Great Smokies Medical Center of Asheville

Archive for the ‘Hormone Replacement Therapy’ Category

Testosterone’s Role in Men’s Health and Vitality

Sunday, January 11th, 2009

No Laughing Matter
Testosterone poisoning, the rationale offered in jest by women to explain male behavior, is a medical rarity compared to its far less humorous counterpart – testosterone deficiency. An estimated five million American men are affected by hypogonadism, the medical term for low serum testosterone levels. Testosterone levels most often decline as a result of aging but can also be deficient from the effects of environmental toxins (especially those from plastics and pesticides), drugs, trauma, surgery, radiation, and abnormalities in hypothalamus or pituitary function.
A Man in the Making
Testosterone is an androgen, a hormone that gives men their male characteristics. Its effects include a deepened voice, increased body hair, maturation of genitals, increased sex drive, fertility, erectile function, ambition, and confidence. Testosterone supports the growth of muscles, bones, and sperm. Ninety-five percent of men’s testosterone is made from cholesterol in specialized cells called Leydig cells of the testicles in response to lutenizing hormone (LH), which is secreted by the pituitary. The remaining 5 percent is made by the adrenal glands.
Free at Last
About 60 percent of total circulating testosterone is not biologically available because it is permanently bound to a protein called sex hormone binding globulin (SHBG). Another 38 percent is more weakly bound to albumin. Testosterone bound to albumin can become free testosterone. The remaining two percent of testosterone is free and biologically active and is thus able to exert its powerful metabolic muscle.
A total serum testosterone level measures all forms of testosterone, bound and free. Because more testosterone is bound to SHBG as age increases, older patients, in particular, may be advised to have their free testosterone levels measured.
A Declining Portfolio
On average, men’s testosterone production peaks in the late teens and starts to decline about age 30 to 35. A 55-year-old man can have significantly less testosterone than during his youth, while an 80-year-old man can be running on fumes. The rate of free testosterone loss is roughly 1.5 percent each year. That?s 30 percent in 20 years. If your stock portfolio fell at that rate, no one would tell you that such a loss is expected with aging stocks. Yet patients with declining testosterone levels are expected to grin and bear their loss.
Signs and Symptoms of Age-Related Testosterone Deficiency
General physical weakness
– Decreased vitality
– Depression, uneasiness, anxiety, and irritability
– Decreased muscle mass
– Increased muscle pains
– Heart disease
– Low motivation for usual activities
– Increased body fat
– Osteoporosis
– Low sperm count
– Loss of sex drive
– Hot flashes

