Archive for the 'Anti Aging – Hormones' Category

Jun 29 2012

FAQ on Testosterone Therapy – Women

Published by under Anti Aging - Hormones

1. What should my testosterone levels be? How do I interpret the results?
While there are no standardized, agreed upon thresholds for what is “normal” testosterone levels at this point, we do find that women who have total testosterone levels of less than 20 ng/dl and free testosterone of 0.9 or less do have symptoms of low libido and/or response.
If your testosterone is low, you can talk to your doctor about potentially replacing your testosterone. If you feel like your sexual response is low and that is feeding into your lack of interest due to pain, dryness, or lack of response or arousal, or physical release, you should consider seeking evaluation and treatment of sexual arousal disorder.

2. My doctor says I’m too young to have my levels checked. What can I tell him?
Tell your doctor that there has been evidence that even young women have low testosterone. We have found it extremely common, for instance, in pre-menopausal women after childbirth.

3. I’m taking estrogen replacement therapy. Can I have my levels checked? Does estrogen replacement affect testosterone levels?

Yes, you can have your levels checked and yes, estrogen can affect testosterone levels. When you replace estrogen without testosterone, the testosterone becomes bound to the cells, increasing something called steroid hormone binding globulin (SHBG). As less testosterone becomes available for the body to use, your levels of free testosterone decrease. You should definitely be checked, and if your testosterone levels are low think about switching to a combined replacement therapy.

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Jun 29 2012

FAQ on Testosterone Therapy – Women

Published by under Anti Aging - Hormones

1. What should my testosterone levels be? How do I interpret the results?
While there are no standardized, agreed upon thresholds for what is “normal” testosterone levels at this point, we do find that women who have total testosterone levels of less than 20 ng/dl and free testosterone of 0.9 or less do have symptoms of low libido and/or response.
If your testosterone is low, you can talk to your doctor about potentially replacing your testosterone. If you feel like your sexual response is low and that is feeding into your lack of interest due to pain, dryness, or lack of response or arousal, or physical release, you should consider seeking evaluation and treatment of sexual arousal disorder.

2. My doctor says I’m too young to have my levels checked. What can I tell him?
Tell your doctor that there has been evidence that even young women have low testosterone. We have found it extremely common, for instance, in pre-menopausal women after childbirth.

3. I’m taking estrogen replacement therapy. Can I have my levels checked? Does estrogen replacement affect testosterone levels?

Yes, you can have your levels checked and yes, estrogen can affect testosterone levels. When you replace estrogen without testosterone, the testosterone becomes bound to the cells, increasing something called steroid hormone binding globulin (SHBG). As less testosterone becomes available for the body to use, your levels of free testosterone decrease. You should definitely be checked, and if your testosterone levels are low think about switching to a combined replacement therapy.

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Sep 23 2010

Testosterone for Women?

Johns Hopkins Health Alert
Testosterone for Women

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If a woman’s sexual problems are biological rather than psychological, testosterone therapy may help.

Men may have grabbed the sexual spotlight with Viagra (sildenafil citrate) and erectile dysfunction (ED), but women are equally prone to have concerns about their sex lives. While there may not be a woman’s equivalent to Viagra, if you are concerned about sex, take comfort in knowing that you are not alone. Upwards of 43% of women report some degree of dissatisfaction with their sexual health — and help is available.

Experts believe that in women, the physical aspect of desire is governed by the male sex hormone, testosterone. Men and women produce both sex hormones, though not in equal amounts. By menopause, a woman produces 50% as much testosterone as she did in her 20s. The loss of testosterone occurs gradually over many years and is unrelated to menopause; however, its impact on desire becomes most evident around menopause, when estrogen production drops off completely. Many experts believe that boosting women’s testosterone levels will improve their libido.

The International Journal of Impotence Research recently reviewed 12 trials comparing testosterone replacement with placebo iACn postmenopausal women taking estrogen and concluded that testosterone therapy stimulates sexual desire and improves sexual satisfaction. The North American Menopause Society (NAMS) has come to similar conclusions and recommends testosterone to treat hypoactive sexual desire disorder (HSDD).

Currently, though, the only testosterone product approved by the FDA for women is Estratest, a combination of estrogen and methyltestosterone (a type of testosterone that can be taken orally). It is approved only to relieve hot flashes. Still, many doctors prescribe the treatment “off-label” — outside of its FDA-approved use — for low desire. Testosterone products approved for men also are sometimes prescribed off-label for women. Less commonly, doctors may use testosterone injections.

There are some safety concerns with long-term testosterone use. A large epidemiological study of postmenopausal women published in the Archives of Internal Medicine reported an association between an increased risk of invasive breast cancer and the use of testosterone and estrogen. NAMS recommends women use testosterone along with estrogen, as it is used in most clinical trials, but that they use it for no more than six months.

Despite these concerns, Leonard DeRogatis, Ph.D., Director of The Center For Sexual Medicine at Sheppard Pratt and a Hopkins faculty member says, “It is highly unlikely that testosterone contributes to breast cancer.” The biggest problem with transdermal (through the skin) versions of testosterone is the potential for facial hair growth and transient acne. In severe instances methyltestosterone can cause liver toxicity, but these effects can be avoided by careful monitoring. “The testosterone patch is probably the most effective delivery system; however, it is not yet available in the United States,” says Dr. DeRogatis.

Although Dr. DeRogatis believes that women will someday benefit more fully from testosterone, he says they should expect to see effective nonhormonal therapies for HSDD in the future: “Some are in the making and development is likely to be pushed along as a result of women beginning to demand more options to improve their sex life.”

Taken from the March 2007 issue of the Johns Hopkins Medical Letter: Health After 50.

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Jun 22 2010

Adrenal Fatigue – What is adrenal fatigue

The adrenal glands, two crescent-shaped glands that sit on top of each kidney, are responsible for regulating the body’s response to stress by controlling the hormones released during stress. Adrenaline, noradrenaline, cortisol, DHEA, estrogen, progesterone and testosterone are all produced in the adrenal glands. These are the hormones that regulate energy production, immune function, heart rate, muscle tone, and other processes necessary to cope with stress. Excessive stress can impair the functioning of the adrenal glands causing a decrease in the output adrenal of hormones, especially cortisol. When this occurs, it leads to adrenal fatigue.

Adrenal fatigue has been known by many other names throughout the past century, including non-Addison’s hypoadrenia, sub-clinical hypoadrenia, neurasthenia, adrenal apathy, and adrenal exhaustion. Although it affects millions of people in the U.S. and around the world, conventional medicine does not yet recognize it as a distinct syndrome. Chronic, severe fatigue is the major complaint of patients with adrenal fatigue. However, adrenal fatigue is often associated with broad spectrum non-specific symptoms making it difficult to diagnose.

What Causes Adrenal Fatigue?

The major insult to the adrenals is caused by either a very intense single stress, or by chronic, repeated stresses that have a cumulative effect. Many times the cause of adrenal fatigue is not obvious because it can be due to a combination of factors. The stress can be physical, emotional, psychological, environmental, infectious, or a combination of these. The adrenals respond to every kind of stress the same, whatever the source. Some examples of stress that can lead to improperly functioning adrenal glands include, poor diets, lack of exercise, use of stimulants (caffeine, nicotine, amphetamines), lack of sleep, lack of relaxation, illness, overwork, major surgery, financial pressures, negative altitudes and beliefs, fears, marital stress, smoking, death of a loved one, stressful job, and recurring bouts of respiratory infections.

Signs and Symptoms
Continuing fatigue not relieved by sleep
Lethargy (lack of energy)
Feeling rundown or overwhelmed
Increased effort to perform daily tasks
Decreased ability to handle stress
Gaining weight, especially around the waist
High frequency of getting the flu and other respiratory diseases
Increased time to recover from illness, injury or trauma
Less enjoyment or happiness with life
Reduced sex drive
Lightheaded when rising from a horizontal position
Thoughts less focused, more fuzzy and memory less accurate
Afternoon low between 3 to 5 pm
Feel better suddenly for a brief period after a meal
Feel more awake, alert and energetic after 6 pm than during the day
Often feel tired from 9 – 10 pm, but resist going to bed
Need coffee or stimulants to get going in the morning
Cravings for salty, fatty, and high protein food such as meat and cheese
Increased symptoms of PMS for women
Pain in the upper back or neck with no apparent reason
Difficulties in getting up in the morning
Mild depression
Food and or inhalant allergies
Dry and thin skin
Hypoglycemia
Low body temperature
Nervousness
Palpitation
Unexplained hair loss
Alternating constipation and diarrhea
Diagnosis

None of the standard laboratory tests currently in use are designed to detect adrenal fatigue. However, there are tests that may contribute to an assessment. One such test, known as postural hypotension, occurs if blood pressure drops when a person stands up from a lying position. Postural hypotension almost always indicates low adrenal function. Another test involves checking cortisol levels either in blood, saliva or urine. Cortisol levels vary throughout the day and are highest between 6-8am. A low 8:00am plasma cortisol level can indicate poorly functioning adrenal glands. Some clinicians prefer testing cortisol levels in saliva because cortisol levels fluctuate during the day. Checking salivary cortisol can easily be done 4 or more times in a day and may detect an abnormality missed by a single blood test. The ACTH (adrenocorticotropic hormone) stimulation test can also used to diagnose poor adrenal function. ACTH is a pituitary hormone that stimulates the adrenal glands to secrete cortisol. When ACTH is injected, there should be an increase in cortisol production. If this does not happen, adrenal fatigue is probable.

