Jim Paoletti BS Pharmacy, FAARM, FIACP Director of Education P2P

Transcription

1 presents Pioneering Technologies For Lifestyle CASE Based STUDIES Medicine with Jim Paoletti BS Pharmacy, FAARM, FIACP Director of Education P2P

2 Clinical Consultant the Director of Education of Education at Power2Practice 30 years of experience creating and using bio-identical hormone therapies in both retail pharmacy and clinical practice Nationally recognized expert in pharmacy, BHRT and custom compounding Previously served as Director of Provider Education for ZRT Laboratory and Education Director for the Professional Compounding Centers of America Pioneering Technologies For Lifestyle Based Medicine Jim Paoletti BS Pharmacy, FAARM, FIACP Director of Education P2P

3 CASE STUDY 1 C.F. First saw late September year old Caucasian in peri-menopause Last cycle was August 20, 2015 Lives with spouse lb. BMI 21.8 waist: unspecified General health good, energy level moderate 3 pregnancies, no related issues

4 CHIEF CONCERNS Goal: My hopes are to decrease all the symptoms of menopause without the harmful use of estrogen Chief complaints/concerns All since January 2105 Hot Flashes Vaginal Dryness Weight Gain

5 PAST MEDICAL HISTORY Medical History Kidney stones, varicose veins, high cholesterol (2/2015) PMS Fibrocystic breasts Family History: none specified Current Meds DōTerra Phytoestrogen Complex Wanted a natural way to treat hot flashes Minimally effective

6 PAST MEDICAL HISTORY Lifestyle Diet good Bicycles twice a week Non-smoker, no alcohol One soda daily Stress high Work Family

7 C.F SYMPTOMS SEVERE: HOT FLASHES, NIGHT SWEATS, VAGINAL DRYNESS/ATROPHY, POOR SLEEP, WEIGHT GAIN, BLEEDING CYCLE CHANGES, IRRITABILITY, ANXIETY, NERVOUSNESS, DECREASED SEX DRIVE, HARDER TO REACH CLIMAX, STRESS MODERATE: FOGGY THINKING, HEART PALPITATIONS, MOOD SWINGS, DECREASED STAMINA, LOSS OF SCALP HAIR, CRAVINGS FOR SWEETS, EVENING FATIGUE MILD: MEMORY LAPSE, INCONTINENCE/LOSS OF BLADDER CONTROL, RAPID HEART BEAT, EMOTIONAL INSTABILITY, DECREASED MUSCLE SIZE/STRENGTH, INCREASED FACIAL/BODY HAIR, ACHES & PAINS, RAPID AGING,NEED FOR CAFFEINE, ALLERGIES, MORNING FATIGUE, DEPRESSION, SENSITIVITY TO COLD, HIGH CHOLESTEROL, MYXEDEMA, DRY OR BRITTLE HAIR, BRITTLE NAILS, CONSTIPATION, DRY SKIN

8 LABS Venous serum testing 1/2015 CBC all WNL Metabolic Panel all WNL Cholesterol 229 Glucose 85 Hemoglobin A1c 5.4 ( ) E2 <6.0 ANA direct negative

9 LABS Venous serum testing 1/2015 TSH 1.62 ft ( ) TPOa 62 (0-34) Thyroglobulin antibody 2.2 (0-0.9) Vitamin D 25 OH 12.8 (optimal 50 ng/dl)

10 LABS Saliva testing 9/22/2015 E2 <0.5 ( ) Progesterone 54 (75-270) Testosterone 33 (WNL but less than optimal) DHEAS 5.9 (WNL but less than optimal) Cortisol AM 3.8 ( ) Noon 2.2 ( ) Evening 1.9 ( ) PM 0.9 ( )

11 LABS

12 TREATMENT PLAN Plan of Care 9/28/2015 E2 0.1 mg/ E3 0.1mg per ml. topical cream. Apply ½ ml daily in the morning on cycle days Apply to forearm, upper inner arm, or upper inner thigh. Rotate sites clockwise daily. Rub in well. Progesterone 150mg SR capsules. One 30 to 60 minutes before bedtime on cycle days 14-25

13 TREATMENT PLAN Plan of Care 9/28/2015, cont d DHEA 5 mg s/l daily Cortisol Calm 1 capsule am, 1 mid-afternoon and 2 capsules 30 to 60 minutes before bedtime. Contains 3 adaptogens and L-theanine MVM Vitamin B mcg s/l. one daily Vitamin D IU daily for 4 weeks, then 5000 IU daily

14 TREATMENT PLAN Plan of Care 9/28/2015, cont d Gluten Free diet (100%) Recommended reading The Guide to a Gluten Free Diet by Dr. David Brownstein and Sheryl Shenefelt C.N. Adrenal Support Adequate water Protein at each meal and for snack if needed Eliminate soda Unrefined salt ½ to 1 teaspoonful daily on food or in water.

15 RETURN VISIT 4 Week FUP Had started gluten free diet and supplements right away but did not start hormone creams for a couple of weeks (financial reasons) She noted that she felt more significant changes with the gluten free diet and supplements than with the hormones themselves Many improvements, symptoms gone or mild

16 RETURN VISIT FUP 12/8/2015 (2 ½ months) Patient reports that hot flashes, night sweats and poor sleep have returned Not nearly as bad as originally but worse than they were the last two months. Menstrual flow started 3 days prior to scheduled stop of hormone creams Indicated that school activities and holidays with the family are both very stressful for her. Recommended meditation and time alone on a daily basis, saying no, and relaxing.

17 RETURN VISIT FUP 1/ 8/2016 Patient reports cycle regular again, hot flashes night sweats and poor sleep are nearly absent Reported she has gone back to doing something at least once day that she really enjoys sewing and/or reading and/or praying/meditating.