Increasing Life Expectancy
Deficient testosterone levels weren?t a health issue when men didn’t live long enough to experience many years without this life-enhancing hormone. The life expectancy of American men is currently 74.5 years, which means they can outlive their ability to produce adequate amounts of testosterone by 20 years.
Taking Pause
Women can usually find trained physicians to treat their age-related hormonal decline, menopause. However, men facing their age-related hormonal decline, andropause, often have difficulty finding a doctor to treat their dwindling vitality and health. Currently, there is about a 20-year gap in clinical experience between treating menopause and treating andropause.
Aim for the Right Target
Because testosterone production naturally declines with age, older men are often told by their doctors that their testosterone levels are “normal.” Having an age-adjusted ?normal? testosterone level at age 75 could, in fact, be the cause of seriously declining health, mood, and vigor. An appropriate and safe target when replacing testosterone for an aging man is the mid to upper limits of the normal range for a 40-year-old man.
Not Guilty by Association
Testosterone is classified as a steroid, along with other health-promoting substances, including cholesterol, cortisol, and Vitamin D. The misuse of synthetic anabolic steroids by athletes (and wanna-be athletes) in doses far higher than the body could possibly produce, have rightfully given synthetic steroids a bad name. Even though testosterone can be responsibly and safely prescribed, it has not escaped a “guilty by association” verdict by the public and even some medical professionals. Young athletes and body builders who take steroids to enhance performance far exceed steroid levels that the body is capable of producing are at high risk for developing serious, even fatal, side effects. In comparison, men whose deficient testosterone levels are restored to physiologically normal levels have far fewer risks.
Paths Often Traveled
Testosterone rapidly converts in the body by one of two major pathways. First, it can be converted to estrogen through the aromatization pathway. The enzyme aromatase, which is required for this conversion, is especially abundant in fat cells, a fact that puts obese men at higher risk for developing signs of feminization from excess estrogen. These signs include testicular atrophy, breast enlargement, loss of body hair, and loss of lean body mass. Monitoring estrogen levels of men taking testosterone replacement therapy (TRT) is thus recommended.
This spiraling loss of masculinity can be offset by weight loss, exercise, consumption of organic, non-genetically-modified soy powder, and avoidance of sugar and other refined carbohydrates. Fish oil, chrysin, and Diindolmethyl (DIM) can also decrease aromatization. DIM occurs naturally in cruciferous vegetables: broccoli, cauliflower, brussel sprouts, collards, kale, and cabbage.
The second pathway that testosterone can take in the body is its conversion to dihydrotestosterone (DHT), the most significant biologically active form of testosterone. This conversion requires the enzyme 5-alpha-reductase, which is especially abundant in the prostate gland. Nearly all testosterone that enters the prostate gland is converted to DHT, which, in turn, stimulates the growth of normal prostate cells. Some scientists and clinicians theorize that DHT can also stimulate the growth of abnormal or cancerous prostate cells.
If developing prostate cancer was simply a result of high levels of testosterone or DHT, a lot of 20-year-old men would be diagnosed with it, because the production of testosterone and DHT is at its highest in young men. The incidence of prostate cancer actually is highest at ages that are associated with the lowest levels of testosterone and DHT in older men. Obviously, other factors contribute to the development of prostate cancer. Because the incidence of prostate cancer is highest at the time of life when men’s estrogen levels are highest, imbalances or excess of estrogen are thought to contribute to the risk of developing prostate cancer.
An Evolving Understanding
Several studies have found a lack of causative relationship between androgen levels and prostate cancer. In a Finnish study involving 16,481 men aged 18 to 78 years, blood samples were drawn between 1966 and 1972. Twenty-five years later, 166 of the men had developed prostate cancer. When levels of testosterone, DHT, and SHBG in men who developed prostate cancer were compared with those in 300 men who did not, no association was found between high androgen levels and prostate cancer.
Every man needs a digital rectal exam of his prostate and a prostate-specific antigen (PSA) blood test prior to starting TRT and at regular intervals during treatment. Men should report any change in their breasts to their doctor.
The presence of male breast cancer, prostate cancer, an elevated prostate-specific antigen (PSA), or a suspicious digital rectal exam is a contraindication for TRT in the United States at this time.
Testosterone’s Benefits
The heart is a muscle, and like any other muscle, it improves in strength and efficiency (a particular benefit in congestive heart failure) when there are adequate levels of testosterone. Whether it is “homemade” or “store-bought,” testosterone has been shown to lower levels of total cholesterol and Lp(a), a fat linked to heart disease risk.
The benefits of TRT in treating impotence can be especially rewarding for a man who has previously been told by his doctor that his “low normal” levels of testosterone are unrelated to his inability to get or maintain an erection. In fact, the boost given to age-related, diminishing sexual performance is one of testosterone?s starring roles.
TRT can enhance vitality, confidence, and cognitive functioning, in addition to decreasing anxiety. Improved muscle strength and visual-spatial performance (necessary for balance that plays an important role in preventing falls) that are associated with adequate testosterone levels help maintain mobility and, therefore, functional independence.
In short, utilizing TRT in older men who have a proven deficiency in testosterone, can help add quality to their years both physically and psychologically.
Safe Prescribing of TRT
Prescribing some hormones (e.g., thyroid hormone or insulin) is a routine, accepted standard of care in medical practice. However, replacement of the hormone testosterone is (most unfortunately for men who suffer from its deficiency) often overlooked.
Considering a patient’s lifestyle, personal preferences, and compliance with therapy regimens, a single injection of long-acting, slow-release testosterone every two to three weeks may be the best option to boost lagging testosterone levels for some men. Others may be prescribed bio-identical testosterone drops, topical gels, or patches applied daily.
Replacing only what the body would normally make (physiological, not pharmaceutical dosing), monitoring TRT with laboratory tests, and tweaking other hormones (thyroid, adrenal, etc.) at the same time that testosterone is taken all contribute to TRT’s effectiveness.
Testosterone Poisoning
Excess testosterone has several known adverse effects. These include acne and fluid retention; increased production of red blood cells (which creates a greater likelihood of clot formation); aggression, infertility, and worsened sleep apnea.
Because a healthy liver breaks down testosterone and estrogen every day for eventual excretion from the body via the kidneys, abnormal liver function can contribute to excessive hormone levels.
In Summary
Because an excess and a deficiency of testosterone both have serious health risks, moderation and balance are the guiding principles for safe, effective TRT.
For several decades, alternative doctors have safely and responsibly prescribed TRT for men who have dwindling health associated with age-related testosterone deficiency.
TRT is best accomplished in a holistic context that includes a thorough medical history and physical exam, a healthy diet, nutritional supplementation, and exercise, in addition to regular laboratory monitoring and clinical follow-up.

Women’s Hormone Therapy: Benefits vs. Risks

Sunday, January 11th, 2009

Complexity in High Heels
Women are complex. They bear children and, generally speaking, are intuitive, emotional, and sensitive. They have good verbal skills and can multitask. Like Ginger Rogers, they do everything Fred Astaire does, except they do it backward and in high heels.
Women’s complexity is evident in their hormonal changes, most notably during menopause, when some women have a hormonal “crash landing.” Compared to men’s gradual entry into their change of life, women have a relatively sudden entry into menopause, with fluctuating levels of several hormones.