Treatment

Treatment begins with an attempt to relieve stressful situations as much as possible. Initiate lifestyle changes, including diet modification and exercise. Limit the consumption of processed foods, alcohol and tobacco because these substances put extra stress on the adrenal glands. Take small breaks to lie down during the day, increase relaxation, eat regular meals, exercise regularly, get to bed early and sleep until at least 9:00 a.m. whenever possible. Try laughing because it increases parasympathetic output which reduces stress and blunts the release of excessive cortisol. Remove negative people from your life and do something fun each day

Below is a list of nutritional supplements that may also offer additional benefits to patients experiencing adrenal fatigue.

Vitamin C 2,000-4,000 mg/day
DHEA 50 mg a day
L-theanine 100-400 mg a day
Vitamin E w/mixed tocopherols 800 IU/day
Vitamin B complex
Melatonin 300 mcg-6 mg (at bedtime)
Niacin (125-150 mg/day) – as inositol hexaniacinate
B-6 150 mg/day
Phosphatidylserine capsules 300 mg a day
Pantothenic acid 1200-1500 mg/day
Magnesium citrate 400-1200 mg
Liquid trace minerals (zinc, manganese, selenium, chromium, molybdenum, copper, iodine)– calming effect

If depression is present – Add SAM.e 200 mg bid; DL-Phenylalanine (DLPA) 500 mg bid
Licorice (Glycyrrhiza glabra) no more than 1000 mg of glycyrrhizin
A diet that would be conducive to treating adrenal fatigue includes one that combines unrefined carbohydrates (whole grains) with protein and oils at most meals—olive, walnut, fiber, flax and high-quality fish oil. It is also important for patients to eat regular meals, avoid junk food and eat a diet with emphasis on vegetables. It may be of additional benefit that patients add sea salt to their diet.
Some herbal remedies that have been noted as possible therapies include Licorice, Ashwagandha, Maca, Siberian Ginseng, and Korean Ginseng. There are several glandular extracts on the market that contain adrenal, hypothalamus, pituitary, thyroid, and gonads that are also often recommended. Physiologic replacement of oral cortisone, DHEA, Pregnenolone, and Progesterone under the supervision of a physician may also be very helpful.

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Aug 03 2009

Progesterone deficiency

Do you suffer from anxiety, depression, irritability, insomnia, muscle pain, inflammation, osteoporosis, decreased HDL-cholesterol levels, weight gain, breast tenderness, decreased libido, heavy periods, dizziness, difficulty concentrating, extreme changes in mood, bloating, and urinary incontinence? If so, you may be deficient in progesterone. Other possible symptoms of low progesterone may include frequent urinary tract infections, interstitial cystitis, changes in appetite, hot flashes, chills and night sweats. Progesterone plays a key role in the tasks necessary for reproduction. Beyond preparation for pregnancy, progesterone has a multitude of effects throughout the body, many of which help oppose the action of estrogen. Numerous physical and psychological problems can be caused by an imbalance between estrogen and progesterone including the symptoms listed above.

A number of factors can cause low progesterone levels. Including:

Stress

Antidepressants

Sugar

Saturated fat

Deficiency of vitamins A, B6, C, zinc

Decreased thyroid hormone

Impaired progesterone production

Excessive arginine consumption

Increased prolactin production

Natural or bio identical progesterone vs. synthetic Progestin

Progesterone is often confused with Progestin. Progestins are synthetic hormones made to mimic the actions of progesterone but have many negative side effects. Bio identical progesterone (also sometimes referred to as natural or human identical) is made from soy or yam and has the exact molecular structure as progesterone made in the human body. Bio identical progesterone is protective against uterine and breast cancer, balances estrogen, acts as a diuretic, builds bone, aids in sleep, restores libido, lowers cholesterol, increases scalp hair, decreases PMS symptoms, decreases carbohydrate cravings and has a natural calming effect. Progestins on the other hand have been known to cause blood clots, fluid retention, acne, weight gain, depression, an increase in heart disease and diabetes.

Griffin Medical prescribes only bio identical progesterone to patients that are deficient after a thorough physical exam and check of blood levels.

Judi Goldstone M.D.

1650 Adams Avenue

Costa Mesa, CA 92626

(714) 549-6580

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Jul 15 2009

The Effects of Estrogen

The importance of balanced and adequate levels of estrogen is tantamount to good health in women.

What are the symptoms and causes of excessive estrogen?

Excessive estrogen, also referred to as estrogen dominance, can cause many unpleasant symptoms and lead to some very serious health issues. Over-stimulation from estrogen of the breast tissue can cause tenderness, swelling, and fibrocystic breasts. In the uterus, excess estrogen stimulation may lead to endometriosis, cervical dysplasia, increased risk of uterine cancer, heavy or irregular menses, menstrual cramping and uterine fibroid tumors. Excessive estrogen can also cause weight gain, constipation, cyclical headaches and migraines, depression, mood swings, fluid retention, low libido, and anxiety.

Women can become estrogen dominant for many reasons. Lack of exercise, impaired elimination of estrogen, not taking in enough dietary fiber, lack of adequate amounts of progesterone to balance estrogen, using birth control pills, and environmental exposure.. Estrogen mimickers are everywhere in the environment in the form of chemicals (xenoestrogens), and foods and plants (phytoestrogens). Pesticides are perhaps the biggest source of xenoestrogens followed by plastics, fuels, drugs, cosmetics, non organic meats and some dairy products. Here are some key points to reducing estrogen dominance:

• Avoid chemical sources of estrogen (xenoestrogen)
• Avoid food sources of estrogen (phytoestrogens)
• Cleanse the liver
• Reduce stress
• Balance Hormones with bio identical estrogen and progesterone
• Metabolize excess estrogen using a supplement like DIM or Breast Health Complete
• Do not heat food in plastic
• Drink out of glass containers, not plastic or Styrofoam
• Exercise

Judi Goldstone M.D.
Board Certified Internal Medicine
Specializing in Age Management Medicine and
Bioidentical Hormone Replacement Therapy
1650 Adams Avenue
Costa Mesa, CA 92626
www.griffinmedical.com
(714) 549-6580

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Jan 20 2009

Turmeric Component Protects Against Toxic Compound Consumed in Many Meals

Curcumin, the pigment that gives turmeric its yellow color, may reduce the damaging effects of acrylamide (AA), a potential carcinogen created when starchy foods are baked, roasted, fried or toasted.

Swedish scientists first reported on acrylamide’s widespread presence in the food supply in 2002, when they found unexpectedly high levels of acrylamide in carbohydrate-rich foods. This was of concern since the toxin causes cancer in laboratory rats. Other scientists have found that acrylamide causes DNA to fragment, increases formation of damaging reactive oxygen species (ROS) and triggers the death of liver cells. It is also genotoxic, meaning that it damages a cell’s genetic material affecting the cell’s integrity. Genotoxic substances have the potential to be carcinogens and can cause genetic mutations that lead to the development of tumors.

Due to its antioxidant abilities, researchers studied curcumin’s effects on human liver cells exposed to acrylamide. They found that curcumin significantly reduced the production of reactive oxygen species that occurred in acrylamide-treated cells. Curcumin also inhibited the acrylamide-induced DNA fragments and significantly reduced the acrylamide-triggered cell death, indicating curcumin could ameliorate acrylamide’s known genotoxicity.

The researchers believe that curcumin’s effects are likely due to its antioxidant abilities. They concluded, “Consumption of curcumin may be a plausible way to prevent AA-mediated genotoxicity.”

Reference:

Cao J, Liu Y, Jia L, Jiang LP, Geng CY, Yao XF, Kong Y, Jiang BN, Zhong LF. Curcumin Attenuates Acrylamide-Induced Cytotoxicity and Genotoxicity in HepG2 Cells by ROS Scavenging. J Agric Food Chem. 2008 Nov 14. Published Online Ahead of Print.

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Jan 20 2009

Grape Seed Extract May Stop Bacteria Involved in Bad Breath and Gum Disease

A new study suggests that grape seed extract may inhibit the bacteria known to cause bad breath and gum disease.

Periodontitis is a gum disease that destroys the soft tissue and bone supporting the teeth. Thirty to 50 percent of the US population suffers from the condition, which is thought to be the second most common disease worldwide.

In an in vitro study, researchers investigated whether grape seed extract could inhibit Porphyromonas gingivalis and Fusobacterium nucleatum, bacteria responsible for both periodontitis and bad breath. The researchers tested the effects of grape seed extract (97 percent polyphenols) on these two anaerobic bacteria.

The results indicated that grape seed extract exhibited antibacterial activity against the two strains. Moreover, the grape seed extract could penetrate the biofilm that surrounded the bacteria. Biofilms serve to protect bacteria against antimicrobial agents and dental plaque’s biofilm is particularly complex.

Grape seed extract also had an antioxidant activity higher than vitamins C and E, according to measures taken with the Trolox equivalent antioxidant capacity (TEAC) test. This was important to the findings of the study because gum disease originates due to the bacteria’s presence and its biofilm protection, but the disease progresses because of an excess release of reactive oxygen species that trigger the inflammatory process. Grape seed extract’s antioxidant abilities may quench the free radicals implicated in the progression of gum disease.

The researchers concluded, “These findings indicated that GSE could be used in oral hygiene for the prevention of periodontitis.”

Reference:

Furiga A, Lonvaud-Funel A, Badet C. In vitro study of antioxidant capacity and antibacterial activity on oral anaerobes of a grape seed extract. Food Chemistry. 15 April 2009;113( 4);1037-1040. Available online prior to April publication date.

