Tired All The Time- What Could Be Wrong? (Part 1)

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I would say that of all the complaints I hear at my clinic, this is by far the commonest. The scary thing is that it seems to transcend age and sex. This means that ‘tired all the time’ (tatt in dr’s world) can attack anyone at any age. So how can you avoid it?


Before we can answer that question, we need to understand what is normal and why tatt happens.


Do you remember looking at kids and their boundless energy levels? When they eat sugar, they get hyperactive and start running around. A totally normal response to excessive sugar in the blood that the body needs to get rid of as sugar is inflammatory and the body knows it. So parents, please let your kids run around- its a good thing. What about in adults? What happens when we consume too much alcohol or sugary drinks (liquid carbs)? How about snacks; including ‘healthy’ snacks? We hardly ever need to run around to burn it after. This is not the ideal response to that sugar excess. So what happens here?


Your body releases insulin. Insulin’s job is to make sure that the excess sugar is picked up and either used or stored. A lot of this happens in the liver. So the liver is now under stress to deal with all this. Cortisol the stress hormone is released. Cortisol and insulin work hand in hand (not quite so simple but good enough for the layperson). You’ll find that if you consume too much rubbish or are overly stressed, you put on weight in the middle- a classic tell tale sign of the start of insulin or cortisol issues. Unfortunately with age, this worsens as the body’s ability to adapt decreases. Now, a lot of nutrients are used up in this process. When we talk about nutrients, we talk about vitamins, minerals, amino acids, antioxidants etc. So someone with a poor diet or highly stressed life actually need more nutrient support as they probably do not get enough from their diet to make up for how quickly things get used up. These hormones also communicate with other hormones- thyroid being an important one. Thyroid controls your metabolism. Or how effectively your body consumes fuel (or sugar/fat). With age, this function goes down as well. Or perhaps you’ve accumulated ‘problems’ over the years that affect your body’s functionality.


What kind of problems are those? A whole host of potential issues. Let’s list some down:

  • Environmental issues such as toxic mold (in a old, damp house), or fumes from a brand new carpet or paintwork

  • Living and working in the city - exposure to exhaust fumes containing lead, arsenic and other heavy metals

  • Accumulation of toxins from food - e.g. mercury from seafood, sprayed chemicals (pesticides) in fruits and veg, chemical fertilisers

  • Accumulation of toxins or change in ionic charge in your body when you have e.g. metal fillings or 2 or more different types of metals in your body. This is really interesting. If you develop tatt after an orthopedic procedure or after getting dental work; including a simple brace- think about this. Its not well known enough so do your due diligence

  • Day to day stresses like SAD (seasonal affective disorder), lowered immunity due to antibiotic overuse or excessive exposure to bugs; overwork

  • Age related hormonal decline

  • Too much screen time

  • Excessive exposure to EMR (electromagnetic radiation)

  • Start or autoimmunity where the body starts attacking itself


This is merely a snapshot. The list goes on. On its own, there probably isn’t enough to knock the average person down but when a few factors are present, the cumulative effect can have a large effect.


This is mostly the reason why the average person will try various things to improve their tatt status and find that they may improve things for awhile but that they cannot shift it. It is also why in long standing cases, most people need help to get over it. It simply is not as easy as it seems to get to the bottom of.


So what can we do? We will investigate this in the second part of this blog series, so stay tuned….


Secret Behind Off Label or Unlicensed Medications

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As a private practice, we are frequently approached by patients who require certain medications “off label” or “unlicensed”. This can sound quite scary for the average person who is deciding to undergo this route or for carers of the patient who may be nervous about what this may entail.

Here's a little background on these off label medications....

Every drug is developed and tested for treating certain conditions. Clinical trials are conducted and the drug is deemed “safe” to use for its intended purpose. Occasionally, the initial purpose a drug is being developed becomes null and void when one of their “side effects” then becomes the more interesting feature of the drug. A good example is Viagra. Viagra was originally developed to treat high blood pressure and angina (chest pain). Its side effect- causing erections- became an unexpected and highly lucrative venture for the manufacturers. Another good example is Botox- initially developed to treat facial tics and spasms. When they had a side effect of decreasing wrinkles, this became its main and highly lucrative use.

Pharmaceutical companies are then allowed to patent the drug for a certain number of years. This is to allow them to claw back their investment in research and development that has gone into making those drugs. It is also to enable them to make a profit- they are a business after all. This system works well. If you consider the number of drugs that don’t make the cut for human use- which translates into millions of dollars of lost revenue for the drug manufacturer, its only fair that the risk they take gets rewarded when one of their experimental drugs do work.

So let’s say that viagra was indeed licensed for high blood pressure. Now according to the medical guidelines, we as doctors, should only prescribe them for that purpose. But we are highly trained and frequently have to use our judgement in every individual case to decide the best course of action for that particular person. Guidelines exist for a reason but at the end of the day, the reason our job is not done by a computer is because of the human quality, experience and instinct that we are able to hone over the years- that beats the computer. This means that I can now decide that for my patient with an erection issue, I can give him viagra in a suitable dose to help with his erection, but not any blood pressure issues (which he may not have). That would be a classic off label use of a drug.

Some examples of off label use medications are low dose naltrexone, clemastine, various hormones, aspirin, cholestyramine and metformin amongst others.

Now lets say that a drug that has been long approved and deemed safe for a purpose has now been found to have another use. A good example is LDN (low dose naltrexone). Initially developed for addictions, it is now used in a very low dose for immuno-modulation amongst other things. This benefit has been stumbled upon. Our challenges as practitioners are listed below:

  • Someone needs to inform other practitioners about this

  • Other practitioners may well be quite sceptical as there are no large trials to “prove” this fact

  • Big pharma are not very interested in conducting large trials. These things cost money and since the initial drug has already lost its patent, there’s no money to be made.

  • So its up to individual practitioners, happy patients and word of mouth to get the word out

  • There are risks and we know it. And there’s a lot we don’t know regarding potential side effects, other uses, risks and benefits. But we’re willing to take the chance and happy to monitor closely

  • In an ideal world, we will all do research and audits on all our patients. Sample sizes will be small but something is better than nothing. However, this does mean tons of paperwork and potentially increase in staff size which unfortunately translates into increased costs for the practitioner. One reason why there are so few trials for off label medications. Its simply a few good doctors and too much work.

  • We as practitioners, also take the risk of being thought to be unsafe by fellow doctors who may not understand our reasons for going off label. This is a big issue and concerns us gravely as it can lead to suspension of our practising privileges.

I hope that this article puts things into perspective a little so that it can be more clearly understood where we- as practitioners- stand when we take the decision to use an unlicensed medication and so that you- as a patient or carer of a patient- will be able to make an informed decision as to how to decide if its the right option for you. It will probably mean more paperwork as we try to safeguard ourselves, we may ask you to participate in trials and we may even ask you to volunteer your time to help us analyse data and eventually make things more available in the future.

Do let us know if you would like to contribute anything at all ie ideas, time, money to help towards pushing these ideas forward. We have recently registered our charity Fighting Chance Foundation. But I envisage that its going to take quite a long time to get anything going mainly due to lack of time and staff at present. We would however, love to hear from you and know that we have some support.

