erect what should you screen for
DM and may beed to reduce aromatase inhibitors
if you have a BPH patient what should you do with testosterone
use normal dose of testosterone unless BPH is not treated
*testosterone does not cause symptomatic BPH
how should you treat a patient with hx of prostate cancer and what lab should be checked
treat with pellets ONLY if has had definitive therapy AND negligible/stable PSA
what lab should we obtain on all asymptomatic, low risk males age prior to pelleting
PSH
when should female labs be drawn
at 6 weeks, unless NO symptom relief then pull at 4 weeks
post pellet expected female labs at 6 weeks: total testosterone
150-250
post pellet expected female labs at 6 weeks: FSH
should decrease by approximately 50% (or <23) IF patient given replacement dose of E2
post pellet womens boost should be done
before 8 weeks since last pellet
(37.5-50mg)
when should male labs be drawn
4 weeks
post pellet expected male lab alue: total testosterone
900-1100
post pellet mens boost should be done
before 8 weeks since last pellet
200-400mg
what are possible side effects
acne 2%-10%
mild facial hair growth 2%-10%
hair thinning <1%
if patient is having hair thinning what should be done
reversing insulin resistance and addressing thyroid and low vitamin D will significantly lower risk of hair loss
is maternal testosterone therapy safe for the breast fed infant?
yes
what is erythrocytosis
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)
what is polycythemia vera (PCV)
myeloproligerative blood cancer
LOW erythropoietin
platelet stickiness
INCREASE thrombosis
blood volume can increase 2x normal
median age 70-79
having problems with swelling or fluid retention while pelleting?
what causes this, for how long, and what can be prescribed
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
having problems with acne?
what causes this, for how long, what can be prescribed
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
what acne prescription is not recommended in pregnancy or in patients trying to conceive
spironolactone
if acne is severe what should be done next pelleting
reduce testosterone by 10%-20% next round
what to consider if patient has hair growth post pellet
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
if patient is having hair loss what shoul dbe done
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
what are the compounding hair solutions for thinning hair
hair rescue: activate (PTD-DBM + methyl vanillateours)
hair rescue: repair (GHK- CU- Zn- thymulin)
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
cannot use if patient is childbearing age and not on contraceptive
*teratogenic category x
if patients hair is thinning and begin RX when can they expect hair growth
6-8 weeks for new hair growth
what if patient says they are still very tired post pellet
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
post pellet issue sstill tired what should be given
was thyroid optimized
methylfactors + daily (b12 injection needed?)
good multivitamin
labs for chrinic fatigue?
when too much testosterone is converted to estradiol
male aromatizer
what medication can help the male aromatizers? (too much testosterone converted to estradiol)
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
when determining aromatization what should you do regarding labs
dont get tricked on initial labs, wait for follow up labs to determine aromatization
post insertion wound concerns: when will you see histamine reactions
most common with 1st insertion
when is pellet extrusion usually seen
seen after 2-3 months of pelleting
if post pellet gets infected, red/cellulitis what should be done
clindamycin 30mg TID x 7 days OR Bactrim DS BID x 7 days
apply heat
how to treat etrusions
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
for a localized histamine reaction what should be done
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
what are alternatives to lidocaine 1% with epi
lidocaine 2% with or without epi
lido 1% plain
if patient has lidocaine allergy what should be given for insertion
marcaine 0.5% with or without epi
only use 1/2 cc of bicarb as it will precipitate