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Jan 20 2009

Low Antioxidant Levels Linked to Asymptomatic Coronary Artery Disease

Low plasma concentrations of the antioxidant vitamins A and E and the carotenoids beta carotene and lycopene are significantly associated with atherosclerosis of the carotid arteries, a new study has found.

Atherosclerosis remains clinically mute for a long time and frequently manifests itself with an acute cardiovascular event. The possibility of detecting this disease in a subclinical phase and reducing or reversing its progression is therefore an issue of relevance.

Researchers studied 220 consecutive, asymptomatic participants and examined their carotid arteries by ultrasound to determine the thickness of the arteries and whether the arteries had developed pre-atherosclerotic lesions. A medical history also was taken, a physical examination was performed and blood samples were analyzed for concentrations of antioxidant vitamins and carotenoids.

The scientists found that low concentrations of vitamin A, vitamin E, lycopene and beta carotene were significantly associated with carotid atherosclerosis as measured by increased thickness of the carotid arteries. In addition, marginally higher body mass index and low levels of high-density lipoprotein cholesterol were also associated with carotid atherosclerosis. Other factors considered in the study (total cholesterol, low-density lipoprotein cholesterol, triglycerides and C-reactive protein) were not significantly associated with carotid atherosclerosis.

According to the researchers, “Low plasma concentrations of antioxidant vitamins (vitamins A, E and beta-carotene) and lycopene were associated with early carotid atherosclerotic lesions as measured by carotid intima-media thickness (CIMT). Regular intake of foods rich in lycopene and antioxidant vitamins may slow the progression of atherosclerosis.”

Reference:

Riccioni G, Bucciarelli T, D’Orazio N, Palumbo N, di Ilio E, Corradi F, Pennelli A, Bazzano LA. Plasma Antioxidants and Asymptomatic Carotid Atherosclerotic Disease. Ann Nutr Metab. 2008 Oct 21;53(2):86-90.

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Jan 20 2009

The Latest Research on Fatigue, Heart Health, Cognitive Function and More

Omega-3s Linked to Prostate Health

Men who increase their intake of omega-3-rich fish have a greater chance of surviving prostate cancer, according to a new study.

Researchers studied 20,167 men who were participating in the Physician’s Health Study. The subjects were free of cancer in 1983, when the study began. During follow-up, 2,161 men were diagnosed with prostate cancer and 230 died of the disease.

Although intake of omega-3-rich fish was unrelated to prostate cancer incidence, it was linked to survival from the disease. Among the men diagnosed with prostate cancer, those consuming fish five or more times per week had a 48 percent lower risk of prostate cancer death than did men consuming fish less than once weekly.

In this study the scientists found no link between fish consumption and a reduced incidence of prostate cancer, but the same researchers conducted an earlier study that found higher intake of the omega-3 fatty acids DHA (docosahexaenoic acid) and EPA (eicosapentaenoic acid) may reduce the risk of developing prostate cancer by 41 percent.

Reference:

Chavarro JE, Stampfer MJ, Hall MN, Sesso HD, Ma J. A 22-y prospective study of fish intake in relation to prostate cancer incidence and mortality. Am J Clin Nutr. 2008 Nov;88(5):1297-303.

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Oct 23 2008

Confusion Over Hormone Replacement Therapy – By Judi Goldstone

Published by under Anti Aging - Hormones

Women are confused, and can you blame them? Ever since the Women’s Health Initiative (WHI), hormonal replacement therapy (HRT) has become an extremely controversial topic, especially since a lot of physicians themselves have a problem explaining the results.

Dr. Judi Goldstone at Griffin Medical Group recently sat down and answered questions on the subject of bio-identical hormone replacement for women. Dr. Goldstone is an expert on the subject and these are comments to questions that were submitted to her blog.

Dr. Goldstone is a board certified internal medicine specialist and Director of the Age Management program at Griffin Medical Group. Dr. Goldstone is also an active member of the American Society of Anti-Aging Medicine (A4M).


Question
: What is the theory behind bio-identical hormone replacement therapy (HRT) in menopausal women?

Dr. Goldstone: When it comes to disease, conventional medicine will restore of low levels of thyroid, insulin and cortisol. This would be the standard and typical medical treatment. Thus, it seems logical to also replace estrogen, progesterone, testosterone growth hormone when a person has low levels of those hormones. However, the evidence leaves clinicians at a loss for clear direction, because different studies, using a variety of types of hormones, methods of hormone administration, and women of different ages, have produced conflicting results.

Question: What are the Normal Hormone Ratios?

Dr. Goldstone: There are three predominant estrogens in non-pregnant, pre-menopausal women: estrone (E1), estradiol (E2) and estriol (E3). These naturally occur in different relative amounts. Typically, E1 will make up 10 to 20 percent of total estrogen, E2 will make up another 10 to 20 percent and E3 will comprise the remaining 60 to 80 percent of total estrogen.

This ratio is protective, because the bulk of estrogen is comprised by the weakest estrogen, E3, which is also the most protective against blood clots and breast cancer. E2 is the strongest estrogen, and E1 is the storage form of estrogen. E1 is sometimes considered the “least desirable” estrogen, because it can stimulate breast tissue production and blood clots. E1 can be metabolized and excreted by the liver, but if the liver systems are overwhelmed or if vitamins B12 and folic acid are deficient, E1 is converted to quinines. These can be mutagenic and carcinogenic, and thus could ultimately lead to cancer and other health problems.

Question: What are bio-identical hormones and how can they mimic protective ratios?

Dr. Goldstone: Estrogen-like hormones can be obtained from horses, soy and yams, but these hormones do not fit exactly into the human receptors. By contrast, bio-identical hormones are an exact match, molecule for molecule, to the hormones produced naturally by a woman’s body. They fit the hormone receptor just like a key fits into its lock, and the body cannot distinguish between a bio-identical hormone and the hormones it makes itself.

Bio-identical hormones can be made in several ways. Sometimes they are created by modifying soy or yam — any molecule that does not exist on the human hormone counterpart is removed. They are produced synthetically in the laboratory to make bio-identical estrogen, testosterone and progesterone transdermal creams and gels.

Question: How are bio-identical hormones prescribed by doctors who use them today?

Dr. Goldstone: The goal is to re-establish the normal protective ratio, a 20:80 ratio of E2 to E3, and avoid E1 altogether. This formula is called Bi-est. Estrogen that comes in the form of a transdermal cream mimics normal ratios better than estrogen that is taken in pill form, because the estrogen pill first has to pass through the liver, where 50 percent is converted into E1 (“bad” estrogen) before being circulated to tissues.

Estrogen applied through a transdermal cream enters the blood at the same ratio in which it is applied to the skin, with no chance for alteration by the liver. Many studies suggest that estrogen administered through a transdermal cream decreases thrombosis, blood pressure, triglycerides and vascular resistance, as opposed to the pill form of estrogen, which is known to increase these effects and can also cause other problems.

Question: Hormone replacement studies have raised questions about the health risks associated with traditional menopause treatment, what has happened since then?

Dr. Goldstone: The Women’s Health Initiative (WHI) was a large study, sponsored by the National Institute of Health, which greatly influenced how American doctors prescribe hormones and how American women receive them. Millions of women stopped hormone replacement therapy (HRT) because of the study’s findings.

But, as with any medical study, there were many problems. The researchers did not take “quality of life” into account. They did not use estrogens in favorable ratios and they did not test hormones that were administered via a transdermal cream. The estrogen used by women in the study was a synthetic, non bio-identical and oral conjugated estrogen from a pregnant mare’s urine called Premarin, which is known to increase the risk of thrombosis and cancer. The study also used the oral estrogen mentioned above combined with progestin, which is a synthetic and non bio-identical progesterone and this to can increase the risk cardiovascular disease and cancer.

Another problem with the study was the age of the women involved. The researchers should have started women on hormone therapy before they developed significant vascular disease, by age 55, instead of at an average age of 63 and higher.

Finally, the researchers should have insisted on media coverage of some of the positive findings they later discovered in their data analysis. Since that study, many American women and their doctors have found an alternative treatment via the bio-identical hormone approach.

Unfortunately, there are no studies on bio-identical hormones comparable to the size of the WHI study available yet. While there is no question that more studies on bio-identical hormone therapies are needed, a large body of evidence points to the potential advantages of the bio-identical approach.

Yours in health,

Griffin Medical Group

www.griffinmedical.com

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Sep 05 2008

Hypothyroidism – by Judi Goldstone, M.D.

Hypothyroidism

Hypothyroidism is a disease state whereby the thyroid gland fails to produce enough thyroid hormone. Epidemiology

In the United States studies have shown the prevalence of hypothyroidism to be anywhere from 3-10%. Internationally the prevalence has been reported as 2-5%, increasing to 15% by age 75 years. Cretinism refers to congenital hypothyroidism, which has been estimated to affect one per 4000 newborns. However, the numbers could be higher due to many cases that go undetected. Even when lab tests are in the “normal range” one must remember normal for one person may be inadequate for someone else. In my practice I look at each patient as an individual and optimize their thyroid function based on symptoms, clinical exam and lab findings. Hypothyroidism is one of the most under diagnosed hormonal imbalances of aging. It is more common in women than men and the incidence increases with age. Other risk factors include having a family history of thyroid problems, a history of chronic fatigue syndrome, female gender, age greater than 50 yrs, exposure to radiation, chemical exposure (flouride, perchlorate), obesity or a history of thyroid surgery.