10 Little Known Vitamin D Facts

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To commemorate this day, I thought I’d share some interesting Vitamin D facts that are not so commonly known…

 

  1. Vitamin D is not technically a vitamin. Vitamins have to be consumed as they cannot be created in the body. It is better classified as a hormone. Or more accurately, a pre-hormone which has to be converted to its active, hormonal component

  2. It regulates the activity of over 200 different genes

  3. You don’t get much Vitamin D from dairy. The main reason is because animals, just like people, need sunlight to make Vitamin D. So if you eat mainly intensely farmed animals and their milk products, it won’t be high in Vitamin D. Look out for free range, grass fed animals. One good example is Kerrygold butter which claims to be from grass fed animals

  4. Lower fat foods fortified with vitamin D won’t be as good as full fat products. Its a fat soluble vitamin and as such, being delivered in a fattier format aids absorption

  5. Obesity is associated with lower Vitamin D levels. The hypothesis here is that the Vitamin hides out in the fat cells. Would be interesting to see more research here

  6. Most Vitamin D rich foods are from an animal source. Hence, vegetarians and vegans need to pay extra attention to supplementing with Vitamin D

  7. Tanning beds can help raise Vitamin D levels- but we are not advocating it!

  8. Darker skin tones or skin that tans easily make less vitamin D compared to paler skin. This is probably a necessary adaptation due to migration of our ancestors into colder regions with less sunshine. In fact, darker skin tones may require 3-6 times more time in the sun to make the same amount of Vitamin D compared to paler skin tones

  9. Older people make less Vitamin D. There may be a few reasons for this. Its believed that absorption may be poorer in older skins. The body also is less efficient in converting it to its active form. Another reason could also be that older people don’t go outdoors as much

  10. Sunscreen with SPF of 30 effectively blocks out UVB rays, hence indirectly reducing Vitamin D production by up to 95%. This piece of info was gleaned from the Journal of Clinical Endocrinology and Metabolism 2011.

 

Hope this has given you some food for thought. I personally recommend a Vitamin D shot into the muscle 4-6 times/year for paler skins and 6-8/year for darker skin tones; spaced out more during summer months. Some people prefer taking higher dose Vitamin D orally. I personally prefer injections as they are easy to administer and receive. Plus I don’t have the hassle of having to remember to consume them. For me, I always know when I’m running low on Vitamin D when my temperature regulation goes out the door. Cold feels too cold and hot feels too hot.

 

This reminds me, I think I’m due for my winter shot now….

Resources:

  1. Ghorbani, Zeinab, et al. “Vitamin D in Migraine Headache: a Comprehensive Review on Literature.” Neurological Sciences, 2019, doi:10.1007/s10072-019-04021-z.

  2. Guo, Jing et al. “A Narrative Review of The Role of Foods as Dietary Sources of Vitamin D of Ethnic Minority Populations with Darker Skin: The Underestimated Challenge.” Nutrients vol. 11,1 81. 3 Jan. 2019, doi:10.3390/nu11010081

  3. Hanel, Andrea, and Carsten Carlberg. “Vitamin D and Evolution: Pharmacologic Implications.” Biochemical Pharmacology, 2019, doi:10.1016/j.bcp.2019.07.024.

  4. Krysiak, Robert, et al. “The Effect of Vitamin D on Thyroid Autoimmunity in Euthyroid Men with Autoimmune Thyroiditis and Testosterone Deficiency.” Pharmacological Reports, vol. 71, no. 5, 2019, pp. 798–803., doi:10.1016/j.pharep.2019.04.010.

  5. Libon, Florence, et al. “Sunscreens Block Cutaneous Vitamin D Production with Only a Minimal Effect on Circulating 25-Hydroxyvitamin D.” Archives of Osteoporosis, vol. 12, no. 1, 2017, doi:10.1007/s11657-017-0361-0.

  6. Piccolo, Brian D et al. “Circulating 25-Hydroxyvitamin D Concentrations in Overweight and Obese Adults Are Explained by Sun Exposure, Skin Reflectance, and Body Composition.” Current developments in nutrition vol. 3,7 nzz065. 27 May. 2019, doi:10.1093/cdn/nzz065

  7. Webb, Ann R et al. “Colour Counts: Sunlight and Skin Type as Drivers of Vitamin D Deficiency at UK Latitudes.” Nutrients vol. 10,4 457. 7 Apr. 2018, doi:10.3390/nu10040457

Testosterone Series 3- Libido and Sexual Dysfunction

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Sexual dysfunction is possibly the commonest reason men visit their doctors for those who think beyond the viagras and cialis; and are keen on understanding their testosterone levels.

 

Some common manifestations of low T sexually in men:

  • decrease in frequency of morning erections

  • decrease in strength of morning erections

  • takes more concentration to get an erection

  • takes more concentration to then keep it going

  • decrease in the volume of ejaculate

  • losing an erection halfway or not able to maintain an erection

  • decrease interest in sex and low libido

  • little to no erection ie sexual dysfunction

  • secondary premature ejaculation (as concerned that one may lose erection)

  • a sense that the penis feels smaller when fully erect than before

 

In women, it mostly manifests as a decrease in libido and loss of interest in sex. Some women will find it harder to orgasm or that it takes longer to stimulate than they used to remember.

 

Its one of those situations that generally creeps up on people with daily life stresses playing a big part. As more and more raw materials are required to keep our stress hormones (that are necessary to survival, unlike testosterone) in good supply, a ‘steal’ situation occurs that reroutes materials so that less is available to make up hormones at the bottom of the hormonal cascade.

 

In many cases, it becomes a situation where the the couple simply prefer the TV to doing anything more physical and slowly start avoiding ‘sexy’ situations without even realising it. Or one partner may perceive a sense of decrease in attention from their partner, occasionally even leading to accusations of cheating.

 

Dealing with these situations can be fairly complex with no easy one size fits all formula. The longer it is left, the worse it can become as it may come to a point where there is psychological impact (much harder to deal with!). Also, a more holistic approach is generally required to prevent so much ‘stealing’ and to balance the other hormones at the same time for optimum performance.

 

On the whole, it is still manageable, preventable and treatable in majority of people. It also adds tremendously to the release of ‘feel good’ neurotransmitters, which then decreases the stress hormones, and gives rise to deeper sleep. So quite frequently a win-win situation!

Resources

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  2. Basaria, Shehzad, and Adrian S. Dobs. “Testosterone Making an Entry Into the Cardiometabolic World.” Circulation, vol. 116, no. 23, 2007, pp. 2658–2661., doi:10.1161/circulationaha.107.740365.

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  4. Bolour, S and G Braunstein. "Testosterone therapy in women: a review." International Journal of Impotence Research. May.17 (2005): 399–408. Print

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  6. Cherrier MM, Craft S, Matsumoto AH. Cognitive changes associated with supplementation of testosterone or dihydrotestosterone in mildly hypogonadal men: a preliminary report. Journal of Andrology. 2003;24(4):568–576.

  7. Clayton, Anita H et al. “Evaluation and Management of Hypoactive Sexual Desire Disorder.” Sexual medicine vol. 6,2 (2018): 59-74. doi:10.1016/j.esxm.2018.01.004

  8. Corona, Giovanni, Giulia Rastrelli, Matteo Monami, André Guay, Jaques Buvat, Alessandra Sforza, Gianni Forti, Edoardo Mannucci, and Mario Maggi. "Hypogonadism as a risk factor for cardiovascular mortality in men: a meta-analytic study". European Journal of Endocrinology 165.5: 687-701. < https://doi.org/10.1530/EJE-11-0447>. Web. 8 Aug. 2019.

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  19. Khaw, Kay-Tee, et al. “Endogenous Testosterone and Mortality Due to All Causes, Cardiovascular Disease, and Cancer in Men.” Circulation, vol. 116, no. 23, 2007, pp. 2694–2701., doi:10.1161/circulationaha.107.719005.

