Good Hormone Health Podcast
Dr. Friedman has a unique practice. He is an experienced, board-certified endocrinologist and researcher. He has the capabilities to diagnose and treat even the most difficult hormonal problems. He is compassionate, a good listener and willing to “think outside the box”.
Good Hormone Health Podcast
Magic Convention - Optimal Replacement for Hypopituitarism
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Dr. Theodore Friedman on Optimal Hormone Replacement for Hypopituitarism – 2024 Magic Convention
Leading endocrinologist Dr. Theodore Friedman presents expert insights on optimal hormone replacement for hypopituitarism at the 2024 Magic Convention. Learn how to effectively manage growth hormone, thyroid, cortisol, and sex hormone deficiencies for better health and quality of life.
🔹 What are the best treatments for hypopituitarism?
🔹 How do you monitor hormone replacement therapy?
🔹 What lab tests ensure optimal dosing?
🔹 How does lifestyle impact hormone balance?
📌 Topics include:
✅ Cortisol replacement (Hydrocortisone vs. Prednisone vs. Cortef vs. Subcutaneous)
✅ Thyroid hormone optimization (T3 vs. T4 combination therapy)
✅ Growth hormone replacement – who benefits most?
✅ Testosterone & estrogen therapy for hypogonadism
✅ Managing adrenal insufficiency & stress dosing
📌 Learn more about optimizing your endocrine health at:
🌐 Good Hormone Health
🔔 Subscribe for more expert endocrine insights!
Optimal replacement for hypopituitarism. That line is causes of hypopitualism, cortisol, the right and wrong way to give, thyroid optimization. We'll talk a lot about desiccated thyroid for sensual hypothyroidism. We'll talk about growth hormone, not just for kids, oxytocin, the love hormone, testosterone, not just for men, stimulus to treat pituitary apathy. Learn about the common medicine you should never take if you're on growth hormone, and learn how hormones interact. So, what's the big deal with pituitary hormone replacement? Pituitary disorders are common, but experts in treating them are not. Many patients with hyperpitualism feel like crap with waking and fatigue. But small changes in repress replacement you feel can make a big difference in your symptoms. Many endocrinologists do not understand properly how to uh treat patients with hyperpituism. They don't understand or they don't believe in monitoring hormone levels, they don't understand that fine-tuning makes a big difference. Um, the little some of the extra things that I do, testosterone for women, oxytocin stimulants, make a huge difference. Most endocrinologists, it's not on the radar. Um we just need to do more. I think that's why you guys are here. Patients with hypertrutrinism that receive conventional hormone therapy, such as steroids, cortisol, and thyroid, um, maybe for a male and testosterone, you have increased mortality. You don't feel that well. These are uh just partial part of the problem. Um, at least it was thought that some of this is due to growth hormone deficiency. Um, and now many patients do get growth hormone thanks to the Magic Foundation and others uh pushing it, uh, in most of the literature. Um, but still there's this decreased uh quality of life in patients and decreased mortality um and maybe due to suboptimal hormone replacement. So you have these axis, these many people know these. The adrenal cordiotrope axis starts with CRH in the hypothalamus, goes to HCTH in the pituitary, and then cortisol and adrenal gland. The thyroid acid is the TRH, goes to TSH and goes to T4 or andor T3. The gananal axis, the gonadotropes are the pituitary. Um, their GNRH is made in the hypothalamus, goes to LH and FSH and the gonatotropes of the pituitary, and then goes to testosterone and estrogen in the end organs. The growth hormones are called somatotropes. The axis is the growth hormone releasing hormone in the hypothalamus, goes to growth hormone in the pituitary, and then Ig of one in the um in the end organs such as the liver. Um prolactin is made by the somatotropes, it really isn't an axis of that. The posterior pituitant makes two important hormones that I think are under recognized, ADH and isotosis. There's a distinct order of deficiencies um with uh hormones. It doesn't always go this way, but it uh frequently does. That growth hormone is the first axis to be affected. You need to have a lot of pituitary damage before you get ACTH deficiency. Prolactin is pretty well dis well uh well uh conserved, and posterior pituitary hormones are also not uh that often affected, but they probably are more likely to need to recognize. So, what causes hypothetic hypopituitarism? Anywhere along the hypothalamic stalk of the infantibulin that connects hypothalamus to pituitary and microadenomas. Kevin, you and I uh spent about 15 years or so published an article that microadenomas DP of hypopituitaries. So you can have pituitary tumors, macroadenomas, microadenomas, pituitary