Thyroid structure and function

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Jun 27 2008

DHEA – A Naturally Safe and Effective Pro-Hormone

“A number of biological indices confi rmed the lack of harmful consequences of this 50 mg/day DHEA administration over one year, also indicating that this kind of replacement therapy normalized some effects of aging, but does not create “supermen/women” (doping).”

Proceedings of the National Academy of Science USA, 2000; 97:4279-84

Dehydroepiandrosterone (DHEA) is a naturally occurring pro-hormone produced primarily by the adrenal glands, testes in men or ovaries in women, while small amounts are also created in the liver and brain. It is known as a “precursor hormone” since it is produced in large amounts in the body and serves as the progenitor for other hormones to be produced such as estrogen and testosterone. Within both the male and female body, DHEA increases dramatically before puberty in children, usually peaks when we’re in our mid-20s, and drops off from this peak throughout the aging process. By the 40th birthday most people have a mere 50 percent of their former youthful levels. It is currently believed that this dramatic and persistent drop in DHEA is related to the aging process, including loss of muscle mass, weight gain, decreased zeal for life, diminished mental clarity, decreased bone density and countless other signs of aging.

Overview

One can succinctly summarize the role of DHEA in the human body as essential for maintaining quality of life and optimal performance. With the dramatic and persistent drop of DHEA levels during the aging process, there is no question that the ability to augment levels is essential and a liberty that should be enjoyed by all those that need to buffer age-related decreased levels or who suffer from health conditions that have been demonstrated to benefit from supplementation.

The clinical research on the use of DHEA is significant and the safety window is broad when used at reasonable and appropriate doses. As the following research summary stated: “Administration of low doses (25 mg) of DHEA positively modulates several endocrine parameters in early and late postmenopausal women, inducing the increase of the androgenic, estrogenic, and progestogenic milieu and reducing the climacteric symptoms, similarly to estroprogestin replacement therapy.”1 Thus, the conclusion is that DHEA can be as effective as hormone replacement therapy at a fraction of the cost to the American Healthcare System.

Basic Biochemistry of DHEA

DHEA and its sulfate ester, dehydroepiandrosterone sulfate (DHEA-S), are interconvertible. The importance of DHEA to human performance is well illustrated by the fact that DHEA is converted to DHEA-S, which serves as a storage form of DHEA.2-3 It is the storage of this dynamic “precursor” pro-hormone that emphasizes its critical biochemical function. When needed, DHEA-S is then converted by the body’s tissues and target organs back to DHEA. It is at the cellular level that DHEA is then converted as needed to other hormones.4

At normal, healthy levels, the concentration of DHEA-S is 100 to 500 times higher than testosterone and 1,000 to 10,000 times higher than estradiol, the body’s most potent estrogen. It is essential to realize that though DHEA serves as a precursor to sex steroid

Circulatory disease is the number one cause of death in the United States and there is now evidence that DHEA can help support the health of the 18,000 miles of the microvascular system within the body.

hormones, it does not perform a direct estrogenic or androgenic role.5 Both DHEA and DHEA-S levels are higher in men than in women and they peak at about 20 years of age and decline rapidly after age 25.6 There is a direct correlation with increased mortality and very low levels of DHEA-S in men under the age of 70. Furthermore, men who smoke and have low DHEA-S levels seem to have a mortality risk more than 6 times greater than nonsmokers with high DHEA-S levels.7

The risk of the body accumulating high levels of DHEA with supplementation of 50 mg of DHEA or less is modest at best. The highly esteemed scientific journal

Proceedings of the National Academy of Science in 2000 reported:

“Two hundred and eighty healthy individuals (women and men 60-79 years old) were given DHEA, 50 mg, or placebo, orally, daily for a year in a double-blind, placebo-controlled study. No potentially harmful accumulation of DHEA-S and active steroids was recorded. Besides the reestablishment of a ‘young’ concentration of DHEA-S, a small increase of testosterone and estradiol was noted, particularly in women, and may be involved in the significantly demonstrated physiological-clinical manifestations here reported. Bone turnover improved selectively in women over 70 years old, as assessed by the dual-energy x-ray absorptiometry (DEXA) technique and the decrease of osteoclastic activity. A significant increase in most libido parameters was also found in these older women. Improvement of the skin status was observed, particularly in women, in terms of hydration, epidermal thickness, sebum production, and pigmentation.

A number of biological indices confirmed the lack of harmful consequences of this 50 mg/day DHEA administration over one year, also indicating that this kind of replacement therapy normalized some effects of aging, but does not create “supermen/women” (doping).”49

Consequences of Lower DHEA Levels

There are several health conditions that seem more prevalent in individuals with lower DHEA levels. The conditions frequently associated with lower levels of DHEA include; but

ted to.8, 9, 10

are not limi

* Anorexia nervosa

* Chronic fatigue

* Congestive heart failure

* Depression

* Diabetes mellitus Type 2

* Erectile dysfunction

* Kidney disease (End-Stage)

* Schizophrenia

* Systemic lupus erythematosus (SLE)

Circulatory disease is the number one cause of death in the United States and there is now evidence that DHEA can help support the health of the 18,000 miles of the microvascular system within the body. The mechanism for this protective effect appears to arise from the inhibition of thromboxane A2 synthesis in platelets; this decrease in thromboxane A2 is accompanied by increased levels of insulin-like growth factor 1 (IGF-1), cyclic guanosine monophosphate (GMP) and nitric oxide synthesis.11 The ability of DHEA to naturally optimize this essential biochemical pathway and the fact that there is a significant drop in DHEA during aging, may account for the increased frequency of heart disease and the associated escalating economic costs of heart disease during the aging process.

Safe and Natural

Dehydroepiandrosterone when used orally and appropriately in the short-term has been shown in numerous studies to be safe and effective for many months.12, 13, 14, 15, 16, 17

Additional studies have used oral DHEA for 12-24 months.18, 19, 20 Another study, lasting twelve months, investigated intravaginally DHEA use with reported safety in postmenopausal women.21 DHEA is well absorbed orally and possesses a serum half-life of 15 to 38 minutes; whereas the half-life of DHEA-S is longer, at 7-22 hours. The kidneys are the primary route of elimination and account for the clearance of 51 percent to 73 percent of DHEA-S and its metabolic endproducts.12

DHEA Clinical Research Applications

There are over two dozen therapeutic applications for DHEA supplementation. The following are some of the areas that have been studied by researchers and reported in the peer-reviewed medical literature.

Adrenal Insuffi ciency

Taking low-dose DHEA orally (20-50 mg daily) has been associated with increased sense of well-being, healthier skin and hair and enhanced sexuality in women with low

23

pituitary function.22,

Addison’s Disease

Preliminary clinical evidence suggests that oral DHEA might improve symptoms of Addison’s disease.24

Aging Skin

Oral DHEA supplementation has been shown to increase epidermal skin thickness, skin hydration, and lessen facial skin discoloration in aging women and men.25

Congestive Heart Failure

Clinical researchers have reported, in a study conducted in the year 2000, that: “These results indicate that the plasma levels of DHEA-S are decreased in patients with CHF in proportion to its severity and that oxidative stress is associated with decreased levels of DHEA-S in patients with CHF.”26

Depression

Clinical use of DHEA to help lessen symptoms of depression and dysthymia (chronic depression) appear promising as reflected in a 1999 study report that states: “These results suggest that DHEA treatment may have significant antidepressant effects in

on.”27, 28

some patients with major depressi

Erectile Dysfunction (ED)

When oral DHEA is taken for 24 weeks, ED symptoms improve along with orgasmic function, libido, and overall satisfaction. Men suffering from ED secondary to high blood pressure or idiopathic causes were those that responded significantly to DHEA treatment.29, 30

Menopausal Symptoms

A 2003 report concluded, “Administration of low doses (25 mg) of DHEA positively modulates several endocrine parameters in early and late postmenopausal women, inducing the increase of the androgenic, estrogenic, and progestogenic milieu and reducing the climacteric symptoms, similarly to estroprogestin replacement therapy.”31

Metabolic Syndrome

Oral use of DHEA, 50 mg daily for 6 months, lead to significant weight reduction, less abdominal fat and improved insulin levels. The Journal of the American Medical Association published a report in 2004 that made the following conclusion, “DHEA replacement could play a role in prevention and treatment of the metabolic syndrome associated with abdominal obesity.”32 With approximately 50 million Americans suffering from Metabolic Syndrome according to the Centers for Disease Control (CDC), this application for DHEA could help lessen the current conversion rate to diabetes that is at a staggering 1.5 million new cases per year.

Osteoporosis

Older men and women with osteoporosis or osteopenia have benefited from an oral dose of DHEA at 50-100 mg daily. These study participants experienced increased bone density.33, 34 Likewise, young women with osteoporosis secondary to anorexia nervosa can often benefit.35

Systemic Lupus Erythematosus (SLE)

Compelling evidence suggests that DHEA administered orally in conjunction with standard medical treatment, can help lessen SLE disease activity, frequency of flare-ups, and the number of glucocorticosteroid doses

38, 39, 40, 41

needed.36, 37,

Vaginal atrophy

Vaginally, application of DHEA appears to be effective for the treatment of vaginal atrophy in postmenopausal women and may also confer a secondary benefit of increased bone mineral density.42

Common Clinical Dosing in Research Studies

Please note that none of the research presented in this paper is intended to serve as either treatment or diagnosis, but rather a clear demonstration of the safety and efficacy of appropriately used DHEA. In that spirit, the information that follows is simply a reflection of some representative dosages of DHEA used in clinical trials around the world. It should be noted that in order to conduct a human study, approval by an IRB (Institutional Review Board) is essential to ensure safety. Thus, the IRB process designed to protect participants in research studies must have deemed these dosages to be safe and reasonable.

