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Repro > week six > Flashcards

week six Flashcards

1
Q

What are risk factors for cognitive decline?

A

Low sex hormones
DM, HTN, metabolic syndrome
Obesity
Poor sleep
Stress
Smoking, alcohol
Sedentary lifestyle
Poor diet, nutrient deficiencies

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2
Q

Lifestyle support for CVD prevention in older pts

A

Smoking cessation
Reduce alcohol intake
Reduce rec drug se
Movement (aerobic, interval training)
Stress management

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3
Q

Nutrition support for CVD prevention in older pts

A

Reduce sugar, refined carbs, processed foods
Promote circulation (garlic, ginger, onions) ESP if on hormone therapy to reduce clot risk
Bioflavonoids (citrus, berries, apples, onions, broccoli, tea, beans)
Fish and fish oil
Soluble fiber

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4
Q

Strategies to enhance digestion in menopausal/andropausal pts

A

Food hygiene
Warming, aromatic, and pungent herbs (cinnamon, turmeric, ginger)
Easy to digest, nutrient rich foods
Fiber rich foods
Probiotics

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5
Q

What GI change occurs with aging?

A

GI motility dec with age;

Constipation
Bloating
Nutritional deficiencies
RF for low bone density

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6
Q

What happens to the levels of cortisol and DHEA (and thus estrogen and testosterone) during high stress levels?

A

Cortisol levels inc
DHEA (+E + T) dec

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7
Q

Is it true that pregnenolone in the adrenals is “stolen” by cortisol for regulation?

A

No

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8
Q

Things you can do to support adrenals for andropause pts

A

Stress management/mindfulness
Break the twitch**?
Sleep hygiene
Veggies, esp leafy greens
Healthy dietary cholesterol
Blood sugar regulation
Adaptogenic herbs

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9
Q

What is the importance of supporting the adrenal glands for male sex hormone production?

A

They are the ONLY source of DHEA, estrogen, progesterone

And after andropause, they are a major source of testosterone

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10
Q

Goals of nutritional therapy for andropause

A

Sx relief
Support adrenals
Weight optimization
Prevent complications of hormone deficiency (CVD, osteoporosis, cognitive decline)

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11
Q

Risks of testosterone abuse/overmedication

A

Stroke
Heart attack
HTN
Inc LDL
Liver damage, tumors
Can cause growth to stop in teens

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12
Q

Signs of testosterone abuse/overmedication

A

Aggression, depression
Acne
Voice change
Elevated BP
Weight gain
Bloating
Inc LDL

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13
Q

Main symptom of excess aromatization of testosterone > estrogen? What is this caused by?

A

Caused by TRT; main sx gynecomastia

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14
Q

What is the cautin with DHEA and why it is important to take supervised by a doctor?

A

Can increase testosterone levels, leading to side effects

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15
Q

Pharmaceutical treatments for andropause

A

Testosterone replacement therapy (TRT)
Aromatase inhibitors for men on TRT who get excess aromatization of testosterone > estrogen
DHEA

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16
Q

Other names for andropause

A

Late onset male hypogonadism
Androgen deficiency syndrome
Androgen deficiency in the aging male
Testosterone deficiency syndrome
Male menopause

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17
Q

Sx of andropause

A

Loss of libido
Erectile dysfunction
Low serum testosterone

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18
Q

How is andropause defined?

A

Sx testosterone deficiency

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19
Q

Around what age does testosterone begin declining? At what rate?

A

30-35
1% each year

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20
Q

Side effects saw palmetto

A

Mild, infrequent, reversible
GI upset, headache, rhinitis, dec libido

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21
Q

MOA b-sitosterol for BPH

A

Anti-inflammatory

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22
Q

MOA saw palmetto for BPH

A

Blocks a1 receptors, dec cell proliferation, inc apoptosis, anti-inflammatory and antioxidant

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23
Q

MOA rye grass pollen for BPH

A

Dec 5-a-reductase
Blocks a1 receptors
Anti-inflammatory

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24
Q

MOA pygeum for BPH

A

Dec 5-a-reductase
Anti-inflammatory

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25
Q

MOA nettle for BPH

A

Dec action sex hormones
Dec proteolytic enzyme

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26
Q

What are two combination treatments for BPH that are shown more effective than each component individually? What markers did they show improvement on?