surgery, pituitary radiation, sheehan syndrome, um, which happens after delivering Simmons Sheehan's pituitary apoplexy, hypo hypophysitis, pituitary inflammation, impicella, malnutrition, or critical illness, and head trauma. Stalker hypothalamic problems include cranial phryngiomas and their treatment, uh, CNS malignancy, surgery, radiation, head traumas and accidents, traumatic brain injury is quite common for every several million people in the United States have it, um, but many of them have untreated hypoplergyrism. Infiltrative disease such as hysteocytosis, accident hemochromatosis, and sarcoid infections. Drugs such as steroids are very common to be of hypoptergeism, dopamine analogs, sematastatic analogs. Um so we have published this paper in 2008. We took 38 patients with non-secreted patriotic microadenomas, mean size 4.2 millimeters, and normal, they had normal HF1 levels near the bottom of the range often. 19% or 15%, 19 or 50% of them were found to grow through the deficient, they had a higher BMI, and they uh and they uh failed the test we did at that time. It was called the GHRHRG test. They um compared to so they were more overweight compared to those who passed the test and healthy controls. 19% of the 19 patients had at least another pituitary deficiency, so most of them had growth hormone, but they often had another deficiency. And we concluded that a substantial number of patients with non-sequenated pituitary microadenomas were growth hormone deficient, despite normal IGF1 levels, and had at least one other pituitary hormone deficiency, suggesting that non-clinic secret microadenomas are not harmless. Um, so many patients have low micro have low IGF1s and microadenomas are believed more uh are even more likely to have be a growth hormone deficient. So this is not that rare. Most patients, most endocrinologists sort of do, I think, the backwards way. Um they only look for hypertuitism if they had prior surgery or radiation. I try to look for hyperperturigism based on their symptoms for most things in medicine. Um many of the guidelines don't recommend testing for growth hormone deficiency in a patient with pituitary tumors. Um I was uh at the endrocide meeting and somebody talked about the replacement, I said, well, what about you looking for growth hormones? Oh, we don't do that. The guidelines say you're not even do that. Um my approach is to measure pituitary hormones first in a patient with symptoms of hypopituitarism. And if it points to hypopituitarism, such as growth hormone deficiency or sensual hypothyroidism, then I get an MRI. And if the MRI shows a small pituitary, such as with empty cella or a tumor and the IGF-1 is low, um, and the patient has symptoms of growth hormone deficiency, then we do a growth hormone stimulation test. Um, or put on growth, traumatic brain injury. Again, very common people in car accidents, get whiplash, head trauma, fell, things like that, get hit in the head with things. Um I think a lot of football players have this personally. Um symptoms would be fatigue, poor exercise performance, feelings of social isolation, mood changes, lack of motivation, easily irritated, memory concentration problems. And these um they commonly develop these problems after a head trauma that are fine before. So what happens if the pituitary gland remains in place as the brain moves forward and then the skull uh then backwards with the skull? So you have the uh surrounded by this bony area, the cella that causes microteres of the pituitary blood supply and nervous system that leads into hypopituitary. A Sheehan syndrome is postpartum pituitary injury and hemorrhage. Um patients would bleed a lot and they get like a very severe headache. Simmons syndrome is atrocuitic destruction of the pituitary interior lower pituitary result in hyper pituitarism, not necessarily with hemorrhage. In a non-pregnancy state, it can also cause partial or complete pituitary failure. Dahan syndrome, which I didn't hear about so I made this slide, is patrun injury due to severe nasal spasm without severe hemorrhage. And pituitary apoplexy is in part of the pituitary adenoma and intramass hemorrhage, which result in injury to hormone production by the gland. So Sheehan syndrome shows here this is a fragile blood system associated with postpartum hemorrhage. Um the pregnancy, the pituitary enlarges due to increased metabolic demand, and then you can sort of like outstrip your blood supply and get a mini stroke. Umcosis not associated with uh pregnancy is called Simmon syndrome. In Sheehan syndrome, you have a postpartum, hypoturinism, and due to patriarchy necrosis as a result of intrapartum or postpartum hemorrhage causing hypotension. So often the blood pressure is quite low. They have very severe headaches, absence of lactation, amenorrhea, oligomenorrhea, just very light periods or no periods, essential hypothyroidism, adrenal