  20. Kyriazis, Ioannis Tzanakis, Kostas Stylianou, Irene katsipi, Demitrios Moisiadis, Antonia Papadaki, Vasiliki Mavroeidi, Stella Kagia, Nikolaos Karkavitsas, Eugene Daphnis, Low serum testosterone, arterial stiffness and mortality in male haemodialysis patients, Nephrology Dialysis Transplantation, Volume 26, Issue 9, September 2011, Pages 2971–2977, https://doi.org/10.1093/ndt/gfq847

  21. Laughlin, Gail A et al. “Low serum testosterone and mortality in older men.” The Journal of clinical endocrinology and metabolism vol. 93,1 (2008): 68-75. doi:10.1210/jc.2007-1792

  22. Lehtonen, Risto Huupponen, Jaakko Tuomilehto, Sirkku Lavonius, Seija Arve, Hannu Isoaho, Ilpo Huhtaniemi, Reijo Tilvis, Serum testosterone but not leptin predicts mortality in elderly men, Age and Ageing, Volume 37, Issue 4, July 2008, Pages 461–464, https://doi.org/10.1093/ageing/afn048

  23. Maggio, Marcello et al. “Relationship between low levels of anabolic hormones and 6-year mortality in older men: the aging in the Chianti Area (InCHIANTI) study.” Archives of internal medicine vol. 167,20 (2007): 2249-54. doi:10.1001/archinte.167.20.2249

  24. Maggio, M, and S Basaria. “Welcoming low testosterone as a cardiovascular risk factor.” International journal of impotence research vol. 21,4 (2009): 261-4. doi:10.1038/ijir.2009.25

  25. Mathur A, Malkin C, Saeed B, Muthusamy R, Hugh Jones T, Channer K. Long-term benefits of testosterone replacement therapy on angina threshold and atheroma in men. European Journal of Endocrinology. 2009;161(3):443–449.

  26. Middleton, T., L. Turner, C. Fennell, S. Savkovic, V. Jayadev, A J Conway, and D J Handelsman. "Complications of injectable testosterone undecanoate in routine clinical practice". European Journal of Endocrinology 172.5: 511-517. < https://doi.org/10.1530/EJE-14-0891>. Web. 6 Aug. 2019.

  27. Moffat, S. D., et al. “Free Testosterone and Risk for Alzheimer Disease in Older Men.” Neurology, vol. 62, no. 2, 2004, pp. 188–193., doi:10.1212/wnl.62.2.188.

  28. Molly M. Shores, Nicholas L. Smith, Christopher W. Forsberg, Bradley D. Anawalt, Alvin M. Matsumoto, Testosterone Treatment and Mortality in Men with Low Testosterone Levels, The Journal of Clinical Endocrinology & Metabolism, Volume 97, Issue 6, 1 June 2012, Pages 2050–2058, https://doi.org/10.1210/jc.2011-2591

  29. Morris, Paul D, and Kevin S Channer. “Testosterone and cardiovascular disease in men.” Asian journal of andrology vol. 14,3 (2012): 428-35. doi:10.1038/aja.2012.21

  30. Muraleedharan, Vakkat, and T Hugh Jones. “Testosterone and the metabolic syndrome.” Therapeutic advances in endocrinology and metabolism vol. 1,5 (2010): 207-23. doi:10.1177/2042018810390258

  31. Muraleedharan, Vakkat, Hazel Marsh, Dheeraj Kapoor, Kevin S Channer, and T Hugh Jones. "Testosterone deficiency is associated with increased risk of mortality and testosterone replacement improves survival in men with type 2 diabetes". European Journal of Endocrinology 169.6: 725-733. <https://doi.org/10.1530/EJE-13-0321>. Web. 8 Aug. 2019.

  32. Ng Tang Fui, Mark et al. “Effects of testosterone treatment on body fat and lean mass in obese men on a hypocaloric diet: a randomised controlled trial.” BMC medicine vol. 14,1 153. 7 Oct. 2016, doi:10.1186/s12916-016-0700-9

  33. Potenza, Matthew, and Mona Shimshi. “Male Hypogonadism: The Unrecognized Cardiovascular Risk Factor.” Journal of Clinical Lipidology, vol. 2, no. 2, 2008, pp. 71–78., doi:10.1016/j.jacl.2008.01.011.

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  35. Sartorius, Gideon et al. “Factors influencing time course of pain after depot oil intramuscular injection of testosterone undecanoate.” Asian journal of andrology vol. 12,2 (2010): 227-33. doi:10.1038/aja.2010.1

  36. Seidman SN, Spatz E, Rizzo C, Roose SP. Testosterone replacement therapy for hypogonadal men with major depressive disorder: a randomized, placebo-controlled clinical trial. Journal of Clinical Psychiatry. 2001;62(6):406–412.

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  41. Toma, Mustafa, et al. “Testosterone Supplementation in Heart Failure.” Circulation: Heart Failure, vol. 5, no. 3, 2012, pp. 315–321., doi:10.1161/circheartfailure.111.965632.

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  48. Wehr, Elisabeth, et al. “Low Free Testosterone Is Associated with Heart Failure Mortality in Older Men Referred for Coronary Angiography.” European Journal of Heart Failure, vol. 13, no. 5, 2011, pp. 482–488., doi:10.1093/eurjhf/hfr007. 

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DHEA, Pregnenolone and Human Growth Hormone- the Mystery Hormones

What are these hormones and what do they do in your body?

 

DHEA and Pregnenolone are precursor hormones. This means that cholesterol makes pregnenolone-the mother hormone, which makes DHEA, which makes oestrogen, progesterone and testosterone, amongst other adrenal hormones (cortisol, aldosterone). So problems or deficiencies in the making of these hormones can lead to problems with the hormones that we are familiar with; namely oestrogen, progesterone, testosterone and stress hormone cortisol. DHEA is better known and many people know a little about it. It is even used in higher doses for fertility in women. Pregnenolone is not well researched and a lot more needs to be done. It is known as the ‘brain’ hormone as that’s one of its main function.

 

Problem making these hormones could be anything from nutritional deficiencies (remember that vitamins and minerals enable reactions to take place) to very low cholesterol (cholesterol is a building block), to problems with enzymes that help these reaction take place smoothly. Many of these problems are easy to handle eg good diet and supplementation. Then of course there's ageing, which causes a gradual decline over the years.

 

Growth hormone (HGH, Human Growth Hormone) is the ‘wear and tear’ hormone. It starts to decline from around 21 years of age. It gets its bad reputation from its use as an anabolic steroid (decrease fat mass but builds muscle mass) where it has been abused by ‘underground’ gym users and competitive sports people. This is due to the obvious advantage it confers to these people. There are also fears regarding its potential to increase growth of existing tumours within the body. This doesn’t make a lot of sense to me as we have large amounts of GH in our teens and twenties (but low levels of tumours) and this switches the older we age ie less GH but more tumours in older people. Of course its not that simple as many other factors come into place. There have been a few studies on this subject, which a quick google search will uncover.

So, what do these hormones actually do in the body?

DHEA

  • it shifts the body to an anabolic or protein building state

  • It increases visceral (surrounding your organs) fat burning

  • Its an anti-depressant and improves mood

  • Improves sexual function and vitality

  • improves memory

  • increases energy

  • enhances the immune system

  • reduces insulin requirements

  • increases bone density

Pregnenolone

  • its a memory enhancer and cellular repairer

  • particularly important for neuronal cellular repair (brain)

  • improves ability to acquire knowledge

  • improves long term memory

  • as a precursor to steroid hormone cortisol, it supports functions where synthetic steroids are required, and in cases of adrenal burn out.

Human Growth Hormone

  • increase metabolism

  • better immune system

  • improves cell repair and overall tissue regeneration

  • increase muscle mass and decreased fat mass

  • increase energy and endurance

  • increased libido

  • better recovery after injury

  • better skin

 

Should we be replacing them? This really depends on one’s view. The same question can be asked of regular HRT (oestrogen/progesterone), testosterone and other hormones like thyroid, insulin etc. Who gets to decide which hormones should be replaced and which ones shouldn’t? Its not an easy question and there is no easy answer. Again, this blog’s intention is for you to question things and to inspire you to ask more questions, research more and come from a position of strength when attempting to answer these questions for yourself.