18 CASE STUDY 2 N.T. 52 yo Caucasian female Menopausal (natural) Married, works part time as secretary Lives with husband and one adult son lb. General health OK, energy low to moderate

19 PAST MEDICAL HISTORY First seen 12/12/2015 Taking PremPro once daily and Armor Thyroid 1 grain b.i.d. Family history Mother: breast cancer, heart disease Father: ulcers

20 PAST MEDICAL HISTORY Medical History Depression Subclinical Hypothyroidism Headaches High Cholesterol Current meds Lovastatin Paroxetine

21 PAST MEDICAL HISTORY Lifestyle Diet pretty good Exercise: walks 2-3 times a week Non smoker Occasional alcohol use 1 1 ½ cups of coffee each morning

22 CHIEF CONCERNS 1. Weight gain 2. Hot flashes 3. Irritability

23 SYMPTOMS Severe: hot flashes, weight gain, mood swings, irritability, depression, headaches, dry skin, constipation, brittle nails, cold body temperature, evening fatigue Moderate: night sweats, vaginal dryness, sensitivity to cold, cold extremities, hearing loss, fluid retention, insomnia Mild: cravings for sweets, anxiety, nervousness, decreased sex drive, harder to reach climax, morning fatigue

24 LABS Saliva test 12/3/2015 E2 6.2 ( ) E ( ) Note: PremPro last taken 25 hours prior to sample collection Progesterone 21 (75-270) Testosterone 36 (16-55) DHEAS 5.6 (2-23) Cortisol AM 6.5 ( ) Noon 1.6 ( ) Evening 0.8 ( ) PM 1.2 ( )

25 LABS Venous serum testing 11/2016 TSH 2.12 TPOa negative TT ( ) ft ( ) ft3 2.5 ( ) Note: sample drawn 8 hours after last dose Ferritin 118 Vitamin D 25 OH 42.8 Vitamin B ( )

26 THYROID GRADIENT LEVELS LABS TT4 ft ft

27 TREATMENT PLAN Dec 12, 2016 Change Prempro to Premarin Taper off Premarion over 1-2 months Then add biest cream Progesterone 150 mg SR daily hs. DHEA 5 mg once daily Patient prefers oral to s/l administration

28 TREATMENT PLAN Estrogen taper Higher than physiological levels reset the threshold for estrogen need within the brain Quick reduction in dosage will cause withdrawal symptoms (severe hot flashes)

29 TREATMENT PLAN Estrogen taper: various protocols Example: decrease conventional estrogen therapy by one-half dose every 3 days, then 2 out of three days, then daily, etc. Example: Premarin give ½ tab QD x 2 wks then ½ tab QOD x 2 wks Use ½ dose every 3rd day for 9-12 days, then ½ dose 2 of 3 days for 9-12 days, then ½ dose daily, then ½ dose 2 out of 3 days for 9-12 days, then ½ dose every other day. When low dose is reached, switch to Bi-est 50:50 cream

30 TREATMENT PLAN Thyroid support Vitamin D IU daily for 2 weeks, then 5000 IU daily MVM Selenium 200 mcg daily Zinc 25 mg daily Wait 2 weeks, then reduce Armor Thyroid dose by 25-30%. Retest no sooner than 90 days Adjust dose (probably reduce based on levels and symptom response

31 TREATMENT PLAN Adrenal support Water Sea salt ½ tsp daily Adaptogens Compensation techniques Protein

32 RETURN VISIT January 2016 Patient tapering of Premarin faster than scheduled as she wants to get on the natural options and reduce risk Was taking Premarin 0.3 every other day, so went ahead and changed to Biest 50:50 topical cream, E2 0.2 mg/e3 0.2 mg per ml, apply ½ ml in the morning 6 out of 7 days Has seen slight improvement in energy and sleep, headaches, and constipation. No change in weight or hot flashes

33 RETURN VISIT February 2016 Significant improvement in all symptoms except little change in vaginal dryness. Hot flashes and night sweats almost completely gone Sleep is great, energy much improved Dry skin, constipation, cold extremities, cold body temperature all improved

34 RETURN VISIT February 2016 Estriol vaginal cream 1.0 mg per ml, apply ½ ml vaginally at bedtime for 2-3 weeks, then decrease to prn use.

35 RETURN VISIT April 2016 Patient reports vaginal dryness only a minor issue now and uses estriol cream once or maybe twice a week Uses extra dose when she anticipates sex Most symptoms are absent or mild She attributes what symptoms she does have to the stressful situations she is going through Hot flashes occur only on days of more stress.

36 CASE STUDY 3 A.F. 44 yo Caucasian female Lives with spouse, not employed lb. BMI 21.6 waist unspecified General health good, energy low First consulted 6/13/2016

37 PAST MEDICAL HISTORY Thermogram 3/2016 negative Family history unspecified

38 PAST MEDICAL HISTORY Fractures 1986 Chronic Fatigue 2013 Depression late 1990s Anxiety Mono as teenage Tension headaches PMS since age 23 2 Pregnancies, took progesterone, first pregnancy ended in miscarriage Allergies to peanuts, cockroaches, cats

39 CURRENT MEDICATIONS Q96 Vitamins & minerals Cod live oil with oil butter (bone health) Garcinia Cambogia CBD oil (back pain) Iodine 6-7 drops daily for thyroid health

40 PAST MEDICAL HISTORY Lifestyle Diet pretty good Exercise: rebounding 5-6 days/wk Non smoker No caffeine 3-4 drinks occasionally on weekends Stress Moderate Too many things to get done. Not enough rest. Clutter in my home makes me anxious Birth control: husband had vasectomy 2012

41 CHIEF CONCERNS 1. Irritability 2. Facial hair 3. Fatigue

42 SYMPTOMS Severe: irritability, anxiety, nervousness, decreased sex drive, decreased stamina, increased facial hair, fatigue (am & pm), low body temperature, cold extremities, sensitivity to cold, dry skin Moderate: poor sleep, weight gain, mood swings, emotional instability, acne, aches and pains, stress, sensitivity to chemicals, depression, headaches Mild: memory lapse, foggy thinking, incontinence, increased urinary urge, night sweats, vaginal dryness, cramps, fluid retention, breast tenderness, scalp hair loss, decreased muscle size & strength, cravings for sweets & salt, allergies, puffy eyes/face, constipation, brittle nails

43 LABS Venous serum testing 9/2015 CBC, Metabolic panel & hematology all WNL Cholesterol 159 Glucose 103 Vitamin B ( ) TSH 1.95 Vitamin D 25 OH 17.3 MTHR gene negative

44 LABS Saliva test 5/20/2016 E2 1.3 ( ) Progesterone 109 (75-270) Testosterone 87 (16-55) DHEA 23 (2-23) Cortisol AM 10.2 ( ) Noon 1.3 ( ) Evening 0.7 ( ) PM 1.1 ( ) Pattern: High to LN to LN to High

45 TREATMENT PLAN Progesterone SR 100 mg minutes before bedtime on cycle days Low glycemic index foods Inositol 500mg b.i.d. MSM 1000mg t.i.d. on empty stomach Saw Palmetto 320 mg daily Recommended reading: The Blood Sugar Solution by Dr. Mark Hyman

46 TREATMENT PLAN Adrenal support Vitamins & minerals Adaptogens Unrefined salt, ½ to 1 tsp daily Adequate water intake Compensation techniques daily Protein at each meal