In postmenopausal women, doses of 25-50 mg daily are commonly used with benefits of lessened menopausal symptoms, improved tissue insulin sensitivity and lower

44, 45, 46

serum triglycerides readings.43,

In cases of depression, doses of DHEA between 30-90 mg daily have been used, either as a stand alone intervention or in conjunction with standard antidepressant therapy. A double blind clinical trial published in 1999 reported, “These results suggest that DHEA treatment may have significant antidepressant effects in some patients with major depression.”47 An earlier 1997 study reported

It is essential to realize that though DHEA serves as a precursor to sex steroid hormones, it does not perform a direct estrogenic or androgenic role.

The Journal of the American Medical Association

published a report in 2004 that made the following conclusion, “DHEA replacement could play a role in prevention and treatment of the metabolic syndrome associated with abdominal obesity.”32

clinical benefits plus improved memory: “These preliminary data suggest DHEA may have antidepressant and promemory effects, and should encourage double-blind trials in depressed patients.”48

A schizophrenia study used increasing doses of DHEA of 25 mg daily for 2 weeks, 25 mg two times daily for 2 weeks, and 50 mg two times daily for 2 weeks. This significant 2003 report of DHEA use and schizophrenia states, “Our preliminary observations report for the first time in double-blind fashion, the efficacy of DHEA augmentation in the management of negative, depressive, and anxiety symptoms of schizophrenia. The findings from this study raise important issues regarding the role of neurosteroids in general, and DHEA in particular, in the ongoing symptomatology and pharmacotherapy of schizophrenia.”16 Dosing for systemic lupus erythematosus (SLE), can be upwards of 200 mg daily, used as addition to standard SLE medical treatment protocols.27

Bone mineral density studies investigating treatment for osteopenia or osteoporosis often use DHEA levels in the range of 50-100 mg per day.33

An erectile dysfunction study utilizing 50 mg of DHEA daily has been conducted. The researchers’ conclusion was simple, “Our results suggest that oral DHEA treatment may be of benefit in the treatment of ED.”18

In the case of prediabetes, also known as metabolic syndrome, 50 mg taken orally at bedtime was employed.33 The result of this study showed that DHEA replacement could play a role in prevention and treatment of the metabolic syndrome associated with abdominal obesity.

Conclusion

The review of the peer-reviewed medical literature clearly demonstrates not only the safety of appropriately used dosages of DHEA, it also elucidates that DHEA can help tens of millions of people alleviate the symptoms produced by drops in DHEA associated with aging and help mitigate various health conditions by optimizing DHEA levels. Clear and convincing evidence is in the medical literature; in addition, IRB boards from around the world have approved the use of DHEA in human clinical trials with a solid record of both safe and effective use. As discussed earlier in this report and stated so aptly in the findings of one of the world’s most revered medical journals, DHEA is not a “doping substance.” Scientific research has documented that DHEA helps normalize the aging process, a beneficial liberty that all humanity must be able to freely partake. Therefore, in conclusion, I will once again quote the above study that demonstrates DHEA’s safety:

A number of biological indices confirmed the lack of harmful consequences of this 50 mg/day DHEA administration over one year, also indicating that this kind of replacement therapy normalized some effects of aging, but does not create “supermen/women” (doping).”49

References

1 Genazzani AD, Stomati M, Bernardi F, et al. Long-term low-dose dehydroepiandrosterone oral supplementation in early and late postmenopausal women modulates endocrine parameters and synthesis of neuroactive steroids. Fertil Steril 2003;80:1495-501. 2 Moffat SD, Zonderman AB, Harman M, et al. The relationship between longitudinal declines in dehydroepiandrosterone sulfate concentrations and cognitive performance in older men. Arch Int Med 2000;160:2193-8. 3 Pepping J. DHEA: dehydroepiandrosterone. Am J Health Syst Pharm 2000;57:2048-50, 2053-4, 2056. 4 Oelkers W. Dehydroepiandosterone for adrenal insufficiency (editorial). N Engl J Med 1999;341:1073-4. 5 Tchernof A, Labrie F. Dehydroepiandrosterone, obesity and cardiovascular disease risk: a review of human studies. Eur J Endocrinol 2004;151:1-14. 6 Villareal DT, Holloszy JO. Effect of DHEA on abdominal fat and insulin action in elderly women and men. JAMA 2004;292:2243-8. 7 Mazat L, Lafont S, Berr C, et al. Prospective measurements of dehydroepiandrosterone sulfate in a cohort of elderly subjects: relationship to gender, subjective health, smoking habits, and 10-year mortality. Proc Natl Acad Sci U S A 2001;98:8145-50. 8 Kroboth PD, Salek FS, Pittenger AL, et al. DHEA and DHEA-S: A review. J Clin Pharmacol 1999;39:327-48. 9 Kuratsune H, Yamaguti K, Sawada M, et al. Dehydroepiandrosterone sulfate deficiency in chronic fatigue syndrome. Int J Mol Med 1998;1:143-6. 10 Reiter WJ, Pycha A, Schatzl G, et al. Serum dehydroepiandrosterone sulfate concentrations in men with erectile dysfunction. Urology 2000;55:755-8. 11 Pepping J. DHEA: dehydroepiandrosterone. Am J Health Syst Pharm 2000;57:2048-50, 2053-4, 2056. 12 Arlt W, Callies F, van Vlijmen JC, et al. Dehydroepiandosterone replacement in women with adrenal insufficiency. N Engl J Med 1999;341:1013-20. 13 Casson PR, Andersen RN, Herrod HG, et al. Oral dehyroepiandosterone in physiologic doses modulates immune function in postmenopausal women. Am J Obstet Gynecol 1995;1536-9. 14 Wit JM, Langenhorst VJ, Jansen M, et al. Dehydroepiandrosterone sulfate treatment for atrichia pubis. Horm Res 2001;56:134-9. 15 Strous RD, Maayan R, Lapidus R, et al. Dehydroepiandrosterone augmentation in the management of negative, depressive, and anxiety symptoms in schizophrenia. Arch Gen Psychiatry 2003;60:133-41. 16 Stomati M, Monteleone P, Casarosa E, et al. Six-month oral dehydroepiandrosterone supplementation in early and late postmenopause. Gynecol Endocrinol 2000;14:342-63. 17 Piketty C, Jayle D, Leplege A, et al. Double-blind placebo-controlled trial of oral dehydroepiandrosterone in patients with advanced HIV disease. Clin Endocrinol (Oxf) 2001;55:325-30. 18 Van Vollenhoven RF, Morabito LM, Engleman EG, et al. Treatment of systemic lupus erythematosus with dehydroepiandrosterone: 50 patients treated up to 12 months. J Rheumatol 1998;25:285-9. 19 Baulieu EE, Thomas G, Legrain S, et al. Dehydroepiandrosterone (DHEA), DHEA sulfate, and aging. Contribution of the DHEAge study to a sociobiomedical issue. Proc Natl Acad Sci U S A 2000;97:4279-84. 20 Genazzani AD, Stomati M, Bernardi F, et al. Long-term low-dose dehydroepiandrosterone oral supplementation in early and late postmenopausal women modulates endocrine parameters and synthesis of neuroactive steroids. Fertil Steril 2003;80:1495-501. 21 Labrie F, Diamond P, Cusan L, et al. Effect of 12 month dehydroepiandrosterone replacement therapy on bone, vagina, and endometrium in postmenopausal women. J Clin Endocrinol Metab 1997;82:3498-505. 22 Arlt W, Callies F, van Vlijmen JC, et al. Dehydroepiandosterone replacement in women with adrenal insufficiency. N Engl J Med 1999;341:1013-20. 23 Johannsson G, Burman P, Wiren L, et al. Low dose dehydroepiandrosterone affects behavior in hypopituitary androgen-deficient women: a placebo-controlled trial. J Clin Endocrinol Metab 2002;87:2046-52. 24 Kim SS, Brody KH. Dehydroepiandrosterone replacement in Addison’s disease. Eur J Obstet Gynecol Reprod Biol 2001;97:96-7. 25 Baulieu EE, Thomas G, Legrain S, et al. Dehydroepiandrosterone (DHEA), DHEA sulfate, and aging. Contribution of the DHEAge study to a sociobiomedical issue. Proc Natl Acad Sci U S A 2000;97:4279-84. 26 Moriyama Y, Yasue H, Yoshimura M, et al. The plasma levels of dehydroepiandrosterone sulfate are decreased in patients with chronic heart failure in proportion to the severity. J Clin Endocrinol Metab 2000;85:1834-40. 27 Wolkowitz OM, Reus VI, Keebler A, et al. Double-blind treatment of major depression with dehydroepiandosterone. Am J Psychiatry 1999;156:646-9. 28 Bloch M, Schmidt PJ, Danaceau MA, et al. Dehydroepiandrosterone treatment of midlife dysthymia. Biol Psychiatry 1999;45:1533-41. 29 Reiter WJ, Pycha A, Schatzl G, et al. Dehydroepiandosterone in the treatment of erectile dysfunction: A prospective, double-blind, randomized, placebo-controlled study. Urol 1999;53:590-5. 30 Reiter WJ, Schatzl G, Mark I, et al. Dehydroepiandrosterone in the treatment of erectile dysfunction in patients with different organic etiologies. Urol Res 2001;29:278-81. 31 Genazzani AD, Stomati M, Bernardi F, et al. Long-term low-dose dehydroepiandrosterone oral supplementation in early and late postmenopausal women modulates endocrine parameters and synthesis of neuroactive steroids. Fertil Steril 2003;80:1495-501. 32 Villareal DT, Holloszy JO. Effect of DHEA on abdominal fat and insulin action in elderly women and men. JAMA 2004;292:2243-8. 33 Sun Y, Mao M, Sun L, et al. Treatment of osteoporosis in men using dehydroepiandrosterone sulfate.Chin Med J (Engl) 2002;115:402-4. 34 Villareal DT, Holloszy JO, Kohrt WM. Effects of DHEA replacement on bone mineral density and body composition in elderly women and men. Clin Endocrinol (Oxf) 2000;53:561-8. 35 Gordon CM, Grace E, Emans SJ, et al. Effects of oral dehydroepiandrosterone on bone density in young women with anorexia nervosa: a randomized trial. J Clin Endocrinol Metab 2002;87:4935-41. 36 Van Vollenhoven RF, Morabito LM, Engleman EG, et al. Treatment of systemic lupus erythematosus with dehydroepiandrosterone: 50 patients treated up to 12 months. J Rheumatol 1998;25:285-9. 37 Van Vollenhoven RF, Engleman EG, McGurie JL. Dehydroepiandrosterone in Systemic Lupus Erythematosus. Arth Rheum 1995;38:1826-31. 38 van Vollenhoven RF, Engleman EG, McGuire JL. Dehydroepiandrosterone in systemic lupus erythematosus. Arthritis Rheum 1994;37:1305-10. 39 van Vollenhoven RF, Park JL, Genovese MC, et al. A double-blind, placebo-controlled, clinical trial of dehydroepiandrosterone in severe lupus erythematosus. Lupus 1999;8:181-7. 40 Petri MA, Mease PJ, Merrill JT, et al. Effects of prasterone on disease activity and symptoms in women with active systemic lupus erythematosus. Arthritis Rheum 2004;50:2858-68. 41 Petri MA, Lahita RG, Van Vollenhoven RF, et al. Effects of prasterone on corticosteroid requirements of women with systemic lupus erythematosus: a double-blind, randomized, placebo-controlled trial. Arthritis Rheum 2002;46:1820-9. 42 Labrie F, Diamond P, Cusan L, et al. Effect of 12 month dehydroepiandrosterone replacement therapy on bone, vagina, and endometrium in postmenopausal women. J Clin Endocrinol Metab 1997;82:3498-505. 43 Casson PR, Faquin LC, Stentz FB. Replacement of dehydroepiandrosterone enhances T-lymphocyte insulin binding in postmenopausal women. (abstract) Fertil Steril 1995;63:1027-31. 44 Morales AJ, Haubrich RH, Hwang JY, et al. The effect of six months treatment with 100 mg daily dose of dehydroepiandrosterone (DHEA) on circulating sex steroids, body composition and muscle strength in age-advanced men and women. [Abstract] Clin Endocrinol (Oxf)1998;49:421-32.