A

Saw palmetto + lycopene > reducing prostate inflammation GF expression, oxidative stress, and histologic features in bladder obstruction model

Saw palmetto + pumpkin seed oil > dec serum PSA, improved QOL

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27
Q

Selenium MOA on prostate cancer prevention

A

Inhibits cell proliferation and stimulates apoptosis, antiinflammatory and antioxidant

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28
Q

Selenium effects on BPH

A

Slows prostate growth and prevents prostate cancer

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29
Q

Proposed MOA lycopene on reducing risk of prostate cancer

A

Antioxidant and anti-inflammatory
Dec 5-a-reductase + IL-6 signaling
Dec cell proliferation in normal prostatic epithelial cells
Promotes apoptosis in hyperplastic prostate tissue

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30
Q

Lycopene effects on prostate conditions

A

Slows progression BPH
Reduces risk prostate cancer

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31
Q

Zinc effect on BPH

A

Dec prostate size; unknown mechanism

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32
Q

Pumpkin seeds effect on BPH

A

Reduced LUTS

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33
Q

MOA pumpkin seeds for BPH

A

Dec elevated DHT, tonic effect on bladder

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34
Q

Why might soy be beneficial in BPH?

A

Contains isoflavones genistein and daidzein; ed 5-a-reductase, inc antioxidant enzymes, dec NF-KB upregulation of apoptosis

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35
Q

Phytotherapy options for BPH

A

Saw palmetto
African plum
South african star grass
Stinging nettle root
Rye pollen extract
Pumpkin seeds
Soy
Grape juice
Cactus flower
Zinc
Selenium

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36
Q

Components of “watchful waiting” with BPH

A

Dec PM fluids
Dec caffeine/EtOH/bladder irritants
Timed voids/double vodis
Treat constipation

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37
Q

BPH tx options

A

Watchful waiting
Phytotherapeutics
Medical management (alpha blockers, 5 ARIs, PDE5i, combination therapy)
Minimally invasive techniques
Surgical techniques

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38
Q

Etiology/RF BPH

A

Higher incidence with higher income and education

Metabolic syndrome increase likelihood

Familial component

20% males 41-50
50% males 51-60
Inc by 10% per 10 years

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39
Q

Clinical sx BPH

A

LUTS: storage vs voiding vs both (nonspecific)

Incomplete emptying
Frequency
Urgency
Intermittency
Weak stream
Straining
Nocturia

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40
Q

BPH macroscopic changes

A

“Enlarged prostate”; DRE, TRUS, CT, MRI

Static (epithelial/having a large blockage)

Dynamic (increased “tone” of muscle fibers)

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41
Q

BPH microscopic changes

A

Proliferation of stromal (fibromuscular) and epithelial (prostate secretory glands) in the transitional zones

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42
Q

Viagra effect on ED; what needs to be present in adequate levels for viagra to result in an erection?

A

Viagra-like drugs artificially shore up cyclic GMP levels by inhibiting its breakdown and will produce an adequate erection provided there is sufficient nitric oxide to stimulate enough cyclic GMP.

Although we now realize that they do stimulate NO, they do not fully correct deficiencies of NO due to poor lifestyle choices. Think of a simple analogy of a fire hose that will become distended if the nozzle is partially closed off, but not if the fire hydrant is partly shut or there is not enough water in the system. It is crucial to have enough NO production for erection to occur, with or without the use of drugs.

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43
Q

Affects of obesity on male fertility

A

Alters sperm function
Increases sperm DNA damage
Dec sperm mitochondrial activity
Induces seminal oxidative stress
Impairs blastocyst development

evidence varies

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44
Q

Substances associated with decreased aromatase activity

A

Zinc
Flaxseed
Nettle
EGCG

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45
Q

What causes decreased 5-a-reductase activity

A

Saw palmetto
Nettle
EGCG
Zinc

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46
Q

What causes increased 5-a-reductase activity

A

High insulin and obesity

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47
Q

Inc Dihydrotestosterone (DHT) is associated with what conditions

A

Prostate enlargement (cancer, BPH)
Male pattern balding
Female hirsutism
Acne
Skin aging
Breast tumors

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48
Q

What enzyme converts testosterone to dihydrotestosterone?

