Two Docs Talk - Cady & Gabhart "On the road again" - Owensboro, KY

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Join Drs. Cady & Gabhart for a scintillating lecture boucing through the peer-reviewed medical literature and their own clinical experiences and adventures with patients, as they clarify the …

Join Drs. Cady & Gabhart for a scintillating lecture boucing through the peer-reviewed medical literature and their own clinical experiences and adventures with patients, as they clarify the appropriate and rational use of hormones in men and women.

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  • Giuseppe Mazzini (22 June 1805 – 10 March 1872), nicknamed "Soul of Italy,"[1] was an Italian politician, journalist and activist for the unification of Italy. His efforts helped bring about the independent and unified Italy[2] in place of the several separate states, many dominated by foreign powers, that existed until the 19th century. He also helped define the modern European movement for popular democracy in a republican state. [ citation needed ] – Source - Wikipedia
  • Addison ’s disease, like so many medical conditions, has a history of being ignored, hidden, and misunderstood.  It is a rare disease that affects about one in every 100,000 Americans and is usually diagnosed around age forty. 
  • Asian J Androl. 2011 Aug 29. doi: 10.1038/aja.2011.116. [Epub ahead of print] Low DHEAS levels are associated with depressive symptoms in elderly Chinese men: results from a large study. Wong SY, Leung JC, Kwok T, Ohlsson C, Vandenput L, Leung PC, Woo J. Source School of Public Health and Primary Care, School of Public Health, The Chinese University of Hong Kong, Hong Kong, China. Abstract This study investigated the association between depressive symptoms in elderly Chinese men and the total testosterone, dehydroepiandrosterone (DHEA), DHEA sulphate (DHEAS), oestradiol and sex hormone-binding globulin (SHBG) levels, and the free androgen index. Cross-sectional data from 1147 community-dwelling elderly men, aged 65 and older, were used. Depressive symptoms were measured using the Chinese Geriatric Depression Scale (GDS). Total testosterone, free testosterone, DHEA, DHEAS, total oestradiol, the free androgen index and SHBG levels were assessed. DHEA was significantly associated with GDS score, and there was a trend towards DHEAS association, but this was not significant (β=-0.110, P=0.015; β=-0.074, P=0.055). However, no association was seen between depressive symptoms and total testosterone levels, free testosterone levels, oestradiol levels or SHBG levels. In terms of the presence of clinically relevant depressive symptoms, there were no statistically significant differences between patients in the lowest quartile of sex steroid hormone levels and those in other quartiles of sex steroid hormone levels. Similarly to Western studies, our study shows that DHEA and DHEAS levels are associated with depressive symptoms.Asian Journal of Andrology advance online publication, 29 August 2011; doi:10.1038/aja.2011.116.
  • One goal is to rectangularize the health span curve. I.e. to improve vitality from middle age onward.
  • These symptoms correlate to decrease in bioavailable testosterone
  • RIA (in-house after diethylether extraction) Total testosterone - T (RIA) 208-1141ng/dL, average 536+/-153ng/dL Bioavailable testosterone - BT (calculated) 78-470ng/dL, average 236+/-63ng/dL
  • Hypogonadal if TT < 200ng/dL or FT < 0.9ng/dL

Transcript

  • 1.  
  • 2. Two Docs Talk: Thyroid, Adrenals & Sex Hormones - A Balancing Act Louis B. Cady, MD – CEO & Founder – Cady Wellness Institute Adjunct Professor – University of Southern Indiana Adjunct Professor – Indiana University School of Medicine The Owensboro Museum of Science and History Owensboro, KY September 22, 2011 Whitney W. Gabhart, ND Cady Wellness Institute
  • 3. Framework for this presentation: “ Slumber not in the tents of your fathers. The world is advancing. Advance with it.” - Giuseppe Mazzine
  • 4. Orientation to this talk
    • Sketch in the fundamental differences between “ wnl ” and OPTIMAL
    • Quick review of hormones having to do with FATIGUE and DEPRESSION:
      • Thyroid
      • DHEA
      • Testosterone/estradiol/progesterone
      • IGF-1 (“food soldier” of growth hormone)
    • Exposure to the literature/ stimulation
  • 5. American Journal of Health Promotion; November/December, 2002 19% of those surveyed were completely healthy with high levels of both physical and mental health and a low level of illness . 18.8% completely unhealthy, defined as having low levels of health with high levels of illness. Two-thirds of the adults reported some degree of mental or physical illness that kept them from being completely healthy. “ Incompletely healthy.” HEALTH continuum DEAD OPTIMAL 66% “ Incompletely healthy”
  • 6.