47 LABS Venous serum testing 6/30/16 TSH 1.93 TT4 7.5 ( ) ft ( ) ft3 3.3 ( ) TPOa 5 (0-34) Ferritin 43 (15-150) (optimal )

48 TREATMEN PLAN Additions to Plan of Care Vitamin D IU daily for 3 weeks, then 5000 IU daily Ferritin 5 mg One tablet daily

49 RETURN VISIT Follow up 7/6/2016 Patient asked how long before she notices the changes that are going to happen Improvements in falling sleep, anxiety, nervousness, mood swings, stamina, Not taking any of recommended supplements, other than Saw Palmetto and MSM Husband is funny about stuff not covered by insurance. Has noticed a huge improvement as far as aches and pains and inflammation

50 RETURN VISIT FUP 7/25/2016 Patient started inositol, ferritin and Vitamin D3 a few days after last FUP Reports that her sleep and mood have significantly improved Fatigue, headaches and memory issues have shown moderate improvement Some improvement in cold body temperature, sensitivity to cold, cold extremities No weight loss (but hasn t gained) Encouraged diet modification compliance

51 RETURN VISIT FUP 8/16/2016 Patient started adrenal support shortly after last consult Doing much better on eating, has lost 3 lb. Feeling much better overall Only complaints at this time are the struggle to lose weight and the fatigue which comes and goes.

52 CASE STUDY 4 K.B. 47yo Caucasian female, homemaker/mom Excellent general health, moderate energy 5 6, 128 lb, BMI 20.7, Waist 29 Peri-menopausal, LMP last month Kidney stones History of PMS and very mild endometriosis Grandmother had diabetes

53 PAST MEDICAL HISTORY K.B. Diet good Gets routine exercise Caffeine: one iced tea daily Non-smoker 1-2 glasses of red wine per week

54 CURRENT MEDICATIONS First saw July 2014 Current Meds Progesterone cream 100mg/ml, applying 1.0 ml days 6-26 of cycle. DHEA 10 mg oral daily Hydrocortisone 5 mg am and 1.5 mg pm Adrenal Cortex Fibercon, Miralax, Magnesium, Potassium, B6, Vitamin A, Vitamin E

55 SYMPTOMS First had symptoms in 2010 when building a new house Symptoms worse during school year as children attend intense private school May, 2013 saw N.D. who recommended saliva testing and hair testing Recommended progesterone, adrenal cortex and DHEA

56 SYMPTOMS Symptoms (self-reported) as of July 2014: Severe: hot flashes, trouble falling and staying asleep, sugar cravings, weight gain, constipation Moderate: night sweats, vaginal dryness, morning fatigue, decreased libido, fibrocystic breasts, swelling Mild: foggy thinking, memory lapse, depressed, heart palpitations, aches & pains, evening fatigue, allergies, stress, irritable, anxious, fluid retention, decreased stamina, decreased muscle size, brittle nails, rapid heartbeat.

57 LABS Saliva test July 2014 E2 3.4 ( ) Progesterone 612 ( ) Testosterone 25 (near mid-normal for age) DHEA 6.9 (mid-range for age) Cortisol am 4.4 ( ) Cortisol noon 1.6 ( ) Cortisol evening 1.1 ( ) Cortisol night 0.4 ( ) Saliva sample collected 24 hours after last progesterone application Patient was instructed to d/c adrenal cortex and hydrocortisone for at least several days prior to testing

58 TREATMENT PLAN JULY 2014 Adrenal support: Vitamin & mineral, one tablet t.i.d. Adaptogens twice daily and increase if needed Patient did not take-- too much stuff and didn t need Adequate water intake (80 oz daily) Unrefined salt ½ to 1 tsp. daily Daily compensation technique Discontinue adrenal cortex and hydrocortisone Change progesterone to oral SR 100mg, minutes before bedtime days Continue DHEA 10 mg Vitamin D IU daily Do Basal Body Temperature test

59 RETURN VISIT K. B. 3 WK Follow-up Discontinued adrenal cortex and hydrocortisone and hot flashes and night sweats disappeared within 2 days All other symptoms except sleep issues are tolerable Did not start taking progesterone capsules because her symptoms cleared up Slept well all summer but since school started has difficulty falling and staying asleep Had period in July but not since and is at day 33 or 34

60 TREATMENT PLAN Aug 2014 Instructed patient to begin progesterone capsules Added product containing adaptogens ashwagandha, rhodiola, magnolia plus l-theanine. Patient claimed l-theanine made her tinnitus worse Added Relora 300 mg 1 cap early evening and 1 capsule before bedtime

61 RETURN VISIT K.B. 7 WK Follow-up Patient feeling much better. All symptoms good other than occasional constipation Recommended Grams Fiber daily Sleep significantly better over the last week Tried oral progesterone twice but stopped because she didn t feel normal Emotional Weepy, slightly depressed

62 TREATMENT PLAN Sept 2014 Change back to topical progesterone 40 mg/ml, apply 0.5 ml once daily 6 days each week.

63 RETURN VISIT K.B. 11 Wk Follow-up Patient reports doing great on new dose of topical progesterone Normal cycle early this month

64 TAKEAWAYS Oral progesterone produces a greater number of metabolites than topical Advantageous for sleep improvement Can be disadvantageous is patient produces too much of a metabolite that produces side effects, i.e. drowsiness, fluid retention, bloating, foggy thinking Topical appears to convert easier to cortisol can be advantageous or disadvantageous. Too much progesterone can down-regulate estrogen receptors and mimic the symptoms of estrogen deficiency. Hydrocortisone therapy can treat the symptoms and mask the cause.

65 CASE STUDY 5 R.B. 36 yo engineer (oil company) Works off shore for up to 3 weeks at a time Wife is Nurse Practitioner Goal: wants to feel normal again Feels like he is 50 years old More energy Lose weight

66 PAST MEDICAL HISTORY lb. BMI 26.4 Waist 36 Good general health, low energy Non-smoker Alcohol: 3 drinks per week Caffeine: 1 cup coffee daily

67 PAST MEDICAL HISTORY Did not list diet or exercise on intake form During consult discovered he often skipped breakfast, and eats whatever they serve offshore Not much exercise, none when off shore Stress Listed as none on intake form. But did list work and kids as a source of stress (??) Listed stress as mild on saliva test intake form

68 OTHER HISTORY Medications: Selenium 100 mcg daily Medical history: Vasectomy July 2013 Family History: none

69 SYMPTOMS Symptoms (self rated) Severe: fatigue, weight gain, irritability, Moderate: decreased stamina, depression, apathy, burned out feeling, aches and pains, decreased muscle size & strength Mild: decreased libido, erectile dysfunction, decreased morning erections, memory lapse Additional: increased alcohol use