deficiency. In their labs, they have low TSH and low T4. So injunction of the two enemies, it looks like they have essential hypothyroidism, low HTH and cortisol, low LH FSH, and low estrogen, um, pituitary. Um, and then you want to replace the hormones with your apoplexy, and the tumor usually has a headache, visual fuel defects, and symptoms of hormone deficiency. Some of the symptoms include menstrual irregularities, um 100% of them had that, absence or as far as puber care, weakness and loss of weight, dry skin, failure to lactate was common. Atrophy of the breast was pretty common at hypotension. So they preview a sheein syndrome prevent with severe headache, hemorrhage, can't lactate, patriarchal insufficiency symptoms may be delayed, although most people seem to recognize remember when it happened. May recover with time. I've had patients that had uh Sheehan syndrome, and then years later they recovered. Um and you replace the hormones as indicated, and you have to correct the rate of the right hormones correctly to talk about. Okay, what about glucocorticoid insufficiency? We'll start with the different axis. We'll talk about glucocorticoid insufficiency. Um it needs a significant impairment of the pituitary function. Classically, the pituitary only affects cortisol, not the mineral corticoids, which are aldosteroles regulating on the adrenals, um, although I think there is a role for the pituitary to regulate aldosterol as well. Uh it can be life-threatening, but most patients do surprisingly well. Symptoms include fatigue, lethargy, nauseousness, vomiting, joint pains, abdominal pain, weight loss, hypoglycemia, which can happen in adults, so it's what happens more commonly in children, and low sodium. And I see a tetrad of GI effects. These are, I think, are what I call the main side of the main effects of hypocritism, hypocortisolism would be nauseousness, vomiting, diarrhea, and abdominal pain. I always ask me.
SPEAKER_02Did you say hypo or hypo?
SPEAKER_07Hypo. Hypo uh hypocortisol glucocorticoid insufficiency. So what I do is I screen with it 80m cortisol. If it's really low, less than three, they have clear-cut glucocorticoid insufficiency. If it was greater than, say 10, and the new assays are more sensitive, so you usually use a little higher value, and they're not under severe stress. Glucocorticoid insufficiency is unlikely. And you have this gray zone of sort of three to 10, where that's um you can do a cocentropin test. Cosentropin test doesn't work if there's an acute injury. You have to have an injury for at least five, at least a month. Um, but the cocyentropin test is widely done. I think neurologists like to do it. Um, it needs to be done in a place that has experience in doing it. Well, it's not that difficult of a test. Um, the cocentropin test, the standard one, is um you give 250 milligrams of IV or IM cocentropin. Um, you measure cortisol at times zero, 30 and 60 minutes. Any value over 16 is normal. They used to say 18, they used to say 20. Now they're going down to 16, which I agree with. The assay is more sensitive. If the peak response is less than 10, glucocortal replacement is required. If it's between 10 and 16, it's recommended during stress. Otherwise, it's individualized. And due to improvements in the cortisol assay, the cortisol cutoff decreased. Yes, Gina?
SPEAKER_01And my uh cortisol goes 11 and 5.
SPEAKER_07So my air and then a lot of it depends on your symptoms and whether you need it or not.
SPEAKER_01So I take it for stress and then take it throughout the day occasionally.
SPEAKER_07Okay.
SPEAKER_01Like mom.
SPEAKER_07No, that sounds good.
SPEAKER_01Okay. Some doctors say, oh, you don't need it at all. And some say, you know, you need to be taking these three times a day.
SPEAKER_07I think what you're doing is correct. Um, other tests would be the ICT and material bone test. These are less widely done. They're non-physiological. They both can you make you feel lousy after doing these tests, uh, rarely needed. The ICT is can require uh physician, needs to require physician supervision, but can be also used to diagnose growth hormone deficiency. Patients often feel bad after the ITT, the material bone test. Meteropone blocks one of the steps of cortisol synthesis. Um, so you've dropped your cortisol by it. Um, there's a company called Alliance that supplies materialone. The dose is 30 milligrams per kilogram. It comes in 250 milligram pills. So for an average person, you have to go with 11 pills. You measure the 11 deoxy cortisol at 8 a.m. and then you give hydrocortisone afterwards because again, people get adrenaline sufficiency in it. And I have one patient I did this on, she really wanted it, showed adrenaline sufficiency, and um started her on cortisol, and she's doing much better on the cortisol.
SPEAKER_01So came at hormonal insufficiency. And and I don't know why you put partial hormonal insufficiency.