Symptoms of Menopause
The symptoms of menopause can be mild to severe and include hot flashes, vaginal dryness, dry eyes, dry skin, loss of skin elasticity (wrinkles), poor bladder control, difficulty thinking and sleeping, frequent urinary tract infections, decreased libido, and mood disturbances. These symptoms can significantly impact relationships, health, and quality of life.

HT Research
In 2002, the Women’s Health Initiative (WHI) study once again raised concerns about the long-term safety of post-menopausal synthetic hormone therapy (HT). The WHI studied more than 161,000 women between the ages of 50 and 79. Women were placed in one of three groups: Premarin-treated, Prempro-treated, or a control group with no treatment. The Prempro group showed increased risks of pulmonary embolism (113%), strokes (41%), heart disease (29%), breast cancer (26%), and deep venous blood clots (11%). Researchers felt that Prempro’s and Premarin’s risks outweighed their benefits and the trial was stopped early.

A Closer Look
Premarin is a combination of estrogenic hormones called Conjugated Equine Estrogens (CEE), which are derived from pregnant mares’ urine (PMU). Of the many estrogens found in Premarin, only two (estrone and estradiol) are bio-identical to human estrogens. The remaining estrogens are many times stronger and longer-acting than human estrogens and are thus thought to have more potential for side effects in humans. Premarin’s label warns that taking it for a year without also taking progesterone raises uterine cancer risk by 14 percent.
Prempro consists of Provera and Premarin. Provera, medroxyprogesterone acetate (MPA), is synthetic progesterone or progestin. Though “progestin” sounds similar to natural “progesterone,” progestins are riddled with serious side effects; natural progesterone has few, minimal side effects. Progesterone levels are naturally high during pregnancy, while progestin in “morning after” pills terminates pregnancy.

Wyeth Has a Hot Flash
When WHI trial results were released, 66 percent of women who’d been prescribed Premarin stopped taking it. Warnings quickly appeared on Premarin’s labels; sales fell and (Premarin manufacturer) Wyeth’s stock plummeted.

Man’s Laws/Nature’s Laws
Natural substances can’t be patented. To ensure profits, manufacturers must alter those substances before they can be patented. Even tiny changes to the structure of a natural substance can result in serious, unforeseen side effects.
Prescribing hormones derived from PMU has been likened to putting Ford parts in a Volvo: they don’t fit, they don?t work as intended, and their use could result in both known and unknown consequences.

A Risky Proposition
Estrogen’s health risks have been known as early as the 1930s. Months after the WHI trial was stopped prematurely in mid-2002 because of serious risks of synthetic hormone use, the National Institute of Environmental Health Sciences’ Toxicology Program added estrogens used in HT and birth control pills to its official list of cancer-causing substances.

Enter Bio-Identical Estrogens
Three natural estrogens occur in balance in healthy women. They are: estrone (E1), estradiol (E2), and estriol (E3). Each can be manufactured to be bio-identical.
Estrone is the dominant estrogen in Premarin and is the main storage form of estrogen in the body. During the reproductive years, estrone is derived from estradiol. Around the time of menopause, estrone is increasingly made from testosterone in fat cells (even more so in women who are overweight or drink alcohol). High levels of estrone have been linked to uterine and breast cancers.
Estradiol, a potent estrogen also linked to cancer, is the active ingredient in nearly all transdermal estrogen patches used to treat menopausal symptoms. Estradiol converts to estrone in the body.
Estriol, a weaker estrogen, comprises about 85 percent of circulating human estrogens. Estriol is theorized to occupy estrogen receptor sites, thereby blocking stronger estrogens from occupying them in uterine and breast tissue, lowering cancer risk. However, estrone levels can increase in some women who take estriol. European studies have shown estriol to be effective in treating vaginal dryness and stress incontinence in postmenopausal women.

Good Estrogen/Bad Estrogen
Pharmaceutical estrogens (when taken orally) and “homemade” estrogens are detoxified by the liver to estrogen metabolites for excretion from the body.
Estrogen metabolites include 2-hydroxyestrone, a “good” metabolite that opposes cancer, and 16-alpha hydroxyestrone, a “bad” metabolite that has been shown to be elevated in women who have breast cancer or who have a family history of breast cancer.
A more potent “bad” estrogen metabolite, 4-hydroxyestrone, is formed when estrone is oxidized and “burns” a hole in DNA, an event that can initiate cancer.
Bad estrogen metabolites promote inflammation and clotting and increase the risk of heart disease and cancer. Cancer risk from estrogen metabolites can be measured by laboratory testing of urine, the preferred method, or serum.
The cancer risk posed by estrogen’s “bad” metabolites may be decreased with a program designed by an alternative practitioner trained in management of women?s HT. This program may include taking ground flax seeds, resveratrol, fish oil, di-indole methane (DIM), calcium d-glucarate, and iodine, and eating cruciferous vegetables (kale, broccoli, cabbage, collards, brussel sprouts, etc.).
Estrogens used transdermally (patch, gel, or cream) bypass the liver and do not break down into risky estrogen metabolites. Also, applying estrogen transdermally results in more stable hormone blood levels than taking estrogen by mouth.