45 Casson PR, Andersen RN, Herrod HG, et al. Oral dehyroepiandosterone in physiologic doses modulates immune function in postmenopausal women. Am J Obstet Gynecol 1995;1536-9. 46 Barnhart KT, Freeman E, Grisso JA, et al. The effect of dehydroepiandrosterone supplementation to symptomatic perimenopausal women on serum endocrine profiles, lipid parameters, and health-related quality of life. J Clin Endocrinol Metab 1999;84:3896-902. 47 Wolkowitz OM, Reus VI, Keebler A, et al. Double-blind treatment of major depression with dehydroepiandosterone. Am J Psychiatry 1999;156:646-9. 48 Wolkowitz OM, Reus VI, Manfredi F, et al. Dehydroepiandrosterone (DHEA) treatment of depression. [Abstract] Biol Psychiatry 1997;41:311-8. 49 Baulieu EE, Thomas G, Legrain S, et al. Dehydroepiandrosterone (DHEA), DHEA sulfate, and aging. Contribution of the DHEAge study to a sociobiomedical issue. Proc Natl Acad Sci U S A 2000;97:4279-84.

As discussed earlier in this report and stated so aptly in the fi ndings of one of the world’s most revered medical journals, DHEA is not a “doping substance.”

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Jun 16 2008

Published by under Anti Aging - Hormones

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Jun 13 2008

Anabolic Hormone Depletion is Common in Men with Chronic Heart Failure

In a study involving 208 men with chronic heart failure (median age: 63 years) and 366 healthy controls, anabolic hormone depletion was found to be quite prevalent among men with chronic heart failure, and was found to be associated with poor prognostic consequences. Immunoassays were used to measure levels of various hormones in subjects. Results found that men of all ages with chronic heart failure were found to have deficiencies in DHEAS, circulating total testosterone (TT), estimated free testosterone (eFT), and insulin-like growth factor-1 (IGF-1). Furthermore, DHEAS, TT, and eFT were found to be inversely associated to New York Heart Association class. After adjusting for established prognostic factors, all four hormones were found to be prognostic markers as well. A positive association was found between DHEAS and left ventricular ejection fraction. Men with chronic heart failure but normal anabolic hormone levels had the best 3-year survival rates compared to those having deficiencies in one, two, or all three anabolic endocrine axes (74%, 55%, and 27%, respectively). These results suggest that men with chronic heart failure who have a deficiency in more than one anabolic hormone may have an increased risk of mortality.

Reference: “Anabolic deficiency in men with chronic heart failure: prevalence and detrimental impact on survival,” Jankowska EA, Biel B, et al, Circulation, 2006; 114(17): 1829-37. (Address: Cardiology Department, Military Hospital, ul. Weigla 5, 50-981 Wroclaw, Poland. E-mail: Ewa.Jankowska@antro.pan.wroc.pl ).

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Jun 10 2008

Testosterone Supplementation Decreases Metabolic Syndrome and Improves Sexual Function

Reports on hormones findings from F. Saad and co-researchers

“Administration of testosterone cypionate over 12 months to men with sexual dysfunction and signs of the metabolic syndrome, restored their plasma testosterone (T) levels to the mid-range of reference values. This had a beneficial effect on their sexual functioning as evidenced by an improvement of their scores on the International Index of Erectile Function,” researchers in Berlin, Germany report (see also Hormones).
“The scores on the Aging Male Symptoms score, AMS, were also improved. Most impressive were the improvements in the parameters of the metabolic syndrome; they all improved and appeared largely correlated (i.e., decline in waist circumference with declines of plasma cholesterol and LDL and increase in plasma HDL). Sex hormone binding globulin, SHBG, may be considered as an indicator of the severity of the metabolic syndrome; levels of SHBG initially fell, probably as a result of rising plasma T levels. But over the last six months of the observation period when plasma T rose further, there was a significant increase in plasma SHBG which may be interpreted to indicate an improvement of the metabolic syndrome. Blood pressure improved slightly but significantly. in this cohort of elderly men (54-76 years; median 64 years) there were no safety concerns over a one year period of T administration. Prostate specific antigen, PSA, levels remained stable; the International Prostate Symptoms Score, IPSS, improved slightly. Liver functions and plasma glucose remained stable,” wrote F. Saad and colleagues.

The researchers concluded: “Hemoglogin and hematocrit values increased but remained within reference values.”

Yours in health,

Griffin Medical Group

www.griffinmedical.com

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May 21 2008

Age Management or Anti Aging Medicine – By Dr. Judi Goldstone

Published by under Anti Aging - Hormones

It is no longer necessary to accept the mental and physical decline associated with aging. A century ago the average life expectancy was 43 to 47. Today, life expectancy has almost doubled, due mostly to advances in medicine and technology. The rapid rate of these advances may put one in position to take advantage of cutting edge technologies in the pipeline, such as genetic engineering, stem cell transplants, therapeutic cloning, nanotechnology, and artificial organs. However, a longer life span is only desirable if living longer means living stronger, healthier, and without disabilities.
This is the premise of Anti-Aging Medicine, which is also known as Age Management Medicine, Longevity Medicine, Preventive-Regenerative Medicine, or Optimal Aging Medicine. Preventive-Regenerative Medicine is a new specialty of heath care based on early detection, prevention, and reversal of the degenerative effects of aging. The primary goal is living healthier for a longer period of time. The Anti-Aging specialty began in 1993 when twelve forward thinking physicians formed the American Academy of Anti-Aging Medicine (A4M). Today, the Academy is composed of 20,000 physicians and scientists from over 70 countries. It is the fastest growing scientific society in the world. The Academy is devoted to examining scientific research pertaining to: the causes of illness; aging; and the decline in physical and mental function as aging occurs. The principals of Preventive-Regenerative Medicine are well documented in medical and scientific journals, and are based on sound and responsible medical care.
Research suggests that aging is likely due to a combination of causes. Some theories of aging include: degeneration of bodily functions due to hormone decline, free radical damage due to lifestyle factors, chronic inflammation, loss of DNA’s ability to reproduce, or too much insulin. When these events are controlled or prevented, the likelihood of illness and disability is reduced or prevented, and it becomes possible to maintain good general health, strong muscles and bones, an efficient immune system, sharp memory, and peak mental and physical function at any age. While traditional medicine focuses on treating the effects of the aging process, Anti- Aging Medicine focuses on treating or preventing the causes of aging. Stated differently, traditional medicine predominately treats external symptoms that have internal causes, while Anti-Aging Medicine addresses the internal causes in order to prevent external symptoms. The different approach may sound subtle, but it can produce substantial differences in a person’s health and well being.
How does Preventive-Regenerative Medicine produce these results? At Griffin Medical Dr. Goldstone customizes a program for each individual after performing a physical exam, obtaining a comprehensive medical history, and conducting a nutritional and fitness evaluation. In addition, Dr. Goldstone obtains an advanced blood analysis, that includes blood count, body chemistries, blood sugar, organ function, hormone levels, cardiovascular and cancer risk factors, and inflammatory markers. She then designs a program based on replacement of deficient hormones and neutraceuticals, exercise, stress reduction, diet, and inflammation control. Bio-identical hormones (i.e., identical to human hormones) are used when replacement is necessary. Hormone levels are restored to a youthful range, and the patient’s progress is regularly monitored by physical exam and lab work, typically every three months for the first year, and every six to twelve months the reafter.
Judi Goldstone, MD is California native and a cum laude graduate of the University of California at Los Angeles. She received her medical degree from Mount Sinai School of Medicine in New York, where she graduated in the top third of her class. She is certified by the American Board of Internal Medicine and has been practicing internal medicine in Southern California most of her career. For the past 8 years Dr Goldstone began practicing bariatric(weight loss) and wellness medicine. She is an active member of the American Society of Bariatric Physicians and the American Academy of Antiaging and Regenerative Medicine. Dr. Goldstone has extensive experience in bio identical hormone replacement therapy, growth hormone replacement, menopause, andropause (male menopause), neutraceutical supplementation, nutrition, and weight loss.