    • VISION: “We dramatically transform the lives of our patients and clients to levels of peak physical and mental health, supporting a lifetime of maximum performance and happiness.”
  • 7. BODY MIND ACTIONS
  • 8. Critical area of concern for men & women. Things that will make them:
    • Tired &/or depressed
    • Unable to cope
    • “ Mean”
    • Stressed
    • Demented
    • Deficient in libido or in the bedroom
  • 9. How would you take care of a classic?
  • 10. “ Age management” “Conventional practice” There are fuel additives we can use to keep our cars burning cleaner and preserve engines. No fuel additives should be used. They are unnatural. Gas is all that is required. We should use optimal quality of gas. Cheap gas causes “pinging” which is hard on the engine. The quality of the gas is irrelevant. Anything that the motor will burn is adequate. We should take our car in for preventive maintenance before anything breaks. Preventive maintenance? This is silly! Wait until something breaks, then have the car towed in so the mechanic can really tell what is wrong.
  • 11.  
  • 12. Toward an INTEGRATED approach: Death Optimal Health Traditional Medicine Functional & Informed Lab Testing No Disease = Health Vitamins , HRT, Nutrition, Exercise INTEGRATED Medicine Diagnose and Treat Disease New Drugs New Surgical Techniques Forestall and PREVENT Disease – Optimize Mood & Function
  • 13. Interesting lab values – Cady – 3/11/03: Lab Value Cenegenics Normal a.m.glucose 87 mg/dl 65 – 85 65 – 109 Fasting insulin 3 u U/ml <5 <20 HgB A1C 4.9 % <5.1% < 6.0 % Cholesterol 241 mg/dl <200 <200 Triglycerides 42 mg/dl <120 <150 Cor. Risk ratio 3.3 <4.0 Av = 5 – 6 Homocysteine 7.9 <8.0 5.4-11.4 DHEA-S 148 350 – 500 59 – 452
  • 14.  
  • 15.  
  • 16. Modern Medicine ’s Paradigm: Two Standard Deviations – “if you are not sick, then you must be well.” “ NORMAL” OPTIMAL
  • 17. 4
  • 18. Releasing Factors Adrenal Gland Ovaries Testicles Thyroid Liver Testosterone Estrogen Cortisol DHEA Progesterone T3 & T4 GH LH & FSH TSH Prolactin ACTH IGF-1 Pituitary Brain Hypothalamus DHEA
  • 19. “ But the doctor told me my thyroid was fine.”
    • Can be “ wnl ” but suboptimal.
    • TSH frequently only thing checked.
    • Nothing known about Free T4 or Free T3.
    • Free T4 can be converted to Reverse T3 under stress (cortisol)
    • Free T4 can be underconverted to T3.
    • Can have normal levels (or slightly elevated levels) of everything and have auto-immune thyroid disease.
  • 20. “ the foot soldier” “ the evil twin ”
  • 21. “ Thyrotropin (Thyroid-Stimulating Hormone or TSH). Measuring TSH is the most sensitive indicator of hypothyroidism. ” (hunh?!) http://www.umm.edu/patiented/articles/how_serious_hypothyroidism_000038_6.htm Accessed: 9/5/2011
  • 22. “ the foot soldier” “ the evil twin ” CORTISOL Se Rev T3
  • 23. Yes, T-3 DOES get into the brain (Transthyretin = carrier protein )
    • Terasaki, T. and Pardridge, W.M.: Stereospecificity of triiodothyronine transport into brain, liver, and salivary gland: role of carrier- and plasma protein-mediated transport. Endocrinology , 121(3):1185-1191, 1987.