70 LABS Venous serum lab work 7/2014 Glucose 87 Cholesterol 197 HDL Cholesterol 49 LDL Cholesterol 125 Triglycerides 100 Homocysteine 11.9 (normal is < 11.4) Total testosterone 144 ( ) Estradiol 19 ( 39) CMP & CBC : all others WNL

71 LABS Venous serum lab work 7/2014 cont d TPOa 226 (0-34) TSH 4.62 (Optimal is ) TT4 7.0 ( ) ft ( ) Vitamin D 25OH 38.9 Ferritin 88 Vitamin B ( ) Folate 14.7 (>5.4)

72 LABS Saliva test 7/2014 E2 1.2 ( ) E1 1.4 (0-3.0) Testosterone 79 (44-148) WNL for age, low end of normal for a 25 yo Cortisol AM 2.8 ( ) Noon 2.1 ( ) Evening 1.8 ( ) PM 0.6 ( )

73 TREATMENT PLAN Plan of Care 7/31/2016 Continue selenium MVM Zinc 50 mg daily for 1 month, then 25 mg daily Vitamin D IU daily for 2 weeks, then 5000 IU daily Vitamin B12 1 mg SQ daily

74 TREATMENT PLAN Plan of Care 7/31/2016, cont d Gluten free 100% for 3 weeks, then add glutamine and probiotic Anti-inflammatory diet Homocysteine Factors 2 capsules daily Folate, methylcobalamin, P5P, TMG Regular exercise Adaptogens

75 RETURN VISIT 3 Week FUP Patient reports feeling much better, with noticeable improvements in fatigue, stamina, and weight. Reports mostly gluten free but hard when working off shore Exercising regularly Wife (RN) prescribed testosterone injection, 1 ml every 2 weeks; he is using half that dose.

76 RETURN VISIT 7 Week FUP Repeated some venous serum testing: Total testosterone 464 (was 144) Free T (35-155) Estradiol 27 (<39) (was 19) TPO 327 (has gone up) Patient notices significant difference when he works on shore and eats correctly. Feels better overall, but noticing peaks and valleys with the testosterone injection.

77 MEDICATION Dosage adjustment Change testosterone to daily sublingual administration 5 mg s/l twice daily 4 weeks later patient reports he felt like he was getting too much testosterone and reduced to one troche daily Off gluten completely and has no issues

78 TAKEAWAYS If a patient has a hormone level that is low for his/her age and not just a normal decline with age, then the question is not how much of that hormone to give the patient, but WHY is his/her hormone level low? Fix the underlying issues that lead to the lower production.

79 TAKEAWAYS Main causes of low testosterone in males Weight gain, especially abdominal o Increases aromatase which converts testosterone to estradiol. Estradiol suppresses LH, which signals Leydig cells to produce testosterone. Less testosterone is made and more is converted to E2. Stress & high cortisol o Stimulates aromatase enzyme o Stress plus weight gain worsens situation Lack of exercise Lack of sleep

80 CASE STUDY 6 M.H. 52yo Caucasian female, office manager Good general health, low energy 5 1, 155 lb., BMI 28.3, waist 36

81 PAST MEDICAL HISTORY Medical history Hysterectomy and bilateral oophorectomy due to pre-cancerous cells on abnormal pap 2003 Ulcers Family History Breast cancer paternal grandmother

82 PAST MEDICAL HISTORY Lifestyle Diet good No exercise 2 cups of coffee daily Occasional alcohol Non-smoker Moderate stress (work related)

83 PAST MEDICAL HISTORY First saw in December 2015 Patient had been on BHRT from 2005 until October 2013 E2 1.5 mg / E3 1.0 mg / Progesterone 40 mg/ DHEA 10 mg / Testosterone 0.5 mg per ml cream Applied 1.0 ml daily Symptoms well managed for the most part until early 2015, seemed to get worse over time Quit taking when refill ran out because felt it wasn t working Taking Vitamin C 1000 mg twice a week

84 SYMPTOMS Symptoms as of December 2015 Severe: vaginal dryness, decreased libido Moderate: aches & pains, weight gain in waist, increased facial/body hair, mood swings, irritable Mild: hot flashes, night sweats, sleep disturbances, weight gain in hips, decreased muscle size, decreased stamina, anxiety, nervousness, depression, hair loss, swelling, puffy eyes, fluid retention, headaches, evening fatigue, thinning skin, rapid aging, increased urinary urge, acne, allergies, stress

85 LABS Saliva test December 2015 E2 1.0 ( ) E1 <1.0 (1.6-5) Progesterone 56 (75-270) Testosterone 20 (low normal for age) DHEA 2.2 (2-23) Cortisol am: 22.4 ( ) Cortisol night: 46.3 ( )

86 LABS High cortisol levels Dermatologist had prescribed hydrocortisone cream which she had not listed Most likely contamination issue Evaluated adrenal function based on symptoms, adrenal questionnaire, and energy/intake evaluation form Appears to have adrenal dysfunction and low cortisol reserve

87 Response OPTIMAL RECEPTOR RESPONSE X X X X Hormone Level X

88 TREATMENT PLAN Dec 2015 E2 0.1 mg / E3 0.1 mg / DHEA 10 mg / Testosterone 2 mg per ml cream Apply 0.5 ml once daily in am 6 days each week (skipping the same day each week) to forearm, upper inner arm or upper inner thigh. Rotate sites. Rub in well. Apply vaginally for 1 st week, then rotate vaginal application 1-2 times per week Progesterone 150mg oral SR capsules daily

89 TREATMENT PLAN Dec 20, 2015 Adrenal support: compensation techniques, adequate water, unrefined salt, vit. & min for adrenals, adaptogens Vitamin D 4000 IU daily Fish oil 1100 mg b.i.d. Herbal Chamomile tea at bedtime Avoid processed foods Basal Body Temperature test Read Adrenal Fatigue by Dr. James Wilson

90 DAY 9 PHONE NOTE Called 9 days after starting prescription to ask question Reported already feeling much better Sleep greatly improved

91 RETURN VISIT 3 Week Follow up Very pleased with results so far Couldn t believe her sex drive would be so good again Vaginal dryness now mild Rotates cream application vaginally once a week Hot flashes down to one mild daily Night sweats only once a week Has improved lifestyle more relaxation Her and husband both read Dr. Wilson s book Almost back to pre-hysterectomy

92 RETURN VISIT 7 week follow up Sex drive has decreased since last follow up Vaginal dryness a problem again Having more hot flashes 3 per day Increased stress Daughter had surgery & she is helping care for grandchild Is relaxing in bath with essential oils most days Still not exercising at all Chamomile tea at bedtime helps sleep