SPEAKER_07So that's probably not the material test, though. It's probably an insulin tolerance test.
SPEAKER_01Yeah, it was the ITT. Right, right. And it came back before it got my it got my blood sugar down to 18, and I ended up feeling I don't know how I got back to the uh go back got back home because I ended up going to the ER.
SPEAKER_07So it is a dangerous test.
SPEAKER_01Pardon me?
SPEAKER_07It is it can be a dangerous test for sure.
SPEAKER_01I ended up going to the ER later that night when I'm having my first adverse insufficiency.
SPEAKER_07Um adrenal insufficiency is diagnosed with 11 deoxycortisol does not exceed 70, and the cortisol is less than five. So again, it's not done too frequently, but it is quite helpful for several patients. So, how much cortisol do you need to give? When I was at the NIH in 1991, a colleague who I didn't really know, Esteban, measured daily cortisol production rates in normal volunteers using a stable cortisol isotope method. Turned out the average person, an adult, maybe 10 milligrams per day, 5.7 milligrams per meter squared. And then most of it is absorbed. So when you take a pill of hydrocortisol, most of it is absorbed, but not all of it. So sort of what the average replacement is probably gonna be about 12 to 15. Most patients are getting on too much of it. Um, and if you're on the right amount and you give it the right way, it's probably pretty benign. But most people aren't on that, they're on too much and it's not given the right time. And you want to mimic the circadian rhythm. So the circadian rhythm means what the body makes. The body usually makes cortisol mostly in the morning, so it's usually given in the morning. Um, and nobody can do as well as Mother Nature. Most glucocard replaces super physiological, meaning people doctors give too much, it leads to glucose intolerance, diabetes, increased infections, and osteoporosis. So you want to give the right amount, not too much, and not too little. Now remember what I said, what I said in the beginning, HTH is the last hormone to be affected in pituity insufficiency. Growth hormones, TSH, ginitropins, are most of the time lost before cortisol. The symptoms of cortisol are also quite unique, weight loss, nausea, abdominal pain, for example. And if you don't have those symptoms and you're not deficient in the other hormones, it's pretty unlikely you have this. You could have this from taking exogenous steroids, but it's less likely to be hypoperturism. So doctors are quick to jump on giving people steroids, and I think that's a mistake. If you have primary adrenaline sufficiency, that's from an adrenal problem. You usually have um also like a high ACTH, a low cortisol, a high renin, a low algosterone. That's also somewhat rare, um, but it can happen, certainly. But for someone to just have a low cortisol, I'd be suspicious before putting them on uh lifetime cortical replacement. Once you start somebody on steroids, it's hard to stop. Have too many patients on too much steroids that were put on inappropriately, and not enough patients that are on the right amount.
SPEAKER_03She's on she's been on both hormones and steroids, and I've asked for endocrinologists like, is there a different way, or can you give her less? And so I feel like it's making her gain so much. Yeah, yeah, yeah. That's why I came there. I was like, what other way can I feel about?
SPEAKER_07So it's a fine art to give uh steroids back, um, but um she should be on the right amount so she's not gaining weight. Come see me. I don't know. Okay. Um so if somebody has just an isolated low cortisol, unless it's in the right context, there might be a false positive test. So I always tell people think twice about starting glucocortigoids, you know, test it again, make sure it's done in the morning because it's applying throughout the day, and then um the right person should go on it. Glucortigoids stimulate mood. So most people feel better on glucocorticoids. It doesn't necessarily mean you have adrenal insufficiency just because you felt better. So I titled this section cortisol right and wrong we can give. Most patients are over-treated. The earliest manifest of excess treatment is easy bruisability. Weight gain and sensual obesity also happen. The earliest manifestation of the inadequate treatment is joint pain, GI issues such as the nauseousness, vomiting, diarrhea, or abdominal pain. And the GI issues exacerbate the glucocorticoid absorption. So it makes a vicious cycle. Somebody that has low cortisol doesn't absorb cortisol, and then they get even lower cortisol. So the way to get around that is to um you may need to give it by subcutaneous route. Um, in general, I endocrinologists try to mimic the circadian rhythm with most but not all the cortisol given first thing in the morning. Other studies have suggested a higher dose with lower doses throughout the day, often four times a day. And I think that's what what I do, and most people sort of on this three or four time a day dosing. Um, you want to avoid large nighttime dosing, as it could relate to sleep absurbances, disturbances. But I did find um when I was at the NIH about 30 years ago, I did a study, you need some glucocorticoids to go into deep sleep if you're adrenaline sufficiency. So too much and too little are both bad. But I think some people do need a little bit before most people need a little bit before they go to bed.