 

Menopause Series 2-How Long Should You Be on HRT? Lets Look at Benefits/Risks and Relevant Studies

You know how it works….you’re on HRT for a few years and most women seem to try to wean themselves off it. Some succeed and find that they have no more menopausal symptoms after a few years on HRT. Others race back to continue as life feels unbearable without it. After some years, most GPs will try to get you off HRT due to all the risk factors involved.

 

So how long can you really be on HRT?

The short answers are….

  • Regular HRT- its complicated!

  • Bioidentical HRT- for life if it were up to me (and other like minded practitioners)

 

Regular HRT

Its complicated in this instance as HRT as a whole, have many beneficial effects, besides easing of common menopausal symptoms. It then becomes a decision where you have to weigh the benefits that it proffers versus the complications that it can give rise to. These ratios are interesting as when one looks at mortality charts, the biggest ‘scare’ ie breast cancer for most women using HRT. However, according to studies, the risk is only 0.08% for every year of use. This is in fact very low. This is then compounded by the WHI reports that stated that heart attacks went up by 29% and strokes by 41%. This is what was reported in the media and it sounds incredibly scary. But a breakdown of what these numbers actually mean is this:

  • 29% heart attacks: It means that per 10,000 person-years, there would be 37 women who used hormone therapy compared with 30 women who used placebo who would have a heart attack. 7 more women out of 10,000 in a year.

  • 41% strokes: 29 cases of stroke in the hormone group vs 21 in the placebo group per 10,000 person-years. Again, only 8 more women in 10,000. (2)

  • Of course these statistics still does not sound great but at least its not 41 out of 100 women or 29 out of 100 women- which is what we were led to believe!

However, it failed to take into account that a large number of people on the study ranged from 50 to 79 years, with a mean age at initial screening of 63.2 years. 66.6% of the women in the hormone group were between 60 and 79 years. It also failed to take into account that many of them had pre-existing diseases and were overweight (BMI>28.5) which would have made them not eligible for that particular hormone combination. Also, there is not a ‘one size fits all’ for hormone replacement in women. (2)

It also failed to highlight all the benefits HRT gives to these women. (1)

Let’s list the advantages

  • Better quality of life

  • 37% reduction in colon cancer (according to that study)

  • 34% decrease in hip fractures (according to that study)

  • Improved cognition and protects against Alzheimer’s disease

  • Improved balance

  • Improved skin

  • Decreased in urinary tract infection and degeneration

  • Better protection for heart disease and stroke (for the right patients when commenced at the right time)

  • Decrease in osteoporosis or thinning of the bone

  • Protects against cataract and macular degeneration

Very importantly, there is no acknowledgement of the fact that something quite contrary to what our bodies consider to be ‘self’ is being used- ie, a non bioidentical compound. In the WHI study, it was Prempro (0.625 mg conjugated equine oestrogens and 2.5 mg medroxyprogesterone acetate)- read- that is oestrogen from a pregnant mare. Why would or should we assume that our bodies will like them?

 

In summary, if you are on ‘regular’ HRT, please take the trouble to understand what you are taking. It has so many benefits, especially when started very early, when menopause first starts. If you have pre-existing diseases or habits eg obesity, smoking, family history etc, with the right practitioner and changes in lifestyle, its still very much a possibility to continue with HRT. At some point though, especially if its really making a difference to your lifestyle, bioidentical is always better.

             

Resources:

  1. Women's Health Initiative Study

  2. Why Individualizing Hormone Therapy Is Crucial: Putting the Results of the WHI Trial Into Perspective

  3. Vallée, Monique. “Neurosteroids and Potential Therapeutics: Focus on Pregnenolone.” The Journal of Steroid Biochemistry and Molecular Biology, vol. 160, 2016, pp. 78–87., doi:10.1016/j.jsbmb.2015.09.030.

  4. Murugan, S., Jakka, P., Namani, S., Mujumdar, V., & Radhakrishnan, G. (2019). The neurosteroid, pregnenolone promotes degradation of key proteins in the innate immune signalling to suppress inflammation. Journal of Biological Chemistry, jbc.RA118.005543. doi:10.1074/jbc.ra118.005543 

  5. Mayo, Willy, et al. “Pregnenolone Sulfate and Aging of Cognitive Functions: Behavioral, Neurochemical, and Morphological Investigations.” Hormones and Behavior, vol. 40, no. 2, 2001, pp. 215–217., doi:10.1006/hbeh.2001.1677.

  6. Takahashi MD, Traci and Kay Johnson MD. "Menopause." Medical Clinics of North America. 99.3 (2015): 521-534.

  7. Al-Safi, Zain A., and Nanette Santoro. “Menopausal Hormone Therapy and Menopausal Symptoms.” Fertility and Sterility, vol. 101, no. 4, 2014, pp. 905–915., doi:10.1016/j.fertnstert.2014.02.032.

  8. Santoro, Nanette et al. “Menopausal Symptoms and Their Management.” Endocrinology and metabolism clinics of North America vol. 44,3 (2015): 497-515. doi:10.1016/j.ecl.2015.05.001

Series 1: Menopause and HRT- an Overview

In this menopause series, I will talk about menopause; what’s done in the NHS, long term implications of HRT, look at some scientific papers and explore your options. This will be over a few blogs that I hope to cover over the next few months.

 

There are a few ways to look at menopause. Some people are simply glad that they don’t have to deal with the ‘dreaded’ monthly bleed anymore. Others take it harder as a sign that they are now officially ‘old’ (although menopause seems to happen earlier these days, as early as late 30s for some, in those with no ovarian failure). Mostly, I find that women are able to laugh with other women about it; sharing their hot flushes over a cup of tea….

For a lot of women, menopause wouldn’t be so bad if it weren’t for the accompanying signs, symptoms and constant reminder that its actually happening. The hot flushes, the night sweats, palpitations, vaginal issues like dryness or itching, libido issues like loss of libido, discomfort and/or pain during sex, foggy brain, changes in mood, insomnia amongst other things.

It also tends to happen at a point in life where things have finally settled down- you know yourself, kids have left home or you’ve (sort of) figured them out, your personal and professional progress is at a point where there’s an element of predictability. This is undoubtedly a generalisation but on the whole, its a period in life when things seem predictable in a good way. Then menopause comes along to shake things up a little.

In my opinion, the lucky ones get all the symptoms. If I had a pound for everytime I hear women commenting on how ‘lucky’ they have been as there had been no symptoms of menopause, I’d be fairly rich. I suppose it is lucky in some ways but I consider symptoms to be a cry for help for the body and also a cry for women to take action. Today, where there are many things that can be done, its not a bad thing.

So what can one do about it?

  • The traditional way to deal with it ranges from natural, plant based supplementation to HRT that your GP prescribes for you.

  • You are told to avoid ‘trigger’ factors like spicy foods, coffee etc.

  • You are advised to eat better, including foods that contain phyto-oestrogens (plant based oestrogens like soy), increase your calcium intake due to potential and probable bone loss and get more sun (Vit D for bone).

  • You’re also told to exercise more.

Does it work?

  • Whilst much slower and subtle with herbs and supplements, it does make a difference. The difference is enough for some but not good enough for others.

  • NHS or regular HRT definitely works but there are a few problems surrounding it. If you have a sympathetic and experienced (in HRT) practitioner, you will probably get a prescription of HRT. They will probably want you to be on it for the least amount of time possible due to potential long term complications like breast cancer and clots. I will go into more depth in a future blog post.

  • Lifestyle changes will certainly make you feel better overall.

 

Then why does it still feel like this is an unresolved issue, with women still attempting to find answers as to what to do, despite all the advancements within this field?

Stay with me on future blogs and we will explore this further.

Resources:

  1. Vallée, Monique. “Neurosteroids and Potential Therapeutics: Focus on Pregnenolone.” The Journal of Steroid Biochemistry and Molecular Biology, vol. 160, 2016, pp. 78–87., doi:10.1016/j.jsbmb.2015.09.030.