93 TREATMENT PLAN Feb 2016 Increase estrogen in hormone cream E mg / E mg / DHEA 10 mg/ Testosterone 2 mg per ml Apply 0.5 ml daily in am to forearm, upper inner arm or upper inner thigh 6 days each week to forearm, upper inner arm or upper inner thigh. Rotate sites. Rub in well. Alternate with once weekly vaginal application

94 RETURN VISIT 11 WEEK FOLLOW UP Sex drive is back to normal Hot flashes only on days of heavy stress Has begun to walk several days a week Is very satisfied with results at this point, hopes they continue this time

95 RETURN VISIT June 2016 Follow Up Hot flashes 2-3 times a day Poor sleep Patient was using 6 days a week topically and once a week vaginally not skipping a day

96 TREATMENT PLAN June 2016 Have patient discontinue use of hormone cream for 2-5 days or until she feels worse. Then restart using only 6 days each week

97 RETURN VISIT July 2016 Discontinued used of hormone cream for 5 days and symptoms improved. Then started back up at 6 days each week No longer needs vaginal application Patient reports all symptoms are completely resolved Feels like she s 25 again

98 TAKEAWAYS Keep the topical estrogen dose physiologic Women make on average mcg of estradiol daily in youth physiologic dosing reflects Too much estrogen down regulates estrogen receptors Symptoms of excess estrogen mimic symptoms of deficiency of estrogen Excess estrogen can increase insulin resistance, provide less cardiovascular protection and less neuroprotection Hormones applied topically can accumulate over time Dose 6 days per week

99 CASE STUDY 7 F.C. 62 female Caucasian Retired Lives with spouse lb. BMI 28.0 Waist 37 General health fair, energy moderate Menopausal (natural) Last menstrual period around age 50

100 MEDICATIONS Armour Thyroid 60 mg Nexium Crestor Zyrtec Vitmain D3 2000IU

101 PAST MEDICAL HISTORY Medical History Asthma Family History Mother had diabetes and rectal cancer

102 PAST MEDICAL HISTORY Lifestyle Good Diet Exercise: goes to gym daily Non smoker Occasional social alcohol use 4-6 cups of coffee daily, 2-3 diet cokes daily Moderate stress Worries about husband s health & grandchildren

103 CHIEF CONCERNS Goals Hopes BHRT helps with hair loss, weight gain, hot flashes and mood swings 3 chief concerns Head sweats (occurred for years) Weight gain (over last 2 years) Hair loss (over last 2 years

104 SYMPTOMS Severe: head sweats, hot flashes, vaginal dryness, weight gain, decreased sex drive, harder to reach climax, cravings for sweets, increased facial & body hair, scalp hair loss, always hungry Moderate: memory lapse, night sweats, cravings for salt Mild: foggy thinking, incontinence, increased urinary urge, evening fatigue, fluid retention, breast tenderness, mood swings, irritability, anxiety, nervousness, decreased stamina, stress, rapid aging, puffy eyes, constipation, dry skin, thinning skin, hearing loss

105 LABS Serum testing 8/11/2015 & 9/1/2015 Anti-Nuclear IgG Antibodies : none Hematology, chemistry and lipids all WNL TSH and (Optimal ) Vitamin D 25 OH Ferritin 127 TT4 5.4 & 7.5 ( ) ft ( ) ft3 3.6 ( ) TPOa 7.3 ( ) Basal Body Temperature: 97.0 ( )

106 LABS Did not do Thyroid Gradient Levels??

107 LABS Saliva testing Estradiol 1.1 ( ) Progesterone 16 ( ) Testosterone 25 Midpoint of normal for age (20 yo 17-55) DHEA <1.0 really low Cortisol AM 0.1 ( ) Noon 0.1 ( ) Evening 0.1 ( ) PM 0.1 ( )

108 TREATMENT PLAN Plan of Care 8/2015 E2 0.1 mg/ E3 0.1 mg / Progesterone 40 mg per ml. Apply 0.5 ml daily 6 out of 7 days Hydrocortisone 5mg One tablet upon arising, one tablet at lunch and one tablet late after or early evening DHEA 10 mg daily Fish oil Vitamin D IU daily x 2 weeks, then 5000 IU daily Gluten free diet

109 THE INFLUENCE OF ESTRIOL ER E2 ER E2 E2

110 THE INFLUENCE OF ESTRIOL ER ER E2 E2 E2 E2 ER ER ER E3 E3 E3 E2 E3

111 THE INFLUENCE OF ESTRIOL E3:E2 1.0 mg Bi-est 80:20 0.4mg Bi-est 50:50 E2 Content 0.2 mg 0.2 mg

112 THE INFLUENCE OF ESTRIOL E3:E2 1.0 mg Bi-est 80:20 0.4mg Bi-est 50:50

113 TREATMENT PLAN Plan of Care 8/2015 cont d Adrenal support Vitamins & minerals Adaptogens Unrefined salt ½ to 1 tsp daily Protein at each meal and protein only snacks prn Adequate water (1/2 pounds body weight in ounces Daily compensation techniques

114 TREATMENE PLAN Plan of Care 8/2015 cont d Recommended reading Adrenal Fatigue: the 21 st Century Syndrome by Dr. James Wilson Drugs That Don t Work and Natural Remedies That Do by Dr. David Brownstein Chapter on acid blockers Guide to a Gluten Free Diet by Dr. David Brownstein and Sheryl Shenefelt, C.N.

115 RETURN VISIT 3 Week FUP Feels a little better overall No longer having head sweats and hot flashes have been significantly reduced Less tired Has been watching diet and exercising, but hasn t lost (or gained) weight Could not rate vaginal dryness or libido as her husband recently had back surgery Has not been successful going gluten free yet Was not convinced that it was a problem with her

116 RETURN VISIT 10/20/2015 Update Was taken off cholesterol medication first week of September Not sure why doctor did so Follow up testing on 10/19/2015 Cholesterol was 230 TSH 7.0 Tried to convince patient to go gluten free

117 RETURN VISIT 11/6/2015 Update Patient off gluten for over 2 weeks, and is feeling 100% better. Improved energy Stomach not giving me any problems Has stopped Nexium Started Glutamine powder, 1 scoop twice a day until gone (about 3.5 weeks) Started extra strength probiotic one daily

118 LABS Serum Testing 1/7/2016 TSH 2.86 Cholesterol 189 TPOa 4.2 (was 7.3) (0-9.0) Patient reports she feels so much better and has reduced hydrocortisone tablets to one in the morning and no longer feels tired all day