A

5-alpha-reductase

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49
Q

Aromatase activity is upregulated in what scenarios

A

Obesity (high activity in adipose tissue)/excess adipose
Hyperinsulinemia
Alcohol use
Inflammation

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50
Q

Testosterone is converted to estrogen via what enzyme

A

Aromatase

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51
Q

Ways to prevent negative estrogen burden

A

Increase:
CYP-1A1
COMT
Quinone reductase
Glutathione conjugation

Decrease:
CYP-1B1
Peroxidase
B-glucuronidase activity

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52
Q

Ways to improve estrogen elimination

A

Support phase 1
Support phase 2
Lower beta glucuronidase

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53
Q

Nutritional strategies for lowering beta-glucuronidase

A

Plant based diet low in animal protein
Raw vegan diet
Prebiotic foods - chicory, asparagus, banana, onions, leeks, nuts and seeds, cruciferous, garlic, shallots, beets, fennel, peas
Prebiotic supplements
Probiotic supplements

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54
Q

During what process does the conjugation and elimination of estrogens in bile take place?

A

Glucuronidation

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55
Q

Supplements to maintain reduced glutathione

A

Reduced glutathione
N-acetyl-cysteine
Lipoic acid
Whey protein
Mg
Vit C
Vit E
Silymarin
Pantothenic acid
SAMe

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56
Q

Dietary sources of glutathione S transferase

A

Cruciferous veggies
Allium veggies
Resveratrol
Citrus
Garlic
Fish oil
Black soybean
Purple sweet potato
Curcumin
Green tea
Rooibos tea
Honeybush tea
Ellagic acid
Rosemary

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57
Q

Steps to improve methylation

A

Increase substrate for COMT (SAMe)
Add methyl donors

58
Q

What enzyme helps control the levels of certain hormones?

A

Catechol O methyltransferase (COMT)

59
Q

What are sulfotransferases/SULTS and in what foods are they found?

A

Enzymes that catalyze the transfer of a sulfo group from a donor molecular to an acceptor alcohol or amine

Caffeine (coffee, cocoa, black tea, green tea)
Retinoic acid (liver, fish, egg, dairy, apple, apricot, artichoke, arugula, asparagus)

60
Q

Issues with phase 2 detox

A

Genetic difficulties with phase 2 > chronic disease, unexplained wt gain, fatigue, mood problems

Phase 2 limited vs phase 1 > toxic intermediates can accumulate

61
Q

Types of pathways for phase 2 liver detox

A

Methylation
Glutathione conjugation
Amino acid conjugation
Sulfation
Acetylation
Glucoronidation

62
Q

What nutrition may support phase one liver detox?

A

Cruciferous veggies
Antioxidant foods
Flavonoids

63
Q

Liver detox pathway

A

Fat soluble toxin > phase 1 reactions > activated intermediate > phase 2 reactions > water soluble compound

64
Q

Phase 2 liver detoxification

A

Transforms fat soluble substances into forms that can be excreted

Conjugation reactions

Conguates toxic intermediate from phase 1 making it non-toxic and able to be removes

6 pathways for phase 2

65
Q

Phase 1 liver detoxification

A

Inactivates chemicals (caffeine, alcohol, meds)

Hydroxylation reactions
CYP450 enzymes

Creates intermediates that are no longer active but may be more toxic to the body. Creates ROS.

66
Q

How does the liver remove toxins?

A

Removes fat soluble toxins into vile for intestines

Transforms fat soluble toxins to water soluble for kidney to remove them

67
Q

How long does it take to regenerate about ½ of liver function?

A

6 weeks

68
Q

How can you support metabolite detox?

A

Promote balanced phase 1 and phase 2 estrogen biotransformation and clearance

Promote a healthy gut microbiome, gut ectology

69
Q

How can you modulate estrogen receptors?

A

Defend cellular sensitivity (estrogen receptors) from other hormones

70
Q

How can you modulate the transport of estrogen?

A

SHBG

Distribution

Interaction with other hormones

71
Q

How can you reduce the estrogen burden?

A

Reduce peripheral production via aromatase inhibition

Reduce exposure to environmental estrogen imitators

72
Q

What are the four components of strategy to improve estrogen biotransformation and clearance

A

Reduce estrogen burden
Modulate transport
Modulate receptors
Support metabolite detox

73
Q

Which metabolite of estrogen is the protective/weak? Which are carcinogen and active?