SPEAKER_01I'm taking like 25 times a day.
SPEAKER_07That's way too much.
SPEAKER_01If I'm having a really routine day, right.
SPEAKER_07I think 25 is too much. You know, I would have to have an appointment with you, but I would say, you know, for most people sort of between 15 and 20 is sort of the reasonable dose. Maybe some people even less, and then um take a little bit at night. Spread it out. Yeah. So I usually give most of it in the morning. I aim between 15 to 20 milligrams in a woman, maybe a little bit higher in a man. And then I try to decrease the dose. Long term, you want to give as little as possible, um, but you want to not have the person feeling miserable having a lot of symptoms. So many people can get by on less. And as I said, this is sort of the last axis to go, so it's the first access to recover. Um, you should decrease the dose until some symptoms develop, and then you can go back on that dose. Um, the small change make a difference, especially between these 15 to 25 milligram dose. That's because of cortisol binding lobin, the cortisol's bound to the cortisol binding gobin and then released um from that. So a little bit of change changes the free cortisol a lot. You do want to increase the dose of illness, but I think it's overdone a little bit. Double the dose is probably good. And short term, it's better to give more, long term, it's better to give less. Um, you could take an extra 2.5 to 5 during exercise, extra during uh traveling is probably good. Um, you know, probably just psychological stress, maybe not so good, but um, stress um traveling is definitely stressful for people. So adrenal crisis is one of the symptoms. GI issues, again, really common, nauseous, vomiting, abdominal pain, diarrhea, fatigue, low or high blood pressure. Most of my patients come, they said they go to the ER, their blood pressure is high, and the doctor says you can't have adrenaline sufficiency because your blood pressure is high. And it actually doesn't make any sense because when you're under stress, you're kicking your adrenaline and you get high blood pressure, right? A high pulse is quite common. Yes. Right.
SPEAKER_03So you lose either way.
SPEAKER_07Right. Uh high pulse weakness, you feel like you're passing out, you have poor circulation. So, what is the how do you treat um glucocortical? How do you do glucocortical replacements? And what do you what do you do if you feel like a crisis coming on? In general, patients on a lower dose, which is what I put when I put people on, I want uh you to be on a lower dose and your daughter to be on a lower dose, you're more likely to get adrenaline crisis because you know you don't have this buffer zone, but it's still better long term. So the trick is to be on the right amount. Um, you um it can be exacerbated by flu or other illnesses. In general, when people have adrenaline crisis, you want to try to figure out what is the underlying cause and um is it an infection or um some uh heart issues or something like that. So patients should try to know when it's coming on, they should know about the symptoms. They start with doubling the dose of orals, they can give uh you know orals two or two or three times, then they can give the IM hydrocortisone, which is called solucortef. It's an actovile and it has a syringe with it, it's available for ion injection. They should drink a lot of salt and fluid like aid, they should take synthetic algosterone, which is called fluidrocortisone, they should have a lot of anti-nouseousness drugs, azophrin and phenogrin on board, pain meds, anxiety meds, like a divine on board. But people should not be stoked, even though the emergency room doctors usually aren't that helpful and you just sit there for a long time, you may have to tell the emergency room doctor what to do. On the other hand, you know, you don't want to die from this either. And I've had unfortunately several couple pages that have passed away when you're in all crises.
SPEAKER_03Right.
SPEAKER_07So I have you know on my website I have a crisis letter and people can should bring that to the emergency room.
SPEAKER_01High blood pressure along with the low sodium, yeah. I have low sodium and I have any gas for the bipass. If I go in and I'm out of sodium 130, they say, Oh, you're you're you're fine, you don't need any other words and it could be, but it could be other things. But I already take five grams of salt film per day.