  2. Murugan, S., Jakka, P., Namani, S., Mujumdar, V., & Radhakrishnan, G. (2019). The neurosteroid, pregnenolone promotes degradation of key proteins in the innate immune signalling to suppress inflammation. Journal of Biological Chemistry, jbc.RA118.005543. doi:10.1074/jbc.ra118.005543 

  3. Mayo, Willy, et al. “Pregnenolone Sulfate and Aging of Cognitive Functions: Behavioral, Neurochemical, and Morphological Investigations.” Hormones and Behavior, vol. 40, no. 2, 2001, pp. 215–217., doi:10.1006/hbeh.2001.1677.

  4. Takahashi MD, Traci and Kay Johnson MD. "Menopause." Medical Clinics of North America. 99.3 (2015): 521-534.

  5. Al-Safi, Zain A., and Nanette Santoro. “Menopausal Hormone Therapy and Menopausal Symptoms.” Fertility and Sterility, vol. 101, no. 4, 2014, pp. 905–915., doi:10.1016/j.fertnstert.2014.02.032.

  6. Santoro, Nanette et al. “Menopausal Symptoms and Their Management.” Endocrinology and metabolism clinics of North America vol. 44,3 (2015): 497-515. doi:10.1016/j.ecl.2015.05.001

 

Testosterone Series 2 - Testosterone, Muscle Mass and Fat

This is a well known use of testosterone (T)- the ‘muscle’ hormone. Not only does it increase the size of muscle mass, it also increases the strength and power of the muscle fibres. (1) There is also some benefit from the other well-known ‘side effect’ of raised T, which is increased oxygen carrying capacity of the blood (due to increase in the number of red blood cell). This leads to better tissue reperfusion after exercise and so one is able to exercise longer and/or more efficiently.

In the young, it is sometimes taken to ‘bulk’ alongside anabolic steroids- this is usually ‘underground’ usage and not what we will be discussing here although I have been hearing a lot from people suffering the repercussions of self-administration.

What happens in someone with normal T?

  • Firstly, everyone has a different normal and it might be a good idea to do a blood test when you feel like you’re at your peak physically just to know what’s your normal. It will come in handy 10 years down the line. For some, low normal may feel great but for others it may seem deficient. Normal blood ranges are there as a guide and should be used as just that- a guide.

  • If you feel symptoms of low T but your blood range is within normal, it may mean that you function better at higher levels. So your normal is NOT another person’s.

  • Within normal ranges, increasing T (by supplementation etc) will not change muscle mass much.

  • Increase in resistance training leads to increase in testosterone production acutely.

  • Supplementation to levels at least 20-30% of top of normal range (supraphysiologic levels) is necessary to make a statistical difference to muscle mass.

What happens in age-related decline?

  • A man first notices a drop in T when exercise does not produce the same results it used to. Diet and activity levels being stable, you will notice the invariable creep of middle or belly fat- the hard to shift love handles. Initially, you may be able to shift it with a change in exercise routine or changes in the diet. After a while, you’ll find that it does not work as well anymore.

  • All over body fat versus muscle mass ratio will see a shift as well. There will be softer bits all over. The tendency will be toward building more fat depots rather than muscle.

  • Again increase in resistance training leads to increase in testosterone production acutely.

  • Over time, a vicious circle develops where increased fat and decreased muscle mass leads to lower energy levels to lower activity levels to increased fat, so on and so forth. This leads to the change in body shape very characteristic of low T.

  • Ageing beyond 35-40 years is associated with a 1-3% decline per year of testosterone according to one study. (2)

  • In women, the most noticeable changes occur after menopause, again with a similar distribution of fat. This is alongside oestrogen and progesterone drop and hence usually missed or brushed off as not being relevant.

So in summary:

  • Low T causes increase in fat mass and is associated with obesity. The mechanism is not well known. One study succeeded in demonstrating that androgens inhibit the creation of fat. (3) There is still a lot of research required in this area but observational studies certainly seems to support this.

  • TRT increases muscle mass, strength and power.

  • The leaner a person is, the higher the testosterone levels. Lean here refers to the lack to fatty tissue as opposed to lean/bulky muscle mass.

  • The fatter a person is, the lower the testosterone levels.

  • Benefits of more muscle mass: leaner, more energy/metabolic efficiency, increase insulin sensitivity and blood sugar control, improve balance and mobility, improve strength, stability and endurance, reduce risk of injury, create metabolic reserve amongst a host of other benefits. 

Resources

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  2. Basaria, Shehzad, and Adrian S. Dobs. “Testosterone Making an Entry Into the Cardiometabolic World.” Circulation, vol. 116, no. 23, 2007, pp. 2658–2661., doi:10.1161/circulationaha.107.740365.

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  49. Weiss, Rita V., Hohl, Alexandre, Athayde, Amanda, Pardini, Dolores, Gomes, Larissa, Oliveira, Monica de, Meirelles, Ricardo, Clapauch, Ruth, & Spritzer, Poli Mara. (2019). Testosterone therapy for women with low sexual desire: a position statement from the Brazilian Society of Endocrinology and Metabolism. Archives of Endocrinology and Metabolism, 63(3), 190-198. Epub July 18, 2019.https://dx.doi.org/10.20945/2359-3997000000152

  50. Wieselman, Brie. "Adrenal Fatigue Part 4: The “Cortisol Steal”—or, How Increased Stress Creates Female Hormone Imbalance." Briewieselman.com. 1 Jan 2018. Web. 1 Aug 2019. <https://briewieselman.com/adrenal-fatigue-part-4-the-cortisol-steal-or-how-increased-stress-creates-female-hormone-imbalance/>.

  51. Zoë Hyde, Paul E. Norman, Leon Flicker, Graeme J. Hankey, Osvaldo P. Almeida, Kieran A. McCaul, S. A. Paul Chubb, Bu B. Yeap, Low Free Testosterone Predicts Mortality from Cardiovascular Disease But Not Other Causes: The Health in Men Study, The Journal of Clinical Endocrinology & Metabolism, Volume 97, Issue 1, 1 January 2012, Pages 179–189, https://doi.org/10.1210/jc.2011-1617

Testosterone Series 1 - an Overview (Relevant to Both Men and Women)


In this series, I'd like to discuss the role of testosterone as part of a health management plan and go into some detail regarding the different questions/issues people may have regarding testosterone. In this first series, we will go over the basics of what testosterone is and can do. Over the coming few days/weeks/months, I will go into more detail regarding different aspects of testosterone replacement therapy, its potential problems including aromatisation, different forms available and the bioavailability, exercise and so on.

I intend to continue these series on different hormones and nutrition. Do keep your comments coming in (person/fb/blog) and let me know if you would like me to research and cover other topics.


Testosterone-vintage diagramme.jpg

Testosterone has a mixed reputation and with some thinking of it as the all singing and dancing “sex and muscle” hormone but others thinking of it as the “aggressive” hormone. Most images depicting testosterone usage tend to focus on these aspects (think “Hulk”).

 

So what is testosterone and what does it do in your body?

  • Testosterone is the male sex hormone that is at the bottom of the steroid hormonal synthesis pathway, starting with cholesterol at the top. This is significant, as will be made clear in future blog posts.

  • Testosterone is present, and hugely important in both men and women- remember it when libido levels dip in both men and women.

  • It declines with age, with a significant jump noted beyond the age of 40 for most men. Some will start the notice the effects of low testosterone much sooner, in their early 30s and some lucky men, will only notice it closer to their 50s.

  • It is usually first noticed when there’s a decline in libido- a classic case of “I like the idea of sex but the TV/computer/book seems more inviting”. This is for both men and women.

  • Others may have noticed it first when their exercise routine stops delivering the same results anymore. They now have a ‘roll’ around the middle that is hard to shift.