    • http://www.kingpharm.com/uploads/pdf_inserts/Cytomel_PI.pdf .
    • Mooradian, A.D.: Blood-brain transport of triiodothyronine is reduced in aged rats. Mech. Ageing Dev ., 52(2-3):141-147, 1990.
    • Cheng, L.Y., Outterbridge, L.V., Covatta, N.D., et al.: Film autoradiography identifies unique features of [125I]3,3'5'-(reverse) triiodothyronine transport from blood to brain. J. Neurophysiol ., 72(1):380-391, 1994.
    • Rudas, P. and Bartha, T.: Thyroxine and triiodothyronine uptake by the brain of chickens. Acta Vet. Hung , 41(3-4):395-408, 1993.
    Or: The idiocy of T4 only thyroid treatment…
  • 24. Per HRSD – 17, remission in: 15.9% on Li 24.7% on T3 Per QIDS-SR16, remission in: 13.2% on Li 24.7% for T3 * * Fava & Covino: Augmentation/Combination Therapy in STAR*D Trial, Medscape Psychiatry LEVEL III RESULTS:
  • 25.  
  • 26.  
  • 27. “ No duh” obvious thyroid teaching points:
    • You must get ALL of your thyroid checked - (not just “TSH.”)
    • Stress and/or selenium deficiency can PROFOUNDLY alter it.
    • Do you want “normal” or “optimal”?
  • 28. Fatigue from Adrenal FAILURE- The Worst Case Scenario: Addison ’s Disease
  • 29. Signs & Symptoms of Adrenal FATIGUE
    • Difficulty getting up in a.m.
    • Ongoing lethargy during the day.
    • Continued fatigue not relieved by sleep.
    • Craving for salt or salty foods.
    • Increased effort to do daily tasks
    • LESS PRODUCTIVE
    • Decreased sex drive
    • Decreased ability to handle stress.
    • Light-headed when standing up quickly
    • Increased recovery time for illness
    • Generally less happy about life.
  • 30. “ Hypoadrenia” : The Adrenal Problem that most conventionally trained physicians don’t know about.
    • Non-Addison ’s hypoadrenia
    • Subclinical hypoadrenia
    • Neurasthenia
    • Adrenal neurasthenia
    • Adrenal apathy
    • Adrenal fatigue
    • “ Adrenal burnout”
    • “ Chronic fatigue syndrome”?!!
    Modern medicine does not recognize it.
  • 31. “ Where did this new-fangled diagnosis come from, anyway?”
  • 32.  
  • 33. Case report:
    • 55 year old male entrepreneur
    • Runs company with 200 employees – multi hundred million dollar budget
    • Stressed with economy
    • Very tired in the a.m.
    • “ Crashes” at night.
    • Still golfing, exercising.
    • Looks marvelous.
  • 34. The state of adrenal exhaustion can be determined Early-stage Chronic Stress Response Mid-stage Chronic Stress Response End-stage (exhausted) Chronic Stress Response
  • 35. DHEA – the critical hormone most doctors never check
    • Produced in the adrenal cortex
      • Humans and primates are unique in secreting large amounts
    • Immune system booster
    • Insulin regulator
    • Energy increase – remarkable
    • Boosts growth hormone
      • 20% in men; 30% in women in one study
        • [Yen, Morales Khorram – one year double-blind placebo controlled crossover experiment – with 100mg DHEA]
  • 36. 334 citations on “DHEA with energy” – as of 07 29 2011
  • 37.  
  • 38. Why isn ’t adrenal fatigue diagnosed?
    • Not severe enough to be an emergency
    • Symptoms can be attributed to other things, including “just neurotic” or “avoidant”
    • “ Functional medicine” testing not typically done (& rarely is DHEA-S checked)
    • Modern medicine focuses on the treatment of sickness, not “less than optimal” function.