119 CASE STUDY 8 W.F. 39 yo Caucasian female Physician Assistant 5 5 ½ 146 lb. BMI 24.1 waist 31 Lives with spouse and 1 young child General heath good, energy moderate First seen 5/2015

120 GOALS Improve sleep, memory, energy and sexual interest Decrease irritability, weight, and wrinkles

121 PAST MEDICAL HISTORY Medical History Hysterectomy 2007 Ovaries remain Abnormal pap: pre-cancerous Symptoms developed in next 2-3 months Mammogram and Bone Density 2015 normal Family History: unspecified

122 MEDICATIONS Adderall 10 mg one daily Monday-Friday For better focus Has been taking for about 1 year

123 PAST MEDICAL HISTORY Lifestyle Diet good except when at work Exercise: runs 4-5 days per week Non-smoker Occasional alcohol A few diet cokes weekly Used to be 6 per day Stress mild (work) Home life great

124 SYMPTOMS Severe: weight gain Moderate: memory lapse, foggy thinking, mood swings, irritability, decreased sex drive, insomnia Mild: incontinence, decreased stamina, fluid retention, stress, cravings for sweets, caffeine need, AM & PM fatigue, dry brittle hair, constipation

125 LABS Venous serum testing 5/21/2015 Glucose 86 Cholesterol 151 Chemistry, CBC all WNL TSH 1.81 TPOa 5 (0-34) TT4 7.2 ( ) T3 Uptake and FTI midpoint of normal Vitamin D 25 OH 31.0 Ferritin 275 (15-150)

126 LABS Saliva testing 5/6/2015 E2 1.4 ( ) Progesterone 22 ( Testosterone 52 (16-55) DHEAS 1.9 (2-23) Cortisol AM 6.6 ( ) Noon 2.5 ( ) Evening 1.4 ( ) PM 0.5 ( )

127 TREATMENT PLAN Progesterone 150 SR hs DHEA 10 mg am MVM Vitamin D IU daily for 2 weeks, then 5000 IU daily BBT test Adaptogens and compensation techniques Diet modifications Low glycemic index foods Protein only snacks at work

128 LABS Additional venous serum testing 6/4/2015 TSH 2.62 TPOa 5 (0-34) TT4 7.3 ( ) ft ( ) ft3 2.7 ( ) Ferritin 89 Vitamin D 25 OH 42 Vitamin B ( )

129 THYROID GRADIENT LEVELS TT ft ft

130 TREATMENT PLAN Additions to Plan of Care Continue Vitamin IU daily for another 2 weeks then decrease to 5000 IU B mg s/l daily Thyroid Synergy 2 capsules daily Contains Vitamin A, Riboflavin-5-Phosphte, Iodine, zinc, selenium, manganese, chromium, American Ginseng, N-acetyl-L- Tyrosine, Forskolin extract

131 RETURN VISIT FUP 6/25/2015 Patient reports more energy and stamina No change in weight Significant improvement in memory issues, mental clarity, mood, hair quality Moderate improvement in libido Constipation gone

132 RETURN VISIT FUP 7/2016 Patient reports 9 lb weight loss Is eating much better at work Has eliminated caffeine Sex drive closer to what it was Takes me time daily to compensate for stress No complaints at this time Wants to know which supplements she should stay on

133 SUPPLEMENTS? As long as work is stressful continue adaptogens and compensation techniques Progesterone: yes DHEA : continue until re-tested and can adjust dose or possible d/c MVM and Vitamin D: should continue B12: can d/c and see if energy remains at same level; retest Thyroid Synergy: if stress was source of poor conversion and is better compensated, d/c in a couple of months and monitor response

134 CASE STUDY 9 S.M. 42yo Caucasian Male Engineer First saw doctor in 2006 (age 35) No past medical conditions Mother had DM, father died from aneurism Lives with spouse and 2 young children Suffering from erectile dysfunction, low energy, anxiety, nervousness, loss of vigor, muscle weakness, hair loss Patient was put on Testim gel 50 mg Worked well for 3-4 months but generally was dissatisfied with results

135 CHIEF CONCERNS First saw patient 3/2014 Patient now on testosterone solution 3%, applying 2 ml (60 mg) daily Complaints of erectile dysfunction, some depression, anxiety, nervousness, loss of vigor, decreased stamina, fatigue, hair loss Takes MVM, DHEA 20 mg and glutamine daily Good diet, works out 4-5 days per week

136 LABS Saliva test 3/2014 Test 2625 ( for topical 5-50mg) Lower end of range is for 5-10 mg dosage Normal range non-supplemented is Cortisol am 3.3 ( ) Cortisol noon 1.1 ( ) Cortisol evening 1.2 ( ) (workout 45 minutes prior to sampling) Cortisol night 0.4 ( ) Sample collected 24 hours after last dose

137 LABS Venous serum 3/2014 E (10-42) E (9-36) DHEAS 310 (95-530) Total testosterone >1009 ( ) Free test. (calculated) >293 (47-244) Insulin 2 (3-19) Cholesterol, Triglycerides and LDL high

138 TREATMENT PLAN Decrease testosterone dose over time Testosterone 3% solution 1 ml (30mg) daily to shoulder area. Avoid body hair. Aromatase inhibitor: Anastrazole 1.0mg, ½ tablet every other day I3C/DIM Adrenal dysfunction: compensation techniques, Vit & min. for adrenals & adaptogens t.i.d. MVM Vitamin D 2000 IU daily

139 RETURN VISIT 3 week follow up Good overall Erectile Dysfunction has improved to mild to moderate Anxiety/nervousness now mild Daily quiet time and prayer Happy with progress Doesn t feel any negative effect of lowering testosterone dose

140 RETURN VISIT 7 Week follow up Patient pleased with progress Sex life improved, has desire, energy and ability to perform ED: improved. Not like I was 20 again, but no issues

141 TREATMENT PLAN June 2014 Decrease testosterone dose to 0.75 mg (22.5mg) daily Change adaptogen combination to Ashwagandha t.i.d. Patient did not like liquid drops Continue I3C/DIM and anastrazole until testing shows normal estrogen levels

142 RETURN VISIT 11 week follow up Patient doing fine, no problems Decreased adrenal supplements from t.i.d. to b.i.d. If notices decrease in energy, up the dosage back to t.i.d.