SPEAKER_07Right. So high blood pressure doesn't exclude age drinal insufficiency, and people should have a meta metalert bracelet that tells uh doctors and first responders what to do. Um, you know, most iPhones now have this sort of emergency page on them, so people should fill it there. And I think most emergency um most first responders don't look there. Um, so I've had several patients on the subcutaneous cortisol. They have patients that have GI issues, they can't absorb all hydrocortisone. Um they you have them take the soluor type, it comes in an actovile of either the 100 or the 250 milligram vial, reconstitute in two mils, so it's 50 milligrams per mil. Um, you can also reconcentrate it in one mil. Um, the had they have a 250 and a 500 and a thousand milligram vial. So those are all options. Um, I've switched patients several patients over to this, and most of them do better. Yes, Boris, I'm sure it always gives you a hard time. Um I dose it usually three to four times a day, uh similar to oral, but you can often cut down the dose because it's better absorbed. Um, some people go on these cortisol pumps and I click after me. Dr. Midget is uh talking about that. I recommend this first and mostly this instead. I think it's easier, cheaper, doesn't get infected. Um, you don't have to worry about the different types of pumps. Um, but you know, there are a few people that probably need a pump like you. The lady behind you on the green. How do you monitor glucocortic replacement? Signs and symptoms, you do a 24-hour urine for 17 hydroxysteroids. 17 hydroxysteroids are cortisol metabolites. Um replacement in replacement. Most of the UFC occurs right after taking the cortisol. Um, so the UFC is less reliable than the 17 hydroxies. The lab seems to have trouble doing the 17 hydroxysteroids. The high high doses of cortisol replacement, if a person takes um you know 20 milligrams in the morning, exceeds the ability of the cortisol binding globulin to bind to it, exceeds the ability of the kidney to absorb it. So you get a bolus of cortisol into your urine at the beginning of the day. 17 hydroxysteroids are throughout the day, so it's more integrated. So I usually do that to monitor it, although not too many people do that. Um, and there are other hormones that affect cortisol metabolism. We'll talk about that in the end. What about steroids coverage for illness or surgery? Depends on the illness. Um, moderate illness is you can take 50 milligrams twice a day. A severe illness, you're hospitalized 100 milligrams of IV hydrocortisone every eight hours. Minor procedure without anesthesia, no extra coverage. Colonoscopy, usually double the hydrocortisone and fluge cortisone if you're on it the day before and the day of the procedure. Endoscopy and arteriography, you can do 100 milligrams of IV hydrocortisone before, and often I get 50 milligrams afterwards. Major surgery, IV hydrocortisone before anesthesia, and every eight hours for um 24 hours, and then the next day you can double your dose. Yes.
SPEAKER_00No.
SPEAKER_01What will it be more sodium when I start taking five?
SPEAKER_07Um there's a lot of reasons to give you low sodium. Right. So adrenal insufficiency can give you low sodium, but a lot of other things can too.
SPEAKER_01What will it be on sodium? It should raise it. Yeah, raise it.
SPEAKER_07Yeah.
SPEAKER_01What will erase its vision?
SPEAKER_07I don't know. There's this concept called adrenal fatigue. Uh, I'd say it's mostly fiction. It's widely proposed by alternative and anti-aging doctors, although maybe a little less so. Lots of internet discussion on it, but maybe died down a little bit. It's often based on these salary cortisol assays called Z, the ones called ZRT. Uh, they're both inaccurate, they lack both precision and accuracy. They're marketed to the patients. Um, I did try to call one of them up and try to get some quality control. And until as soon as I asked that, they weren't responsive at all. Um, the theory is that stress, quote unquote, leads the adrenals to work harder and make more cortisol. Um, and then it burns out or peters out and makes less cortisol. Dr. Tori Hudson, a naturopathic physician, says it's like a hormone factory and it wanes in its production. One of the ways it wanes is just by stress. Alternative doctors may give herbs and supplements to stimulate the adrenal gland. There's a product it used to be called, it's called isocort. It used to be ground-up sheep uh adrenals. Now it's supplements. I think it's a lot safer. I think with this out, with less isocort around, less doctors are doing this. Um, some of these alternative doctors give hydrocortisone. One alternative doctor said uh eat lean, green, and clean is the treatment for adrenal fatigue. Don't disagree with that, but um, that was part of my last talk. So the fact is that adrenals upregulate are upregulated during stress, they're not downregulated, so you know they don't burn out and make more cortisol, uh, not less cortisol. There's a paper in psychoneuroendocrinology in 2006 studying 74 clinically diagnosed burnout individuals compared to uh 35 healthy controls. They found similar cortisol patterns after awakening and at different times of day and after even overnight dexaminosome suppression tests in the two groups. So patients should not be put on cortisol unless they have been shown to have adrenaline insufficiency, not just for quote-unquote adrenaline fatigue. Okay, let's go to central hypothyroidism. It's common even with small tumors. Um, mild cases can be manifest clinically. Um, I