    • “ Bell Curve” paradigm
  • 39. Modern Medicine ’s Paradigm: 2 Standard Deviations – a model “ NORMAL” OPTIMAL
  • 40. 432 citations on DHEA with depression as of 9/5/2011 “ Neuroeconomic paramaters predicted to be related to suicidal behavior. ” DHEA is related to these, acting in amygdala. Low levels of DHEA/DHEA-S assoc. with depression, as per Western studies. “DHEA was significantly assoc. w/ [Chinese] Geriatric Depression Scale (GDS).”
  • 41. “ Women’s issues”
  • 42. “ Real doctoring”: The Chance to Change Patient’s BRAINS
  • 43. One destigmatizing notion: Estrogen as MAOI
    • Estrogen & Testosterone (!) decrease MAO
      • Luin, VN. Brain Res. 1975;86:273-306
    • Platelet MAO levels inversely correlated to estradiol levels
      • Klaiber EL et al. Psychoneuroendo- crinology. 1997 Oct;22(7):549-58.
    • Estrogen decreases MAO-A & MAO-B
      • Holschneider DP et al. Life Sci. 1998;63(3):155-60
  • 44. Estrogen-related mood disorders – reproductive life cycle factors. Douma SL et al. Adv. Nursing Sci. 2005. 28 (4):364-375
    • “ Clinical recovery from depression postpartum, perimenopause , and postmenopause through restoration of stable/optimal levels of estrogen has been noted.”
  • 45. Symptoms of estrogen imbalances*:
    • Hot flushes or flashes; night sweats
    • Mood swings
    • DEPRESSION, and/or anxiety, panic attacks
    • “ Concentration” issues: Memory, communication, and attention span loss, “brain fog.” (Think: “MORE MAO.”)
    • Insomnia
    • Weight gain – “appetite changes”
    • SOMATIC symptoms : aches and pain
    • General deterioration: Incontinence, digestive disturbances, sensory function loss, aging skin . . . thinning, wrinkles, sagging
    * Adapted from Whitney Gabhart, N.D.
  • 46. Psychoactive Progesterone*
    • Increases energy and libido
    • Has a calming effect , acting like a benzodiazepine to the brain (HS dosing)
    • Enhances mood
    • Balances blood sugar (appetite)
    • Regulates fluid balance, sodium mineral balance
    • Necessary for fertility
    • Helps relieve menopausal symptoms
    • Decreases risk of endometrial cancer and may help protect against breast cancer, fibrocystic breasts, and osteoporosis
    * Adapted from Whitney Gabhart, N.D.
  • 47. Testosterone: The “sexist” bias against women
    • Fall in the circulating testosterone and the adrenal preandrogens most closely parallel increasing age.
    • Accelerated decrease occurs in the years preceding menopause (like estrogen).
    • Their loss affects: libido , vasomotor symptoms (hot flashes) , mood , well-being , bone structure, and muscle mass.
      • Burd, Bachmann. Androgen replacement in menopause. Curr Womens Health Rep. 2001 Dec; 1(3):202-5.
  • 48. Traditional vs. Bio-identical “HRT”:
    • Synthetic means that the molecule is not natural to the human body.
    • Bio-identical hormone is one whose molecule is identical to that made by a human organ. 
    SV2003-
  • 49. Women ’s Health Initiative Study
    • Flawed study - it was designed as a “Premarin & Provera” study, not a bioidentical estrogen study.
    • Premarin is a non-bio-identical substance
    • Provera is a non-bio-identical substance
    • Premarin is an equine derived array of 30+ female horse hormones .
    SV2003-
  • 50. Women ’s Health Initiative Study
    • The results presented did not justify their overall broad conclusion:
    • “ Premarin & Provera yielded these findings; therefore, Hormone Replacement Therapy is not appropriate for women.”
    SV2003-
  • 51. Women ’s Health Initiative Study
    • THE PARTICIPANTS:
    • 2/3 of the women in the study were older than sixty
    • Of these women, most were first-time users of HRT.
    • Had already experienced cessation of endogenous hormone production (for a DECADE!!!) , therefore, at risk for:
      • Heart attacks, strokes, clots, cancer
    SV2003-
  • 52. Women ’s Health Initiative Study Facts You Should Know
    • In the first 1-3 years there was a higher incidence of M.I. ’s.