Enter Menopause
Women who have a sudden entry into menopause (usually from surgical removal of their ovaries with a total hysterectomy) may develop symptoms of estrogen deficiency. Suddenly stopping estrogen prescriptions can also cause the same symptoms.
However, in women who have a natural, more gradual entry into menopause, the adrenal glands increase their production of pregnenolone and DHEA, which support the production of estrogens, progesterone, and testosterone that, in effect, can help moderate the symptoms of estrogen deficiency.
Because fat cells produce estrogen, overweight women may have fewer symptoms of estrogen decline.

Vital Woman
Testosterone may be used in small doses in a comprehensive HT program to strengthen women’s overall vitality and, when applied transmucosally, to enhance sexual response.

Estrogen Dominance
The modern environment is increasingly estrogen-laden. Health experts are concerned about estrogen-mimicking substances that include pesticides, plasticizers (phthalates and bisphenol A), synthetic estrogens both in meat and those that are excreted into the water supply by people who take HT. Excess estrogen contributes to early puberty, blood clots, diabetes, endometriosis, cancer, obesity, liver stress, and fibroids.
Natural micronized progesterone can help offset estrogen?s cancer, vascular, and clotting risks and also has beneficial effects on cholesterol levels. Most over-the-counter plant- or yam-based creams do not have this benefit, while synthetic progestin increases these risks.

Menopause Treatment Options
Non-hormonal treatment of menopausal symptoms includes balancing neurotransmitters and making lifestyle changes, e.g., reducing intake of harmful dietary fat and alcohol, eating more cruciferous vegetables, eating fermented soy (miso and tempeh) and ground flax seeds, addressing thyroid and adrenal imbalances, getting regular exercise, and reducing stress. Because the liver detoxifies and excretes excess estrogens from the body, supporting liver health can help lower estrogen toxicity. Dietary fiber can assist in removing toxic estrogen stores from the body. Maintaining normal body weight can help lower risks of estrogen toxicity.
Helpful herbs include soy isoflavones, chasteberry, dong quai, black cohosh, red clover, and Siberian ginseng.

Hot Flashes/Cold Turkey
When family or personal risk for heart disease, clot formation, or cancer makes it advisable for a woman to stop HT, or if stopping prescribed HT “cold turkey” results in symptoms, tapering hormone doses slowly over a period of months mimics the healthy, gradual decline of hormones during menopause. An herbalist can often help ease withdrawal from estrogen therapy (ET). Medical monitoring is advised during this process.

Health risks from estrogen stem from a woman’s cumulative estrogen exposure during her lifetime – early onset of menstrual periods, late onset of menopause, use of birth control pills and other hormone therapies, and exposure to chemicals that mimic estrogen.
The lowest effective dose of ET should be used for the shortest amount of time possible. Herbs, diet, environmental controls, nutritional support, and exercise can be used to support healthy estrogen metabolism.
HT is not one-size-fits-all, a fact making individualized medical management of women’s HT essential. Each woman with peri-menopausal health concerns should be individually assessed for vascular disease, clot, and cancer risks prior to receiving HT. Women taking HT should inform their doctors if they develop breast swelling, pain, or discharge, uterine bleeding or pain, or nausea. Women taking HT need annual pap smears and breast cancer screening, in addition to ongoing lab testing of hormone levels to guide the practitioner’s dosing to optimize HT’s safety.

List of Bio-Identical Hormones
Estrone, estradiol, estriol, testosterone, micronized progesterone, Alora, Biest, Climera, Estrace, Estraderm, EstroGel, FemPatch, Menostar, Prometrium, Estring, Triest, Vivelle, and Vivelle Dot.

Relief in Sight
Estrogen deficiency and imbalances that occur at menopause can seriously undermine women’s health and quality of life and should not be left untreated. Many women with moderate to severe peri-menopausal symptoms can be assured that options to synthetic HT exist. Properly prescribed, monitored bio-identical HT offers safe and effective relief for the symptoms of menopause, and at the same time, enhances bone, heart, and cognitive health, and helps lessen hormone-related aging symptoms.
Balancing the need for relief from the symptoms of estrogen deficiency against the risks and side effects of synthetic HT can be accomplished by consulting an alternative practitioner trained in the use bio-identical HT

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