  • Others still may notice that their ability to party has declined (again preferring a quiet night in or out), their ability to cope at work decreases, home life feels like a drag.

  • Some find that their fuse is shorter; they get more anxious and worry more, have more frequent bouts of feeling down or even depression and most importantly, their “aggression” or more accurately the “go-getter” in them starts to flail.

Specifically testosterone:

  • increases the libido and sexual function in men and women

  • is responsible for male sexual characteristics including functions of the male sexual organs

  • increases muscle mass while decreasing fat mass

  • increase in strength and volume of muscle mass

  • increases production of red blood cells, which is the carrier of oxygen to all cells of the body

  • increases bone density alongside oestrogen (men have oestrogen too)

  • improves mood, anxiety, depression, and in normal physiological doses, improves aggression (despite its bad reputation for causing aggression)- an overall improved sense of well being.

  • sharper mind

  • thicker skin, increased sebum/oil production in skin, male-pattern of hair distribution

Low testosterone levels is debilitating and happens to all men and women with increase in age. Occasionally, it happens in younger men too, either due to various genetic or environmental factors or in post anabolic steroid therapy (to increase muscle mass in gyms) where their levels refuse to normalise after stopping the anabolic steroids. 

Optimised levels offers a lot of benefit to both sexes. This will be discussed in more detail over the coming series of blogs.

 

 

Resources

  1. Araujo, Andre B et al. “Clinical review: Endogenous testosterone and mortality in men: a systematic review and meta-analysis.” The Journal of clinical endocrinology and metabolism vol. 96,10 (2011): 3007-19. doi:10.1210/jc.2011-1137

  2. Basaria, Shehzad, and Adrian S. Dobs. “Testosterone Making an Entry Into the Cardiometabolic World.” Circulation, vol. 116, no. 23, 2007, pp. 2658–2661., doi:10.1161/circulationaha.107.740365.

  3. Bhasin S, Woodhouse L, Casaburi R, Singh AB, Bhasin D, Berman N, Chen X, Yarasheski KE, Magliano L, Dzekov C, et al Testosterone dose-response relationships in healthy young men. American Journal of Physiology: Endocrinology and Metabolism 2001. 281 E1172–E1181. (10.1152/ajpendo.2001.281.6.E1172)

  4. Bolour, S and G Braunstein. "Testosterone therapy in women: a review." International Journal of Impotence Research. May.17 (2005): 399–408. Print

  5. Borst, Stephen E et al. “Cognitive effects of testosterone and finasteride administration in older hypogonadal men.” Clinical interventions in aging vol. 9 1327-33. 12 Aug. 2014, doi:10.2147/CIA.S61760

  6. Cherrier MM, Craft S, Matsumoto AH. Cognitive changes associated with supplementation of testosterone or dihydrotestosterone in mildly hypogonadal men: a preliminary report. Journal of Andrology. 2003;24(4):568–576.

  7. Clayton, Anita H et al. “Evaluation and Management of Hypoactive Sexual Desire Disorder.” Sexual medicine vol. 6,2 (2018): 59-74. doi:10.1016/j.esxm.2018.01.004

  8. Corona, Giovanni, Giulia Rastrelli, Matteo Monami, André Guay, Jaques Buvat, Alessandra Sforza, Gianni Forti, Edoardo Mannucci, and Mario Maggi. "Hypogonadism as a risk factor for cardiovascular mortality in men: a meta-analytic study". European Journal of Endocrinology 165.5: 687-701. < https://doi.org/10.1530/EJE-11-0447>. Web. 8 Aug. 2019.

  9. Elisabeth Hak A., Jacqueline C. M. Witteman, Frank H. de Jong, Mirjam I. Geerlings, Albert Hofman, Huibert A. P. Pols, Low Levels of Endogenous Androgens Increase the Risk of Atherosclerosis in Elderly Men: The Rotterdam Study, The Journal of Clinical Endocrinology & Metabolism, Volume 87, Issue 8, 1 August 2002, Pages 3632–3639, https://doi.org/10.1210/jcem.87.8.8762

  10. Emmelot-Vonk MH, Verhaar HJJ, Nakhai Pour HR, et al. Effect of testosterone supplementation on functional mobility, cognition, and other parameters in older men: a randomized controlled trial. The Journal of the American Medical Association. 2008;299(1):39–52.

  11. Fletcher, Jenna and Daniel Murrell MD. "What are the symptoms of low testosterone?." Medicalnewstoday.com. Medical News Today, 1 Aug 2018. Web. 1 Jun 2019. <https://www.medicalnewstoday.com/articles/322647.php>.

  12. Ghelani BPharm, MRPharmS, Rita. "Sustanon 250 injection (testosterone): a treatment to boost low testosterone levels." Netdoctor.co.uk. Netdoctor, 22 Jul 2019. Web. 1 Aug 2019. <https://www.netdoctor.co.uk/medicines/a7593/sustanon-injection-testosterone/>.

  13. Giorgi, A, RP Weatherby and PW Murphy. "Muscular strength, body composition and health responses to the use of testosterone enanthate: a double blind study." Journal of Science and Medicine in Sport. 2.4 (1999): 341-55.

  14. Haring, Henry Völzke, Antje Steveling, Alexander Krebs, Stephan B. Felix, Christof Schöfl, Marcus Dörr, Matthias Nauck, Henri Wallaschofski, Low serum testosterone levels are associated with increased risk of mortality in a population-based cohort of men aged 20–79, European Heart Journal, Volume 31, Issue 12, June 2010, Pages 1494–1501, https://doi.org/10.1093/eurheartj/ehq009

  15. Islam PhD, Rakibul, Robin Bell MBBS and Sally Green PhD. "Safety and efficacy of testosterone for women: a systematic review and meta-analysis of randomised controlled trial data.." The Lancet Diabetes and Endocrinology. (2019): Web.<https://doi.org/10.1016/S2213-8587(19)30189-5>.

  16. Jackson, Testosterone deficiency syndrome (TDS) and the heart, European Heart Journal, Volume 31, Issue 12, June 2010, Pages 1436–1437, https://doi.org/10.1093/eurheartj/ehq096

  17. Jones, T. H., et al. “Testosterone Replacement in Hypogonadal Men With Type 2 Diabetes and/or Metabolic Syndrome (the TIMES2 Study).” Diabetes Care, vol. 34, no. 4, 2011, pp. 828–837., doi:10.2337/dc10-1233.

  18. Kelly, Daniel M, and T Hugh Jones. "Testosterone: a metabolic hormone in health and disease". Journal of Endocrinology 217.3: R25-R45. <https://doi.org/10.1530/JOE-12-0455>. Web. 8 Aug. 2019. 

  19. Khaw, Kay-Tee, et al. “Endogenous Testosterone and Mortality Due to All Causes, Cardiovascular Disease, and Cancer in Men.” Circulation, vol. 116, no. 23, 2007, pp. 2694–2701., doi:10.1161/circulationaha.107.719005.