143 LABS Saliva test August 2014 E2 1.6 ( ) E1 1.7 (0-3.0) Testosterone 1588 ( ) Sample taken 24 hours after last dose

144 TREATMENT PLAN Aug 2014 Decrease testosterone dose to 0.5 ml (15 mg) daily Discontinue I3C/DIM Continued anastrazole patient choice Decreased adrenal supplements to once daily

145 RETURN VISIT Oct 2014 All is well, no complaints Hasn t noticed any negative effects to decreasing testosterone dose from 60 mg daily to 15 mg daily

146 TAKEAWAYS Symptoms of too much testosterone mimic symptoms of too little testosterone Males product 5-10 mg daily in youth physiologic dosing should reflect Don t decrease supraphysiologic doses too quickly Adrenal/cortisol issues affect testosterone production and function as well as cause symptoms which may appear to be from low testosterone

147 CASE STUDY 10 MB 41 year old Caucasian male lb. Salon owner Lives with spouse who is office manager at a doctor s office General health excellent, energy moderate Initially consulted 12/1/2014

148 PAST MEDICAL HISTORY Medical History: Kidney stones (2/2014) Family history: Breast cancer(mother) Colon cancer(father) Prostate cancer (uncle)

149 CURRENT MEDICATIONS Testosterone injection 200mg IM weekly Previously had used Androgel, effectiveness wore off Vervita Present Moment essential oil (healthy grieving) Vervita Immune Harmony essential oil Omega 3 Rhodiola (2/d) Holy Basil (1/d) MVM Gingko Biloba

150 PAST MEDICAL HISTORY Lifestyle No diet info on intake form Exercise: weights/cardio 5 days/wk. Non-smoker No alcohol Caffeine:??? (sips on coffee all day) Stress: moderate to high Self-employed, kids, wife s in menopause, clients, body is falling apart

151 SYMPTOMS Severe: memory lapse, foggy thinking, mood swings, anxiety, nervousness, irritability, scalp hair loss, increased body hair Moderate: lack of am erection, sleep disturbances, evening fatigue, apathy Mild: frequency of erections, difficulty maintaining erection, increased urinary urge, decreased sex drive, decrease stamina, aches & pains, cravings for sweets & salt, allergies, headaches, depression, low body temperature, loss of hearing

152 LABS Venous serum testing Oct Cholesterol 194 LDL high and HDL low Glucose 80 Red blood cell count, hemoglobin and hematocrit all high PSA 0.9 (<4.0) Total Testosterone 1036 ( ) Free testosterone (35-155) No Estradiol or Estrone level done

153 LABS Saliva testing 11/20/14 2 days post testosterone injection Estradiol 3.9 ( ) Estrone 4.2 (0-3.0) Progesterone 63 (12-100) Testosterone 473 (44-148) DHEAS 12.6 (2-23) Cortisol AM 7.4 ( ) Noon 2.0 ( ) Evening 1.3 ( ) PM 0.3 ( )

154 TREATMENT PLAN Testosterone Cypionate 200mg/ml Inject 0.05 ml (10 mg) subcutaneously daily. EstroDIM 1 capsule daily. Adrenal support Adaptogens Compensation techniques Protein, sea salt and adequate water intake Liver Detoxification

155 LIVER DETOX SIGNS & SYMPTOMS Headaches Muscle aches & pains Asthma Allergies Mood swings FATIGUE Skin disorders, including acne & rosacea Unexplained weight gain & inability to lose weight High blood pressure Fatty yellowish lumps around eyes Abdominal bloating Excessive abdominal fat Pain or discomfort over the liver POOR MENTAL FUNCTION Trouble digesting fatty foods Acid reflux and heartburn Dark spots on skin Chronic Infections Over-heating of the body & excessive perspiration Lowered stress tolerance Decreased Libido Infertility

156 RETURN VISIT 3 Week FUP Went off testosterone injection for two weeks before initiating new lower dose Improvement in almost all his symptoms Did not start liver detoxification

157 RETURN VISIT Patient had been dosing testosterone injection at 0.1ml daily instead of 0.05 mg. Changed to 0.1 every other day about 2 weeks ago Feeling a little tired, less strength and stamina when exercising, issues with attentiveness and retention Suggested drop in dose was too quick and told him to use 0.1 ml every day Questioned about checking thyroid Explained we could work on high testosterone & estrone, and cortisol for 2-3 months and see if symptoms of low thyroid function improve Patient wants to do a BBT as a baseline to compare to later

158 RETURN VISIT Feb 2015 Patient had reported in late January an average of oral BBT of 96.4 ( ) and thyroid labs were requested Serum testing 2/2015 TSH 2.26 TPOa <1 (<9) Vitamin D 25 OH 28.1 Ferritin 88 TT4 8.1 ( ) ft4 1.1 ( ) ft3 3.3 ( )

159 THYROID GRADIENT LEVELS TT ft4 1.1 ft

160 PAST MEDICAL HISTORY ft4 is usually converted peripherally to ft3 based upon need, therefore a ft3 level high relative to the ft4 level is not normal Common causes of high ft3:ft4 Autoimmune reaction If TPOa is below high normal and patient has systemic symptoms, check TgAb Patient not adequately at rest prior to blood draw. Patient needs to be at complete rest at least 15 minutes (preferably 30) Low iodine

161 TREATMEN PLAN Addition to Plan of Care Vitamin D IU daily for 4 weeks, then 5000IU daily. Retest in 2-3 months Additional note: doctor had rechecked red blood cell count, hemoglobin, and hematocrit and all were normal.

162 RETURN VISIT Update 7/2015 Patient called to report some urinary issues the last few weeks. Feels prostate is enlarging and blocking urinary flow somewhat Doctor ran tests and did digital rectal exam and everything checked out fine Also reported acne and skin bumps coming and going over past 4-6 weeks and increase in headaches last 3-4 weeks

163 TREATMEN PLAN Update to Plan of Care Added Prostate Supreme 2 capsules daily Zinc 10, Saw Palmetto 450mg, Nettle Root 250mg, Chrysin 100mg, DIM 100mg, Pumpkin Seed Ext.60mg, Lycopene 20mg, ++ Initiate Liver Detoxification 10 day program

164 RETURN VISIT Update 8/2015 Patient called to report his prostate enlargement had improved by 75% and could he increase his Prostate Supreme dosage to see if there would be greater improvement Increased dosage to 3 capsules daily, d/c Estrodim Did 10 day detox program and feels much better Resolution of headaches, and acne. Better energy Improved mental clarity, sleep & sex now great Did have bad reaction first two days, felt like the flu

165 TREATMENT PLAN Suggested daily support for Phase I and Phase II liver detoxification

166 CASE STUDY 11 B.C. 42 yo white Caucasian female Peri-menopausal Married, no children, works full time RN on third shift lb General health good, energy good

167 PAST MEDICAL HISTORY Medical History Menstrual cycle started at age 11 PMS since teenager Gallbladder surgery age 36 HTN OC use as teenager for 12 years Family History Breast cancer: mother, sister, grandmother Prostate cancer: father