    • Patients who stayed on that program beyond the 8 th year started to actually outperform women on placebo.
    • WHY????
    SV2003-
  • 53. Women ’s Health Initiative Study Facts You Should Know
    • When the W.H.I. Study was organized, the subjects were not prescreened for heart disease.
    • Without prescreening, a group of women was included with pre-existing heart disease.
    SV2003-
  • 54. Hx of Baseline Health Characteristics (total # of participants 16,608) 37% 11% 2%
  • 55. Traditional vs. Bio-identical “HRT”:
    • Premarin raises C-reactive protein significantly.
    • CRP is an inflammation marker.
    • Inflammation is either the root cause (e.g., rupturing plaque ), or a strongly contributing cause, of both Cancer & Heart Disease .
    SV2003-
  • 56. Some of the “10 reasons” to be happy [Studd J. Menopause Int. 2010 Mar;16(1):44-6
    • Trans-derm safer than oral
      • Coag factors not induced in liver
    • Safe for tx of flushes, sweats, vaginal dryness
    • Estrogens prevent osteoporotic fracutres – should be FIRST CHOICE rather bisphosphonates
    • HRT protects intervertebral discs
    • Est + T helps “reproductive depression”
    • Improves energy & libido
    • Reduces incidence of heart attakcs.
    • Beneficial effects on collagen
    • Note 1 % increased lifetime risk of breast cancer
  • 57. 50’ish year old female, post-menopausal, on no hormones
    • On aggressive supplement regimen with daily MVI and others
    • Not ill
    • Top rated medical care with previous labs done
    • Nothing identified as seriously abnormal
    • “ Just interested in having my hormones checked.”
  • 58.  
  • 59.  
  • 60.  
  • 61.  
  • 62. Treatment for this “normal” patient
    • Armour thyroid – ¼ grain for 1 week, then ½ grain. (Aiming for T3 in “high 3’s.”
    • DHEA – 25 mg SR micronized, compounded – in a.m.
    • Progesterone – 50 mg SR compounded – at night.
    • Testosterone – 3mg topical per day x 1 wk, then 6 mg. “Decrease dosing as needed for side effects.”
    • Vitamin D – 5,000 IU twice daily x 3 weeks, then decrease to one dose per day.
    • Fish oil – 4.6 grams (c. 1660 mg EPA and 1,250 mg DHA by compound weight, plus misc. Omega 3)
  • 63.  
  • 64. What’s life like now?
    • “ it’s like the colors of the rainbow have gotten more into the pink.”
    • “ My computer will survive – I use to ‘lose it’ over my computer. I would swear obscenities.”
    • “ I’ve gotten into a zen like mode. Handling everything that life can throw at me.”
    • “ It’s almost as if I’ve taken a pill or drug that jus makes me handle everything that life is throwing at me. I can roll with it.”
    • “ I’m not irritable any more. Time pressure has just one away.”
  • 65.  
  • 66.  
  • 67. November 2009 “Alpha Male” issue
    • Observational study of randomly selected men – Boston
    • 3 cohorts of men: 1987-1989; 1995-1997; 2002 -2004.
    • 1374, 906, and 489 men, respectively.
    • “ Age independent decline in T that does not appear to be attributable to observed changes in explanatory factors, including lifestyle characteristics such as smoking and obesity.”
    • “ Recent years have seen a SUBSTANTIAL , and as yet UNRECOGNIZED age-independent population-level decrease in T in American men.” Travison, Araujo, et al. Jrnl of Clin. Endocrinol & Metabol 92:1; 196-202.
  • 68. Fast food (low Zn) is bad for you.
    • Fast food = high energy density = low essential micronutrient density, ESPECIALLY ZINC
    • Antioxidant processes are dependent on Zinc
    • Fast food = severe decrease in antioxidant vitamins and zinc, correlating with inflammation in testicular tissue – with underdevelopment of testicular tissue and decreased testosterone levels
  • 69. Special needs - Zinc
    • Low Zinc- associated with low testosterone
      • Per USDA, 60% of US men between 20 – 49 years of age do not get enough .