  20. Kyriazis, Ioannis Tzanakis, Kostas Stylianou, Irene katsipi, Demitrios Moisiadis, Antonia Papadaki, Vasiliki Mavroeidi, Stella Kagia, Nikolaos Karkavitsas, Eugene Daphnis, Low serum testosterone, arterial stiffness and mortality in male haemodialysis patients, Nephrology Dialysis Transplantation, Volume 26, Issue 9, September 2011, Pages 2971–2977, https://doi.org/10.1093/ndt/gfq847

  21. Laughlin, Gail A et al. “Low serum testosterone and mortality in older men.” The Journal of clinical endocrinology and metabolism vol. 93,1 (2008): 68-75. doi:10.1210/jc.2007-1792

  22. Lehtonen, Risto Huupponen, Jaakko Tuomilehto, Sirkku Lavonius, Seija Arve, Hannu Isoaho, Ilpo Huhtaniemi, Reijo Tilvis, Serum testosterone but not leptin predicts mortality in elderly men, Age and Ageing, Volume 37, Issue 4, July 2008, Pages 461–464, https://doi.org/10.1093/ageing/afn048

  23. Maggio, Marcello et al. “Relationship between low levels of anabolic hormones and 6-year mortality in older men: the aging in the Chianti Area (InCHIANTI) study.” Archives of internal medicine vol. 167,20 (2007): 2249-54. doi:10.1001/archinte.167.20.2249

  24. Maggio, M, and S Basaria. “Welcoming low testosterone as a cardiovascular risk factor.” International journal of impotence research vol. 21,4 (2009): 261-4. doi:10.1038/ijir.2009.25

  25. Mathur A, Malkin C, Saeed B, Muthusamy R, Hugh Jones T, Channer K. Long-term benefits of testosterone replacement therapy on angina threshold and atheroma in men. European Journal of Endocrinology. 2009;161(3):443–449.

  26. Middleton, T., L. Turner, C. Fennell, S. Savkovic, V. Jayadev, A J Conway, and D J Handelsman. "Complications of injectable testosterone undecanoate in routine clinical practice". European Journal of Endocrinology 172.5: 511-517. < https://doi.org/10.1530/EJE-14-0891>. Web. 6 Aug. 2019.

  27. Moffat, S. D., et al. “Free Testosterone and Risk for Alzheimer Disease in Older Men.” Neurology, vol. 62, no. 2, 2004, pp. 188–193., doi:10.1212/wnl.62.2.188.

  28. Molly M. Shores, Nicholas L. Smith, Christopher W. Forsberg, Bradley D. Anawalt, Alvin M. Matsumoto, Testosterone Treatment and Mortality in Men with Low Testosterone Levels, The Journal of Clinical Endocrinology & Metabolism, Volume 97, Issue 6, 1 June 2012, Pages 2050–2058, https://doi.org/10.1210/jc.2011-2591

  29. Morris, Paul D, and Kevin S Channer. “Testosterone and cardiovascular disease in men.” Asian journal of andrology vol. 14,3 (2012): 428-35. doi:10.1038/aja.2012.21

  30. Muraleedharan, Vakkat, and T Hugh Jones. “Testosterone and the metabolic syndrome.” Therapeutic advances in endocrinology and metabolism vol. 1,5 (2010): 207-23. doi:10.1177/2042018810390258

  31. Muraleedharan, Vakkat, Hazel Marsh, Dheeraj Kapoor, Kevin S Channer, and T Hugh Jones. "Testosterone deficiency is associated with increased risk of mortality and testosterone replacement improves survival in men with type 2 diabetes". European Journal of Endocrinology 169.6: 725-733. <https://doi.org/10.1530/EJE-13-0321>. Web. 8 Aug. 2019.

  32. Ng Tang Fui, Mark et al. “Effects of testosterone treatment on body fat and lean mass in obese men on a hypocaloric diet: a randomised controlled trial.” BMC medicine vol. 14,1 153. 7 Oct. 2016, doi:10.1186/s12916-016-0700-9

  33. Potenza, Matthew, and Mona Shimshi. “Male Hypogonadism: The Unrecognized Cardiovascular Risk Factor.” Journal of Clinical Lipidology, vol. 2, no. 2, 2008, pp. 71–78., doi:10.1016/j.jacl.2008.01.011.

  34. Redmond, GP. "Hormones and sexual function.." International Journal of Fertility and Women's Medicine. 44.4 (1999): 193-7. Print

  35. Sartorius, Gideon et al. “Factors influencing time course of pain after depot oil intramuscular injection of testosterone undecanoate.” Asian journal of andrology vol. 12,2 (2010): 227-33. doi:10.1038/aja.2010.1

  36. Seidman SN, Spatz E, Rizzo C, Roose SP. Testosterone replacement therapy for hypogonadal men with major depressive disorder: a randomized, placebo-controlled clinical trial. Journal of Clinical Psychiatry. 2001;62(6):406–412.

  37. Selvin, E., et al. “Androgens and Diabetes in Men: Results from the Third National Health and Nutrition Examination Survey (NHANES III).” Diabetes Care, vol. 30, no. 2, 2007, pp. 234–238., doi:10.2337/dc06-1579.

  38. Shifren J.L. Testosterone for midlife women: the hormone of desire? Menopause. 2015;22:1147–1149

  39. Singh, Rajan. "Testosterone inhibits adipogenic differentiation in 3T3-L1 cells: nuclear translocation of androgen receptor complex with beta-catenin and T-cell factor 4 may bypass canonical Wnt signaling to down-regulate adipogenic transcription factors.." Endocrinology. January.147 (2006): 141-54.

  40. Surampudi, Prasanth N et al. “Hypogonadism in the aging male diagnosis, potential benefits, and risks of testosterone replacement therapy.” International journal of endocrinology vol. 2012 (2012): 625434. doi:10.1155/2012/625434

  41. Toma, Mustafa, et al. “Testosterone Supplementation in Heart Failure.” Circulation: Heart Failure, vol. 5, no. 3, 2012, pp. 315–321., doi:10.1161/circheartfailure.111.965632.

  42. Traish, A. M., et al. “The Dark Side of Testosterone Deficiency: II. Type 2 Diabetes and Insulin Resistance.” Journal of Andrology, vol. 30, no. 1, 2008, pp. 23–32., doi:10.2164/jandrol.108.005751.

  43. Van der Meij, L, A Demetriou, M Tulin and I Mendez. "Hormones in speed-dating: The role of testosterone and cortisol in attraction.." Elsevier Hormonal Behaviour. (2019): Web.<https://www.ncbi.nlm.nih.gov/pubmed/31348926>.

  44. Vingren, Jakob. "Testosterone physiology in resistance exercise and training: the up-stream regulatory elements." Sports Medicine. 40.12 (2010): 1037–1053.

  45. Vlachopoulos, Nikolaos Ioakeimidis, Dimitrios Terentes-Printzios, Konstantinos Aznaouridis, Konstantinos Rokkas, Athanassios Aggelis, Alexandros Synodinos, George Lazaros, Christodoulos Stefanadis, Plasma Total Testosterone and Incident Cardiovascular Events in Hypertensive Patients, American Journal of Hypertension, Volume 26, Issue 3, March 2013, Pages 373–381, https://doi.org/10.1093/ajh/hps056

  46. Wang C, Alexander G, Berman N, et al. Testosterone replacement therapy improves mood in hypogonadal men—a clinical research center study. The Journal of Clinical Endocrinology & Metabolism. 1996;81(10):3578–3583.

  47. Wang C, Swerdloff RS, Iranmanesh A, et al. Transdermal testosterone gel improves sexual function, mood, muscle strength, and body composition parameters in hypogonadal men. The Journal of Clinical Endocrinology & Metabolism. 2000;85(8):2839–2853. 

  48. Wehr, Elisabeth, et al. “Low Free Testosterone Is Associated with Heart Failure Mortality in Older Men Referred for Coronary Angiography.” European Journal of Heart Failure, vol. 13, no. 5, 2011, pp. 482–488., doi:10.1093/eurjhf/hfr007. 

  49. Weiss, Rita V., Hohl, Alexandre, Athayde, Amanda, Pardini, Dolores, Gomes, Larissa, Oliveira, Monica de, Meirelles, Ricardo, Clapauch, Ruth, & Spritzer, Poli Mara. (2019). Testosterone therapy for women with low sexual desire: a position statement from the Brazilian Society of Endocrinology and Metabolism. Archives of Endocrinology and Metabolism, 63(3), 190-198. Epub July 18, 2019.https://dx.doi.org/10.20945/2359-3997000000152

  50. Wieselman, Brie. "Adrenal Fatigue Part 4: The “Cortisol Steal”—or, How Increased Stress Creates Female Hormone Imbalance." Briewieselman.com. 1 Jan 2018. Web. 1 Aug 2019. <https://briewieselman.com/adrenal-fatigue-part-4-the-cortisol-steal-or-how-increased-stress-creates-female-hormone-imbalance/>.