168 CURRENT MEDICATION HCTZ 1-a-day vitamin for women

169 PAST MEDICAL HISTORY Lifestyle Diet includes fast foods & processed foods No regular exercise Non smoker Alcohol: 1-2 glasses of wine after work to get to sleep Stress: Moderate to high 3 rd shift, time with husband limited, unable to get pregnant, loss of both parents in past 2 years

170 SYMPTOMS Only wrote these are the things that bother me to the extent they must be addressed Weight, fatigue, insomnia, irregular cycles, mood swings, irritability, anxiety, nervousness, headaches, aches and pains, memory lapse, foggy thinking, hot flashes, night sweats, and vaginal dryness Deeply concerned with breast cancer risk

171 BREAST CANCER RISK FACTORS Overweight High night cortisol Family history History of OC use No full term pregnancies Inflammation Low Vitamin D Caucasian Menstrual cycles below age 12 Lack of exercise Smoking Light exposure at night Pesticides, preservatives, antibiotics & hormones in food animals, chemicals in cosmetics, mercury in fish Low iodine Plastics (Bisphenol A) Sunscreen use Tap water

172 LABS Serum testing info on abnormal levels from doctors office Vitamin D 25 OH: 22.0 Cholesterol 201 C-reactive protein (CRP) slightly high

173 LABS Saliva testing E2 1.6 ( ) Progesterone 26 (75-20) Testosterone 28 (16-55) DHEAS 2.2 (2.3-23) Cortisol (adjusted): 3 rd shift, her morning is 5:00pm and PM is 7-8 AM AM 9.2 ( ) Noon 1.4 ( ) Evening 1.0 ( ) PM 1.6 ( )

174 TREATMENT PLAN Progesterone 200 mg SR. 1 capsule 60 minutes before bedtime cycle days DHEA 10 mg am Vitamin D 10000U Magnesium mg 1 hour before hs Anti-inflammatory diet, Fish Oil, MSM N-Acetyl-Cysteine 600mg b.i.d Resveratrol

175 TREATMENT PLAN Adrenal support: V/M, Adaptogens, Compensation techniques, adequate water, protein, unrefined salt Regular exercise Recommended she get off third shift. Gave list of cancer risk factors to avoid Mentioned BRCA gene testing, metabolite testing

176 RETURN VISIT 1 month FUP Hot flashes, night sweats now mild Cycle still slightly early but normal flow & length Good improvement in mood, memory issues, sleep, fatigue Great improvement in aches and pains, headaches gone No weight change (but happy she did not gain) Avoiding all the bad things, switched to special cosmetics, all natural household products, filtered water, etc. Feels so much less stressed knowing she is decreasing risks

177 CATECHOL ESTROGENS: THE ORIGINS OF BREAST CANCER AND DETOXIFICATION PATHWAYS 17 B-HSD type II ESTRADIOL ESTRONE ESTRIOL 17 B-HSD type I P450-1B1 COMT + SAMe 4-CATECHOL LIPID PEROXIDASE ESTROGENS + transhydrogenated oils METHYLATED ESTROGENS CANCER MUTATIONS 4-ESTROGEN QUINONES ESTROGEN-DNA ADDUCTS GLUTATHIONE TRANSFERASE +GSH ESTROGEN-GSH CONJUGATES David Zava, PhD 2003

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179 CASE STUDY 12 O.L. 69 yo menopausal female Retired school teacher Lives alone, On Medicare and fixed income Any costs associated with program would be paid by daughter which she is not comfortable with lb. Good general health, moderate energy Doesn t feel she really needs hormones at her age but wants to feel better

180 PAST MEDICAL HISTORY Medical History Osteopenia (slight) HTN Family History: none listed Current Meds: HCTZ When asked, consider 5 supplements would be the max she would take

181 PAST MEDICAL HISTORY Lifestyle Diet: coffee only for breakfast, salad and diet Coke for lunch, meat or fish and vegetables for dinner, CH snacks 3-4 times a day, 1-2 diet Cokes in afternoon Exercise: occasional walk Non smoker, no alcohol Stress high Worries about having to move in with daughter, son s legal issues, grandson s troubles, unmarried granddaughters pregnancy

182 SYMPTOMS Doesn t like to fill out forms, but did share that she had issues with low energy (felt wired but tired), mood swings, irritability, memory and focus issues (felt it was her age), cold extremities, cold all the time, aches & pains, insomnia and sleep disturbances, headaches, dry skin, weight (has gained 5 lb. in last 6 months)

183 LABS Serum testing Vitamin B ( ) TSH 2.87 TPOa <1 (<9) Vitamin D 25 OH 31 Ferritin 138 TT4 7.0 ( ) ft4 1.5 ( ) ft3 2.6 ( )

184 THYROID GRADIENT LEVELS TT ft4 1.5 ft

185 TREATMENT PLAN No salivary testing because patient cannot afford Alternate methods to rate adrenal function Questionnaire in book Adrenal Fatigue: The 21 st Century Syndrome by Dr. James Wilson Energy/Intake form Patient records energy (1-10) at least every 2 hours while awake and intake of any food, drinks or drugs

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187 TREATMENT PLAN Strongly suggested Adrenal support Water, protein at each meal & for snacks, eat breakfast (protein), unrefined salt, compensation techniques, cut back caffeine, walk daily MVM B mg daily s/l D IU daily x 2 wk., then 5000IU daily Magnesium mg hs Fish Oil Anti-inflammatory diet

188 TREATMENT PLAN Suggested Bone support formula Adaptogens MSM Thyroid Synergy Estriol vaginal cream

189 RETURN VISIT 30 Day Follow Up Did not get fish oil or anything not strongly suggested Sleeping better (6-7 hours most nights), less tired Believes in the bible but did not read cause she could not get the message. Had suggested a learning bible which she loves and reads 30 minutes twice a day Told her daughter to back off Reduced caffeine intake to ½ of previous Some improvement in constipation, not as cold all the time

190 RETURN VISIT 60 Day Follow Up Decided after last FUP to try Fish oil and MSM Stated her aches & pains, and headaches, are almost eliminated and she is moving around like she was 20 years younger Has been compliant on diet, down to ½ cup coffee and 1 Coke (not diet) daily Walks now for 30 minutes twice a day after reading the bible Increased magnesium to 2 tablets and is sleeping 7 hrs. most night

191 RETURN VISIT 60 Day FUP cont d Since you seem to know what you are talking about she will consider adding bone support

192 Jim Paoletti BS Pharmacy, FAARM, FIACP Director of Education P2P THANK YOU! If you would like a copy of this presentation, please contact: jpaoletti@power2practi