A

2-OH - protective

16a-OH and 4-OH** - carcinogen

74
Q

Estrogen metabolism biochem

A

Phase 1 detox - estrone and estradiol hydroxylated by CYP450 enzymes > 2-hydroxy/4-hydroxy metabolites

Phase 2 detox - in liver; sulfotransferases, glucuronidation, COMT, glutathione

Human estrobolome: aggregate of enteric bacterial genes; products are capable of metabolizing estrogens

75
Q

3 P’s of hormone disruptors and their sources

A

Plastics: food storage, plastic bottles, produce bags

Parabens: cleaning products, makeup, hair products

Pesticides

76
Q

Sources of xenoestrogens

A

Commercial meat and dairy
Microwaved plastic
Baby bottles (BPA)
Conventional produce
Children’s toys
Plastic
Sunscreen
Synthetic hormones

77
Q

What are some effects of estrogen on the body?

A

Breast development
Stimulate bone growth
Epiphyseal closure
Small amount of increase protein deposition
Increased subcutaneous fat deposition (hips, thigh, butt)
Increased skin vascularity, warmth, and softness

78
Q

What enzyme is present in ovaries and what can it do?

A

What enzyme is present in ovaries and what can it do?

79
Q

What does cholesterol get converted into before estrogen? By what?

A

Pregnenolone; by ovarian cells

80
Q

What can cause decreased progesterone?

A

Stress
Insulin
Opioids
Luteal phase defect
High prolactin
Underweight
Hypothyroid
Birth control pills

81
Q

What can cause increased progesterone?

A

Vitex
Pregnancy

82
Q

What actions can be taken to normalize estrogen production? Give examples of nutritional tx for each of these.

A

Decrease inflammation: anti-inflammatory diet, omega 3 FA

Normalize insulin and glucose dynamics: low glycemic diet, alpha lipoic acid, chromium, cinnamon

Increase SHBG: lowering insulin levels, EFAs, flax

83
Q

Adiposity biochemical effects

A

Induces IR
Increases IGF-1 and suppresses hepatic binding proteins, increasing free unbound bioavailable circulating estrogens

Insulin = growth factor for tumor cells

84
Q

Adiposity is linked to higher circulating ____ and increased risk of _____.

A

Estrogens

Breast, ovarian, endometrial cancers

85
Q

What happens to hormone levels in underweight females or those who exercise excessively?

A

Non-essential hormone processes cease; sex hormone productino declines and infertility increase. Loss of interest in sex and dec sexual responsiveness.

Dec release of gonadotropin releasing hormone and LH/FSH

86
Q

“Obesity” may have what effect on puberty?

A

Early onset of puberty in girls

87
Q

“Obesity” is associated with alterations of what hormones and metabolites?

A

In males:
Dec SHBG
Dec total testosterone
Higher urinary estrone metabolites

Women:
Disturbed LH pulsatility
Dec SHBG levels by insulin
Insulin stimulates inc production of androgen from ovaries (PCOS)

88
Q

What is the substance in red yeast rice that makes it similar to a statin in terms of lowering cholesterol and sex hormone production?

A

Monacolin K

89
Q

Why would people on statins have altered serum sex hormone concentrations?

A

Statins inhibit the enzyme 3-hydroxy-3-methyl-glutaryl-CoA (HMG-CoA) reductase, reducing cholesterol production. Cholesterol is the starting product for sex hormone production.

90
Q

What is the effect of Mentha spicata on androgens?

A

Anti-androgenic effect in PCOS

91
Q

What is the effect of Camellia sinensis on SHBG?

A

Inc SHBG

92
Q

What is the difference between angelica sinensis that is prepared from fresh root versus that which is decocted?

A

If volatile oils present - circulatory stimulant, analgesic, antispasmodic

If decocted - uterine stimulant

93
Q

Rheum rhaponticum is particularly useful in perimenopausal states with associated with _____

A

Depression and anxiety

94
Q

Paeonia lactiflora is described in Chinese medicine as nourishing the yin. How does this relate to its effects on sex hormone regulation?

A

Nourishes blood and regulates menses
Invigorates blood and dispels blood stasis

95
Q

Explain the theory of how Vitex agnus-castus works to treat mastalgia

A

Vitex suppresses the stress-induced latent hyperprolactinemia (a release of increased levels of prolactin in some patients in response to stressful stimuli).

Vitex could be effective in the treatment of cyclical mastalgia by inhibiting the release of excess prolactin by blocking Dopamine-2 receptor type on the pituitary.