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May 21 2008

Quality Assurance Alert – Toxic Chemicals in Raw Materials

As you know by now, Griffin Medical Group only prescribes pharmaceutical vitamins and supplements. We are one of only a few medical groups that seek quality in all the products we recommend. We feel that we are the leader in quality assurance. Contamination in natural products is a huge issue, whether the material comes from China, India, Europe or the United States. It is not where the material comes from that matters, but how thoroughly it was tested for purity before it gets put into a product and sold. Here are a few of the solvent tainted raw materials that we have been advised of by the pharmaceutical companies we work with. The following raw materials were deemed unacceptable to pharmaceutical supplement companies. Continue Reading »

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Mar 18 2008

Study: After hormone therapy, new cancers arise

Published by under Anti Aging - Hormones

The first follow-up of a landmark study of hormone use after menopause shows heart problems linked with the pills seem to fade after women stop taking them, while surprising new cancer risks appear.

That heart trouble associated with hormones may not be permanent is good news for millions of women who quit taking them after the government study was halted six years ago because of heart risks and breast cancer.

But the new risks for other cancers, particularly lung tumors, in women who had taken estrogen-progestin pills for about five years puzzled the researchers and outside experts.

Those risks “were completely unanticipated,” said Dr. Gerardo Heiss of the University of North Carolina in Chapel Hill, lead author of the follow-up analysis. Continue Reading »

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Mar 18 2008

IODINE IS VITAL FOR GOOD HEALTH

By Dr. James Howenstine, MD.
November 5, 2005

Lack of iodine is widespread in the United States today. For many years iodine was added to bread in generous quantities which prevented iodine deficiency. Each slice of bread contained 150 mcg. of iodine filling the whole days RDA of iodine In 1960 the average diet consumed about 1 mg. of iodine daily with bakery products accounting for about 75 % of the total. This quantity of iodine was enough to decrease the thyroid glands ability to absorb radioactive iodine and it was also sufficient to prevent excess release of thyroid hormone thus preventing many cases of hyperthyroidism (Grave’s Disease). Continue Reading »

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Mar 18 2008

Sorting Through the Choices For Menopause Hormones

March 11, 2008; 

Excerpt from the Wall Street Journal

Amid all the confusion over hormone-replacement therapy(HRT) for women, one key aspect is often overlooked: Not all HRT products are the same.

The big Women’s Health Initiative that has been generating headlines since 2002 studied women using Premarin and Prempro, both made by Wyeth, which were the state-of-the-art hormone drugs many years ago. Today, estrogen and progesterone are available in forms that are much closer to what women lose in menopause. While the Food and Drug Administration has said it thinks all HRT products pose the same risks, a growing number of doctors and patients prefer the newer varieties. Continue Reading »

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Mar 18 2008

Grumpy Old Men: Maybe It’s A Question of Testosterone

February 26, 2008;

They’re bullish on testosterone here at the 6th Annual World Congress on the Aging Male.

Physicians and researchers from around the world gathered to review the latest findings on what low levels of the male hormone means for men, how replacing it might help and why it hasn’t caught on broadly.

“If we had a drug that could restore sexual function in men, make them stronger, build their bones, reduce fat and get rid of the blues, you’d say, ‘Oh my God, why doesn’t everybody know about it?’ ” says Abraham Morgentaler, a urologist at Harvard Medical School and director of the Men’s Health Boston clinic. “There is a drug like that — but the public associates testosterone with cheating and illicit behavior and the fact that 40 years ago, it was thought to give people prostate cancer.” Continue Reading »

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Jan 10 2008

What is Sermorelin?

Sermorelin is a biological active analog of growth hormone releasing hormone (GHRH) that is produced by the human brain to stimulate production and release of growth hormone by the pituitary gland.Sermorelin stimulates production of the body’s own HGH. It is a truncated analog of growth hormone releasing factor (GRF 1-44) that is naturally produced by the brain to stimulate pituitary production and secretion of HGH.

During youth, ample amounts of GHRH are produced so that the pituitary is able to provide the body with sufficient growth hormone to sustain health, vitality and otherwise normal aspects of form and function. GHRH declines with age causing reduced production and secretion of pituitary HGH and thereby increasing the sequelae of growth hormone insufficiency.

Unlike HGH, Sermorelin affects a more primary source of failure in the GH neuroendocrine axis, has more physiological activity, has a better safety profile, and its use for adult hormone deficiency is not restricted.

Sermorelin benefits:

  • Increases natural production of Growth Hormone
  • Improves Physical Performance
  • Improves Immune Function
  • Increases IGF-1
  • Improves sleep quality

While Sermorelin produces the same effects on body composition and provides the other benefits of HGH, it also has some additional and important benefits.

The effects of Sermorelin are regulated at the level of the pituitary gland by negative feedback and by release of somatostatin so that safety concerns associated the HGH overdosing are minimized or completely avoided.

Tissue exposure to HGH released by the pituitary under the influence of Sermorelin is episodic not “square wave”, and therefore, prevents tachyphylaxis by mimicking normal physiology. By stimulating the pituitary it preserves more of the growth hormone neuroendocrine axis that is the first to fail during aging.

Until recently the effects of Growth Hormone Deficiency in adults were unknown. It is now recognized as a specific clinical syndrome with numerous physiological consequences with effects on;

  • Changes in body composition, including central obesity.
  • Lipids in the blood.
  • Muscle strength.
  • Bone composition.
  • Exercise capacity and energy.
  • Cardiovascular risk.
  • Psychological well-being.

Adult Growth Hormone Deficiency (AGHD) can be effectively treated with recombinant human Growth Hormone. A medically supervised HGH program has many benefits that can improve the user’s life on every level imaginable and AAG Health specializes in treating adults who are experiencing symptoms and problems associated with AGHD. Griffin Medical Group prescribes Sermorelin injections for patients with AGHD. Typically, patients inject themselves with a specific dose once a night.

Effects of Sermorelin and HGH Therapy

  • SKIN - Increased skin elasticity, texture, and tightness.
  • ENERGY – Increased energy and emotional stability.
  • BONE – Improved bone strength.
  • SEXUAL POWER – Increased sexual potency and frequency.
  • MUSCLE – Increased muscle strength and mass.
  • FAT – Decreased fat tissue.
  • MEMORY – Improved mental functioning and strength.
  • HEART – Improved cardiovascular strength and lower blood pressure.
  • KIDNEY – Improved kidney function.
  • IMMUNE SYSTEM – Improved immunity and healing.
  • HAIR – Improved hair texture.
  • CHOLESTEROL – Elevated HDL and lowered LDL.

Hormones can be thought of as “messengers” that are produced by the endocrine glands and then sent all over the body to stimulate specified activities. For example, growth, digestion, reproduction, and sexual functions are all triggered by hormones and they all depend on hormones to work properly.

HGH is one of several endocrine hormones such as estrogen, progesterone, testosterone, melatonin and DHEA that decline in production as we age. As its name suggests, human Growth Hormone is an endocrine hormone that makes humans grow.

HGH is a complex protein molecule of 191 amino acids linked in a specific sequence. It is secreted in pulses by the pituitary gland. These pulses vary between 10 and 30 per day and can be strengthened by exercise. For years, doctors have prescribed HGH for children who needed a growth boost but growth deficiencies do not just affect children, they can be a significant problem for adults too. HGH is critical for tissue repair, healing, muscle growth, bone strength, brain function, physical and mental health, energy, and metabolism.

Somatropin, or Somatotropin, is the man-made version of human Growth Hormone. Griffin Medical Group prescribes Omnitrope. It is available only by prescription and administered by injection.

HGH is produced at a rate that peaks during adolescence, at time when normal growth is accelerated. The production of HGH decreases with age, 14% each year on average. Humans normally produce about 500 micrograms of HGH daily at age 20.By age 80, the daily production falls to 60 (or less) micrograms. Many doctors consider IGF-1 levels below 200 to be HGH deficient and a diagnosis on Adult Onset Growth Hormone Deficiency Syndrome is made.

In the month of August of 1996, the FDA approved recombinant human Growth Hormone for the use in adult patients for the first time. Before, it was approved it only was authorized for use to promote growth in short children with growth deficiencies. Now HGH can be prescribed for deficient adults to treat Adult Onset Growth Hormone Deficiency Syndrome.