would say there's more symptoms for central hypothyroidism than subclinical hypothyroidism because the hormones are actually low. In central hypo and subclinical hypothyroidism due to a thyroid basis, your TSH is high, your free T4 and Free T3 are normal. However, in central hypothyroidism, you actually have a low free T4 and sometimes a low free T3. Um, so it's similar symptoms to primary, your fatigue, tired, waking, sluggish reactions, things like that. Um, most of the cases the free T4 is low between 0.7 and 1. The free T3 is often unhelpful, but sometimes it can be low also because growth hormone converts T4 to T3. So if I see somebody with a low T4 and a low T3, it's a hint that they might have growth hormone deficiency. Well, most people have a conserved conversion from T4 to T3, and it's usually normal. So the diagnosis is usually made from a low baseline to 3T4 and TSH. So there's a lot of options for treatment. Um, olivothoroxin, the different brands of levotheroxin include um levotheroxin, synthroid, levoxyl, tyrosin, unithroid, these are all T4 preparasis. Levotheroxin is generic. You can have T4 gel capsules, tyrosin, generic chair, tyrosin, thyquidity, these are all T4 gels. You can have T3 alone, cytomyl or lithyrinine. You can have combinations of T4 and T3. You can have desiccated thyroids, which we're going to talk about extensively, ethesa, armor, gnathyroid, WP thyroid, which is no longer around, IRFA. These are from pig thyroids, they're often called natural desiccated thyroid or NDT or desiccated thyroid extract DTE. There's thyroid gold, which is available over the counter. Um, it comes from New Zealand cows. You can mix T4 and T uh desiccated thyroid and T4. And in general, I would say this is an art, the proper thyroid treatment needs to be individualized, not just one blood pressure medicine, not just one thyroid medicine. Multiple studies have shown that people with hypothyroidism, including sensual hypothyroidism on T4 with a proper numbers, have poor quality of life. For people with primary hypothyroidism, it's thought to be somewhere between 15 and 20 percent. Um, so these this is a real problem. People don't do that well in T4. And I think that T4, T3, or nature throughid is a good solution. Uh, the one that um uh you meant Gina, Gina mentioned before is uh WP thyroid and nature throid. They were made by RLC labs. They haven't they haven't been available for about five years. I don't see them coming back. So, what can you give leavothhyroxin? Um, I think most people do better on this T4, T3 combination or T4 desiccated thyroid. Growth hormone deficiency can lead to an impaired T4, T3 conversion. Um the T4 and T3 uh or desiccated thyroid may especially be beneficial in central hypothyroidism. Treating with growth hormone can decrease free T4 levels and unmass central hypothyroidism. But I do recommend that doesn't mean you shouldn't treat the growth hormone deficiency. So you can have um normal free T4, you can start the growth hormone, the T and the Free T4 goes down and the Free T3 goes up, but you should still do both of them, still treat both the growth hormone. In general, I aim to monitor to have the free T4 sort of the upper half of the range, 1.5 to 1.7. The TSH is resuppressed. I don't measure it often, but sometimes I measure just to make sure it's not too high. And patients with hypothyroid primary hypothyroidism and central hypothyroidism, both you should also monitor them with free T4 and not TSH measurements.
SPEAKER_01I do.
SPEAKER_05I do, definitely. I do for sure. You want the both the both them to be to be in the top arrangement.
SPEAKER_07Yeah, you should go and be on T3 or desiccated thyroid that raised it.
SPEAKER_01Well, I'm RBM T3 I should have.
SPEAKER_07I guess so, but you know, you have to work with your doctor.
SPEAKER_01Yes.
SPEAKER_07So armor thyroid is the most common brand of desiccated thyroid. It's made by a company called Abvi. Um there is it's a big company. Um, there is concerns about variability and preparation, lack of standardization, but that's no longer true. ABV does a good job of this product. I think it's very uh pure. MP thyroid is the one I use the most. It's a brand of desiccated thyroid, it has minimal binders or fillers. Uh at Thesa is a new product. What's the advantage of the Thesa is they test each lot for potency, so you make sure that it's really what it says on it. So this is a good product. I think the companies invest a lot of money into this product. I think it's a good, it's really um improvement. In general, desiccated thyroid has a higher T3, T4 ratio than human thyroid. So when you give um patients on desiccithyroid, they often have a higher free T3, a lower free T4, and a lower TSH. Um, but I see less of the low T4 on MP thyroid or athesa than armor. So I used to have to give everybody some T4 when I was giving armor. Now that I give MP thyroid or thesa, I often don't. Levothora uh lithiurine T3 has a short half-life. That means it's gone in your body. So he has to give the levothyroxide the lylothyroid, sorry, or the desiccated thyroid twice a day. People that give it once a day don't do well. I don't see why doctors would do that, including some smart doctors. It really has to be twice a day. Yes, sir. So primary means your thyroid itself the problem. You have a usually enlarged thyroid, you have a TP on your body, your TSH is high. Central hypothyroid mean your pituitary is affected. Most people in this room have a central because they had pituitary problems, and they have a low F4 and a low TSH.