96
Q

List 5 effects of phytoestrogenic constituents aside from effects on reproductive function

A

Positive effects on
Bone density
Skin aging
CVD risk
Metabolic syndrome
Nervous system and immune function
Cancer risk and recurrence

97
Q

Name the 8 major types of phytoestrogens and give examples of herbs in which they are found

A

Chalcones - glycyrrhiza
Flavonols - glycyrrhiza
Isoflavones - medicago sativa (alfalfa), trifolium pratense (red clover),
Prenylated isoflavonoids
Coumestans - medicago sativa (alfalfa)
Lignans - flaxseed
Stilbenoids - rheum rhaponticum (false rhubarb)
Resocyclic acids of lactones

98
Q

Hot sitz bath indications

A

Painful spasms (vaginismus, tenesmus)
Colic
Neuralgia (ovarian,testicular, intestinal)
Sciatica
Lumbago
Insomnia
Suppressed menses
Congestive headache (derivative)
Painful hemorrhoids

99
Q

Hot sitz baths CI

A

Hemorrhage
Menorrhagia
Prolapse
Pelvic congestion
Acute UTI

100
Q

Alternating hot and cold sitz actions

A

Dec stagnation of blood and lymph
Inc tissue tone
Activates spinal cord reflexes to underlying pelvic and abdominal organs

101
Q

Alternating hot and cold sitz indications

A

Vaginal infections (esp with pelvic congestion)
Chronic UTI
IC
PID
Hemorrhoids
Anal fissure
Prostatitis/BPH
Atonic constipation
Chronic sciatica, lumbago
Laxity of pelvic fibers (postpartum and perimenopausal)

102
Q

Alternating hot and cold sitz CI

A

Hemorrhage
Acute cystitis

103
Q

Neutral sitz action

A

Calming and soothing to inflamed/irritated tissues

104
Q

Hot sitz actions

A

Relieves/relaxes muscle spasm

105
Q

Neutral sitz indications

A

Acute PID
Acute cystitis
Endometriosis
Mental restlessness with any condition
Vaginitis with pruritis
Pruruitic ani

106
Q

perineal bath actions

A

Dec swelling, inflammation, pain

107
Q

Perineal bath indications

A

After childbirth
After rectal or perineal surgery

108
Q

Hot foot bath indications

A

Congestive headache
Epistaxis
Lung congestion
Pelvic congestion/prostatic conditions
Suppressed menses/dysmenorrhea
Chill
Fatigue
Renal and gallstone colic
May prevent or shorten cold/flu
Prep for wet sock treatment

109
Q

Hot foot bath CI

A

Peripheral vascular disease
DM
Loss of sensation to extremities

110
Q

Douches actions

A

Soothe irritated and inflamed tissues
Heal injured tissues
Restore balance to imbalanced vaginal microbiome

111
Q

Douche CI

A

Pregnancy
Don’t use on a regular basis

112
Q

Castor oil pack actions

A

Emollient
Softens scars and adhesions
Shrinks cysts/non malignant growths
Shrinks warts
Detoxifying/drawing
Stimulates smooth muscle
Laxative
Anti-inflammatory
Oxytotic (inc uterine contractions)

113
Q

Castor oil pack indications

A

Liver/GB detox
Migraines/headaches
Abdominal adhesions post surgery
Ovarian cysts
Fibrocystic breast disease
Uterine fibroids/lipomas
Hormonal imbalances:
PMS
Endometriosis
Dysmenorrhea
FBD
Menopause
Inflammation

114
Q

Castor oil pack CI

A

Uterine growths
Bleeding
Pregnancy
Ulcers
While menstruating

115
Q

High frequency VITA RAY actions

A

Dec inflammation
Inc circulation of blood and lymph
Speed up wound healing
Antiseptic

116
Q

High frequency VITA RAY indications

A

Acne
Increased facial tone (wrinkles, etc)
Male pattern baldness prevention

Instead of sine for:
Dysmenorrhea
Heavy menses
Ovarian cysts
Prostatitis/high PSA
Uterine fibroids
Abdominal scar tissue
Breast cysts
Mastitis

117
Q

High frequency VITA RAY CI

A

All electrical CI
Over metal implants
Over moisture on the skin

118
Q

Heating trunk pack actions

A

Promotes gastric secretions, liver activity
Normalizes motility of GI tract

119
Q

Hydro treatments for constipation

A

2 glasses of water when waking, waiting an hour until eating

Contrast showers,, long hot short cold (esp to abdomen and anal)