  51. Zoë Hyde, Paul E. Norman, Leon Flicker, Graeme J. Hankey, Osvaldo P. Almeida, Kieran A. McCaul, S. A. Paul Chubb, Bu B. Yeap, Low Free Testosterone Predicts Mortality from Cardiovascular Disease But Not Other Causes: The Health in Men Study, The Journal of Clinical Endocrinology & Metabolism, Volume 97, Issue 1, 1 January 2012, Pages 179–189, https://doi.org/10.1210/jc.2011-1617

Compounded Bioidentical Hormones versus Generic and is there a Difference between Labs?

I already mentioned briefly about the difference between bioidentical and regular (non bioidentical) hormones. Here I will explain it in more detail.

Bioidentical means that its basic molecular structure is the same as what is naturally present in your body. It does not, however, mean that it is from a completely natural sources eg yam, animals etc. It could have been made up in a lab but the important thing is that its structure is the same and so the body recognises it as being the same and thus will not reject it. Something natural and readily existing in nature may be from a plant or animal (pregnant mare being the most famous as that is where generic oestrogen is sourced from). Why should we expect a hormone from a plant or an animal to be compatible with what we have in our bodies? They will certainly deliver some of the same results but there is bound to be side effects that we prefer did not exist like the breast cancer scare in the famous WHI study (the study that put a stop to widespread HRT prescriptions). 

The term compounding pharmacy is big in the US but unfortunately not here except for veterinary purposes. However it still exists albeit not in a big, publicised way. They are incredibly hard to find and when you do find one, there are many different aspects to look at, a lot of which may not be fulfilled. I source my hormones from an EU country and love their quality.

Whilst researching the finer points of getting the best products- including visits to labs-

What I have learnt is this:

  • The advantage of a bespoke product is that you can get the right dose in the right carrier which could mean having to take a smaller number of tablets/capsules.

  • The right carrier (or excipient) can make a huge difference to a product. Something taken orally is broken down in the liver. If for some reason, you don't want this to happen, you can choose a delivery system which may work better for that person. Some hormones don't work well in certain delivery systems- hugely important to understand especially when balancing hormones.

  • Another importance of the right excipient is its ability to carry the active ingredients to where it needs to be delivered more efficiently and effectively.

  • You could get it in a non bovine or non animal form for the religiously inclined or for those who prefer it.

  • Most importantly is a process called micronisation which means breaking down the raw ingredients to very small particles which is easily absorbed by the body. This means that a 10mg of generic product may or may not deliver 10mg but a micronised product is more likely to. Hence controlling dosage is much easier as its a purer product.

These pharmacies work on a narrow percentage of error which means the end product is close to perfect (within these parameters). The downside is naturally the cost. If affordability is an issue, do use generic bioidentical products-its worth it! Keep in mind that it certainly is worth the money for the right product formulated just right and bespoke for you. Savile Row versus off the peg (without looking at labels, one can usually tell that it looks better). As one wonderful personal trainer tells her clients (a different context but the message is the same)- you should certainly save your money on these things, you need the money to pay for your bypass!

 

 

 

Sex and testosterone - how I got there...

testosterone_1.jpg

I had the opportunity to watch “Hope Springs” with Meryl Streep and Tommy Lee Jones as part of inflight entertainment last year- a movie with a subject matter that is strangely close to my heart as they seemed to be like a lot of my patients. For those who have not seen this movie, its about a 50 something seemingly contented couple with underlying currents of discontent. The wife (Streep) is increasingly bothered by this and decides to seek ‘intensive’ therapy which the husband (Jones) has no choice but to go to. And so ensues multiple cringe worthy exercises they have to do under direction of the therapist (Steve Carrell). One exercise in particular led them to rip each others clothes off (ok, not quite rip!) and have intercouse. While thrusting, Jones is on top and looks away, Streep looks at him and wants him to connect with her and so turns his head towards her and wham! The erection is gone. What ensues is quite typical, she gets mad and takes it personally that he has indeed lost interest in having sex.

 

Now, I bring this up because I realise that my view of some of the scenes are actually quite contrary to common perception (including Streep’s in the movie) and possibly even the man in this particular instance mostly because its something that’s hard to admit.

I believe that what actually happened is this: Its been a while since they had had sex and he’s probably really relieved its even up, not to mention super thrilled. He is probably able to get it up most of the time but has trouble maintaining his erection and usually really needs to concentrate really hard so that it doesn’t go soft halfway- the slightest distraction is usually enough to derail things. Hence the eyes closing (yes, it possibly might mean plunging into the deepest depths of memory archives to dig up whatever it takes to keep it up- but not necessarily). Because he knows that if he loses it halfway- the partner may take it personally; the partner may think he’s a lesser man; the partner may think he’s cheating; most importantly, he may himself think that he’s a lesser man, that he’s losing it for good.

 

What usually happens in this instance is that the man, like all normal human beings, tries to avoid these situations- one tends to choose the path of least resistance. However much he tries not to think about it, its there in his subconscious- and stays there. The kinder the partner is to him in regards to intimacy- the worse he feels that he’s letting her down. So he pulls away. If the partner then treats him badly for being a ‘lesser’ man, at least he is allowed to be angry (somewhat soothing to be able to be angry legitimately). Some may even decide to stray to see if its different with other women- it could very well be for the first couple times (novelty does make a difference) but it invariably raises it ugly head eventually. They then either ignore the situation and hope it goes away or go online for cialis or viagra or see their GP.

 

This is just one example of the people who come to see me during my time in Harley Street and my advice helped a good number of them but not all. Naturally it is not realistic to expect treatment to help everyone but I felt that there was something missing. It didn’t feel right to treat only the one symptom (when it had multiple causes) and I felt powerless to help in other ways where their main carers, their family GP, was supposed to help but couldn’t due to NHS time constraints and targets. This was a holistic problem which required a holistic approach which couldn’t realistically be dealt with in the half hour I had with my patients (I was employed then and had to go by the employer’s rules which by all accounts was a fair amount of time compared to a GP’s 10 mins). I felt like I needed much more time to educate them, to talk to them, to find out the gist of the problem, to speak to their partners, to examine them, to get a feel for my patients, to really help them.

In my search for answers, I stumbled upon age management medicine. A logical, completely evidence based form of medical practice, which prevents problems before they happen. A movement that puts the responsibility in the patient’s hands- not a bad thing- empowers a patient with knowledge and know how- keeps the patient vital with a little help from me. I signed on to learn more in the USA (where else) where the movement is gathering momentum, met more inspiring people in a week than I have in years- all people who believe in change for the better and were not afraid to put themselves out there. Passion times infinity! What a wonderful way to start the journey!

 

Bioidentical hormones are the mainstay of vitality management and my average patient will be 40-70. Occasionally I see younger people who may be depleted for any number of reasons, one of the commonest being Androgen Induced Hypogonadism (post anabolic steroids for building muscle mass). Most hormonal levels go down with age and contribute to the ‘growing old’ feel we all get. The good news is that it doesn’t really need to happen. I also have developed a special interest post pregnancy blues and menopause alongside my main interest of sexual dysfunction. However, the most important category of people that should come to me does not need to have a ‘problem’. You should just want to feel like the way you did when you were younger- vital, full of energy and life! I will equip you with the know how to do your part and I will do my part.

 

Vigor Quest – NY Times

A few years old now, but a classic in my book and the article that first got me interested in the promise of medical age management.  It was the start of my journey into understanding what can be achieved with a combination or the right lifestyle and medical treatment where needed to do what the body can no longer do for itself.