Griffin Medical Group offers, to qualified individuals based on medical necessity, HGH therapy in the form of medically supervised programs that are designed to safely replenish and replace your body’s own production of HGH.

For most people the pituitary gland produces sufficient HGH to retain a youthful appearance until age 35 or so. Then, somewhere between age 40 and 50, the body’s ability to produce HGH declines to the point where the signs of Adult Growth hormone Deficiency (AGHD) begin to show.

Signs of Adult Onset Growth Hormone Deficiency (AGHD):

  • SKIN Skin loses elasticity and becomes thinner which causes wrinkles.
  • ENERGY Loss of vigor and stamina.
  • BONE Bones lose strength. Tendency toward osteoporosis.
  • SEXUAL POWER Loss of sexual powers and libido.
  • MUSCLE Muscles lose strength and mass.
  • FAT Fat tissue increases and accumulates.
  • MEMORY Memory begins to fade.
  • HEART Heart muscle loses strength.
  • KIDNEY Decreased kidney function.
  • IMMUNE SYSTEM Decreased immunity and increased healing time.
  • HAIR Hair becomes thinner and loses color.
  • CHOLESTEROL Increased cholesterol level.

The first major study showing the promise of HGH therapy was published in the New England Journal of Medicine (Rudman; 323:1-6 1990). This study was orchestrated by the renowned Dr. Daniel Rudman. It divided 21 men (between the ages of 60 and 80) with IGF-1 levels less than 350 IU per liter into two groups: 12 test subjects and 9 control subjects.

A 6-month period of data collection was followed by a 6-month period in which the 12 test subjects received HGH injections and the 9 control subjects did not. The results were promising: increases in lean muscle mass, decreases in adipose fat tissue, and increases in vertebral bone height. All test subjects had measurable increases in HGH levels, as measured by IGF-1 blood values.

The control group had none of these results. The effects of six months of human growth hormone on body mass and adipose-tissue mass were equivalent in magnitude to the changes incurred during the 10 to 20 years of aging.

Since Rudman’s landmark study, leading doctors and healthcare professionals worldwide have performed many studies that all come to the same conclusion – HGH therapy works. For a complete background on recent and past HGH studies and information on HGH therapy in general, the book entitled “Grow Young With HGH” by Dr. Ronald Klatz (ISBN 0-06-098434-1) is fascinating reading and a “must read”.

The nervous system and brain are made up of cells called neurons, which are permanent and never grow back once damaged. HGH stimulates the repair and rejuvenation of these particular neurons. The proteins in the brain that are responsible for storing our memories are also affected in a positive way.

Learning, memory, and intelligence all depend on adequate supplies of HGH. According to a team of Swedish Scientists they discovered why HGH therapy makes so many people feel so good. HGH acts in the brain exactly like an antidepressant, raising the level of neurotransmitter B- endorphin, which has been called the brain’s own opiate. It also lowers the level of dopamine, which is associated with feelings of agitation. It reverses the outlooks, expectations and attitudes associated with the aging process.

Many other experts expressed that it appears to reduce stress itself, & improves focus and concentration, and builds self esteem and self confidence. HGH can also reverse the decline in memory and cognitive performance.

About 68%of Americans are classified as overweight individuals. Obesity is the 2nd most common preventable death in the United States. Human Growth Hormone may be one of the most effective fat loss regimens ever discovered.

The psychological and emotional symptoms associated with Adult Growth hormone Deficiency (AGHD) include a reduced sense of well being, low energy, vitality, capacity for work, emotional liability, including mood swings, anxiety, depression, and increased social isolation. Important physical signs are increased body fat, especially around the waist (apple shape rather than pear shape), decrease in muscle mass, and thin, wrinkled, or prematurely aged skin. Other symptoms may consist of the following: Reduced cardiac performance, poor sleep, decreased muscle mass and strength, little to no sex drive.

Aging takes place at a more rapid pace when your hormones start to decrease. Once the hormone levels start to decrease, your body starts to change. You tend to gain weight easier, your not as athletic, you tend to be more up tight about things, depressed more frequently, these are all signs that your hormone levels are beginning to drop. Natural hormones are protective and aging is related to the loss of these hormones. Replacing the hormone level to youthful levels delays the aging process.

All of the things that you already know about healthy living are still true, whether you are starting HGH therapy or not. If you are serious about treating your hormone deficiencies with hormone therapy remember that all good programs consist of discipline and commitment in five major areas:

  1. HORMONE REPLACEMENT/SUPPLEMENTATION
  2. PROPER DIET
  3. NUTRITION
  4. EXERCISE
  5. SLEEP

Griffin Medical Group

 info@griffinmedical.com
(714) 549-6550

Dr. Alan Ivar

Dr. Judi Goldstone

Dr. Alvin Yee

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Aug 14 2007

Sermorelin- More info…

Published by under Anti Aging - Hormones

Sermorelin 

Clinically tested for over 10 years and initially designed for children with growth hormone deficiency, Sermorelin is
a great option for adult patients who would like a safe and proven alternative to traditional hGH.
 What is Sermorelin Acetate?
Sermorelin is a form of GRF that contains only the first 29 amino acids. GRF that is produced by neurosecretory neurons in the brain contains 44 amino acids. When the structure of GRF was first described by the Nobel Laureates, R. Guilleman and A. Shalley in the 1970’s one of their students, William Wehrenberg sought to determine which part of the molecule was essential for its pituitary stimulating action. By eliminating individual amino acids and then testing the remaining peptide, he found that only the first 29 amino acids are responsible for stimulating pituitary production and secretion of hGH. Therefore, the chemical name for Sermorelin is GRH 1-29 NH 2 . The NH 2 is included in the name so as to indicate the amino terminus of the molecule.
  Continue Reading »

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Aug 02 2007

Sermorelin – What is it?

Published by under Anti Aging - Hormones

Griffin Medical Group is currently independantly testing Sermorelin. If sermorelin is something you might be interested in, please let us know.

Sermorelin is a biological active analog of growth hormone releasing hormone (GHRH) that is produced by the human brain to stimulate production and release of growth hormone by the pituitary gland. During youth, ample amounts of GHRH are produced so that the pituitary is able to provide the body with sufficient growth hormone to sustain health, vitality and otherwise normal aspects of form and function. However, during aging, GHRH declines causing reduced production and secretion of pituitary hGH and thereby increasing the sequelae of growth hormone insufficiency that erodes health, vigor and vitality during later life. Unlike hGH, Sermorelin affects a more primary source of age-failure in the GH neuroendocrine axis, has more physiological activity, a better safety profile. Thus, Sermorelin should be considered a valuable alternative to hGH.

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Apr 03 2007

Pharmaceutical Grade Vitamins (supplements) vs. Regular Vitamins (supplements)

Published by under Anti Aging - Hormones

Vitamins are necessary for human life and health. They are required in minute amounts, and with the exception of Vitamin B12, cannot be manufactured in your bodies. These organic compounds need to be obtained from diet, and if deprived of a particular vitamin, you will suffer from disease specific to that vitamin. It is a matter of record that you are not getting enough vitamins. Though we Americans are living longer, our quality of life leaves much to be desired. Continue Reading »

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Apr 03 2007

Blood Sugar Control:

Published by under Anti Aging - Hormones

This month, I will discuss blood sugar, an issue of the utmost importance to not only those at risk of diabetes but also anyone who wants to enhance his or her weight loss efforts, eliminate fatigue and increase energy.
In this article, I will address blood sugar control’s important role in weight management efforts, its importance in any natural strategy to increase energy, and the destructive role that stress plays in disrupting glycemic balance. I will also discuss additional nutrients and botanicals and lifestyle factors that can help restore glycemic balance.

Far-Reaching Implications Continue Reading »

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Mar 21 2007

Omega-3s Important for Bone Health of Young Males

Published by under Anti Aging - Hormones

Young males who have the highest levels of omega-3 fatty acids, especially docosahexaenoic acid (DHA), have the highest bone mineral density, a new study by Swedish researchers has found. Continue Reading »

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Mar 21 2007

Obesity in Men Linked to Testosterone-Lowering Chemical

Published by under Anti Aging - Hormones

A new study by University of Rochester researchers has linked exposure to a common chemical found in plastics and soaps to insulin resistance and obesity in men.
Previous studies have found that exposure to phthalates—found in cosmetics, shampoos, soaps, lotions, lubricants, paint, pesticides, plastics and in the coating of some timed-release medicines—may be associated with reproductive problems. More than 75 percent of the United States population is thought to have measurable levels of several phthalates in their urine. Continue Reading »

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Mar 19 2007

Getting Old is natural, Feeling Old is Optional, – You can’t turn back the clock but you can wind it up again.

Published by under Anti Aging - Hormones

About Andropause

The existence of andropause is recognised by some of the best researchers in medical science, including the international medical community.
In fact, a recent World Health Organization (WHO) report, states that “male androgens progressively decline with age.” The study tested androgen levels at age 25 and by age 70, androgen levels were only 10 percent of what they were during youth. Continue Reading »

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Supply of hospital pharmacies operating externally due to cost savings will continue to grow all over the next years. Even today, 90% of all pharmacies pribolnichnyh organized in cooperation provisioning This shows that the Canadian pharmacy online has become not take seriously the business partner compared with the pharmaceutical industry. However, the development of recent years shows that the industry sees its price registration stronger with the number of sales, thus strengthening the competitiveness of supplying hospital pharmacies in the long term due to more efficient logistics and a lot of sales.