Cold abdominal compress (long term constipation)

Reflex water therapy (hot shoulder, cold hip, cold back shower)

120
Q

MOA using cold hydro to improve digestion and elimination

A

Contraction of muscles and organs
Dilation of arteries to liver
Inc gastric secretion
Inc free and total hydrochloric acid

121
Q

Dysmenorrhea hydro tx

A

Hot herbal teas such as peppermint, chamomile, linden

2 cups rock/coarse salt roasted 15 mines and wrapped in a towel applied to abdomen/ovaries

Cold shallow bath with hot foot bath

Hot moist compresses to spine/abdomen

Hot water bottle

Keep extremities warm

Before/during start of menses lower half body hot pack, cold friction rub, finish neutral bath

122
Q

Profuse menses hydro tx

A

Cold foot bath
Ice between thighs
Cold water irrigation of vagina
Cold sitz baths, hot foot bath
Cold hip baths/cold mitten friction

123
Q

Delayed/suppressed menses hydro tx

A

Alternate hot and cold sitz or compresses
Irrigate vagina with alternating hot and cold douches
Prolonged hot moist compresses
Hot herbal teas

124
Q

Childbirth hydro tx

A

Red raspberry leaf tea
Cold compresses or showers to breasts
Short cold foot baths
Hot moist compress on pubic area
Warm deep sit bath at early labor

125
Q

Postpartum hydro tx

A

2 days after - hot dry pack to breasts, ACV douches

5 days - cold sheet pack over abdomen and breasts

Cracked breasts - Vit E oil, hot moist compresses then cool sponging

126
Q

Insomnia hydro tx

A

Neutral and warm tub baths
Hot moist compresses on head
Alternating hot and cold leg baths
Hot milk and honey
Neutral or warm bath
Wet sheet pack starting neutral
Prolonged mild hot baths
Heating compresses
Heating pad

127
Q

Different actions of neutral/warm baths and alternating hot and cold leg baths on insomnia

A

Neutral and warm baths calm and sedate body

Alternating hot and cold leg baths reduce congestion and help with sleep

128
Q

Nausea hydro tx

A

Ice pack to base of skull and neck and one at solar plexus
Peppermint tea
Heating trunk pack with hot water bottle on upper abdomen

129
Q

Spasms in bladder/rectum/uterus hydro tx

A

Prolonged hot moist compresses to pelvic
Shoulder showers

130
Q

Pelvic period cramps and pelvic inflammation hydro tx

A

Cold shallow bath + hot foot bath

131
Q

Pelvic congestion hydro tx

A

Hot foot bath
Alternating hot and cold sitz bath

132
Q

Non inflammatory pelvic problems hydro tx

A

Hot shallow bath
Hot foot bath

133
Q

Uterine hemorrhage hydro tx

A

Cold compress on inner thighs, perineum, lower back

134
Q

Uterine inflammation hydro tx

A

Cold low pressure shower from naval to pubic bone

135
Q

Vaginismus hydro tx

A

Hot water/rosemary tea douche
Hot shallow sitz baths
Hot foot baths
Ice pack from shoulder to neck

136
Q

Yeast vaginitis hydro tx

A

Douche with acidophilus and water, ACV

137
Q

Mastitis hydro tx

A

Castor oil packs

138
Q

Acute Prostatitis hydro tx

A

Hot OR cold, not both
Hot shallow bath
Cold ice pack to area

139
Q

Chronic Prostatitis hydro tx

A

Alternate hot and cold perineal spray
Graduated cold shallow bath
Hot sitz
Lower half body pack
Small hot retention enema

140
Q

Liver imbalance hydro tx

A

Cold abdominal compress
Alternating compresses
Hot lemonade

141
Q

Congestion of liver hydro tx

A

Alternate long hot and short cold percussion of shower sprays to area

Alternate hot and cold compresses

142
Q

Phytoestrogen herbs

A

Glycyrrhiza (licorice)
Medicago saliva (alfalfa)
Trifolium pratense (red clover)
Humulus lupulus (hops)
Vitex agnus cactus (chaste berry)
Actea racemosa (black cohosh)
Lepidium (maca)
Trigonella foenum graecum (fenugreek)
Paeonia lactiflora (peony)
Rheum rhaponticum (false rhubarb)

Repro (7 decks)

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