      • N.B.: Do not supplement with > 50 mg daily (can interfere with Cu+ metabolism)
        • Tsai, E.C., Boyko, E.J., Leonetti, D.L., & Fujimoto, W.Y. (2000). Low serum testosterone level as a predictor of increased visceral fat in Japanese-American men. International Journal of Obesity and Related Metabolic Disorders, 24, 485-491
  • 70. Testosterone functions (Men AND Women)
    • Enhances sex drive
    • Builds muscle & decreases fat
    • Elevates mood
    • Prevents osteoporosis
    • Improves memory
    • Lowers cholesterol
    • Protects against heart disease
  • 71. “ Hence, among older men reporting excellent asymptomatic health , age has no effect on serum T or E2 with a minor increase in DHT while obesity decreases serum androgens…”
  • 72.
    • Decline in male sex steroids not as abrupt as menopause, but equally debilitating
      • Between 40 – 70, average male loses:
        • Nearly 2&quot; of height
        • 15% of bone density
        • 10 – 20 pounds of muscle
    • At 70 yoa, 15% completely impotent
    Testosterone (Men)
  • 73. Andropause: Characteristics of Change
    • Insidious & unpredictable onset
    • Slow progression
    • Subtle & variable manifestations
    • Cannot be linked directly to a decrease in the hormone testosterone
    • Very different from menopause in women!
    Charlton R. JMHG . 1(2004): 55-9 Kaufman JM. Endocrine Reviews . 26(2005):833-76
  • 74. T vs Cognitive Function Rosario ER. JAMA . 292(2004):1431-2
  • 75. T vs Cognitive Function Rosario ER. JAMA . 292(2004):1431-2 “ Testosterone depletion likely precedes and thus may contribute t o rather than result from the development of AD, since low brain testosterone is observed in men with early indications of AD neuropathology”
  • 76. T vs Cognitive Function
    • 400 independently living men, 40-80yo
      • 100 in each age decade
      • MMSE 21-30, average 28
      • TT: 208-1141ng/dL; Bio-avail T 78-470ng/dL
    • HIGHER T = better cognitive performance in OLDEST AGE category
    • Men with lowest 1/5 T = worse than men with highest 1/5 T
    • Highest Bio-available T more significant than TT, age, intelligence level, mood, smoking, and alcohol.
    Muller M. Neurology . 64(2005):866-71
  • 77. T vs Mood in men
    • Study: 278 men, > 45yo, followed 2 years
    • Compared to eugonadal patients, hypogonadal men w/TT < 200ng/dL had
      • 4-fold increase risk of depression
      • Significantly shorter time to depression diagnosis
    • Depression risk inversely related to TT w/statistical significance < 280ng/dL
    Shores MM, Arch Gen Psychiatry . 61(2004):162-7
  • 78. Treatment options – not just “the needle”
  • 79. Testosterone and “Prostate Cancer risk”
    • Prostate CA found 2.15 & 2.26 times more likely in lowest compared to highest tertile of total and free testosterone
    • “ . . . there are several papers showing a relationship between LOW testosterone and prostate cancer . Specifically, low testosterone has been associated with high-grade tumors , advanced stage of presentation , and worse prognosis .”
    Morgentaler A. Eur Urol . 50(2006):935-9 Morgentaler A. Urology . 68(2006):1263-7
  • 80.  
  • 81. HOW OBVIOUS DOES IT HAVE TO BE? The Challenge of Empathic Listening & CREATIVE THINKING Ron Hunt lost an eye but suffered no brain damage after a freak accident with a large drill bit. (ABCNEWS.com)
  • 82. Do you really want to try 100,000 miles without changing the oil?
  • 83. Definition of ‘normal’ – “where your hormone levels are as lousy as everyone else’s.” Neal Rouzier, MD “ NORMAL” OPTIMAL
  • 84. www.slideshare.net/lcadymd 3 2 1
  • 85. “ For me, the practice of medicine has opened the door to the greatest adventure in life. Medicine is like a hallway lined with doors, each door opening into a different room, and each room opening into another hallway, again lined with doors. Medicine is always wonderful and never will be finished. ” - Charles H. Mayo, M.D.