SPEAKER_01So why do things like the vaccine? Why do you need to not eat an hour? Yeah, you take it and then you wait to an hour and eat.
SPEAKER_07Right. So um that's probably overblown, but in general, food does interfere with the absorption of thyroid medicine. The tyrus in the gel capsule is much less. And you know, I think if you're consistent, every day you do the same thing, you monitor your levels, it's probably not that big of a deal. Um, but you know, generally it's recommended to do it on an empty stomach. Next over here.
SPEAKER_00Um so primary Hachi models would call it to that.
SPEAKER_06Correct.
SPEAKER_00And then if you had Hachi models for a very long time, then you can do the same. Right, so you can have both.
SPEAKER_07And then you when you have both, you monitor the freaking four and you know, sort of replace people like they like they have central.
SPEAKER_02Um your live show can throw the two four in the lower range and they're still monitoring TSH. Do you recommend it twice a day? Yeah.
SPEAKER_07So a lot of times they're all low if they just give them once a day, especially in the morning. People would feel hyper right after taking their pill once a day, and then they feel hypo in the evening and the next morning. You give it twice a day and sort of evens each other out. In general, I would say for central the free T4 and Free T3, you want them sort of mixed upper range. That's more important than having the TSH. TSH supposed to be low.
SPEAKER_02Then we recommend uh, or do you see better results if they go on the desiccator?
SPEAKER_07Yes, a lot of people do better on the desiccator. For sure, we'll talk about that.
SPEAKER_01Yes.
SPEAKER_07Not bad, it's gonna be a little bit higher. Yes.
SPEAKER_01Um taking other medication, and once I take it, I think I have to wait two hours before I'm gonna do it. Right.
SPEAKER_07I think he needs I I think he needs to go back to pharmacy school. So, you know, the uh the main medicine. No, no, complete myths. So the main medicine he's concerned about is calcium and iron and vitamins that have calcium and iron. There's a little bit of concern about the uh the prolice, the mirazol type of medicines. But basically, I think this is overblown. And um, you know, if you have a choice, take it separately from food. But I don't think you have to wait up four hours. I think an hour is plenty. I mean, if it gets absorbed, certainly within an hour, and maybe it's you know, even a half hour is probably mostly absorbed. Yeah.
SPEAKER_01I've had PR in that prominent central surgery on line drives, bacterial nine drives, I mean produced 0.011 TSA.
SPEAKER_07Yeah, you have sensual hypothermia. Um okay, so um again, the importance of keeping the freaking foreign freaking freaking upper range, the importance of giving it twice a day. Um so there was a landmark article published by Wang, H-U-A-N-G, from the Walter Reed National Medical Center in Bethesda, which is where the presidents get their treatment from. Um it's a pretty good place. It was a randomized crossover study. They give 70 patients received either desiccated thyroid or levathyroxin and then cross them over. Um they were supposed to be on a stable dose of levothyroxin, had a normal TSH before the study. 78 patients were randomized, 70 concluded, 35 received armour thyroid at the beginning, and 35 received levotheroxin at the beginning, and then they switched them over. The dose was adjusted, so the TSH was between 0.5 and 3. So it was really looking at the TSH. Dr. Wang um Wang Wong, I think it is, um, really monitors TSH, which I don't think is correct. They continued that dose for an additional 10 weeks. After 16 weeks, they were switched over to the other compound within the same adjustment period and continue for another 10 weeks. Um, so there was not a statistical improvement in symptoms of general health questionnaires, nor psychological testing. There was a trend improvement in the group that did the desiccated thyroid compared to the levotheroxin, so it wasn't powered enough to show an improvement. It was a fairly small study. However, there was a 2.9 pound weight loss among the group that took desiccated thyroid compared to the levotheroxin that was significant. The patients on the levather on armor had a slightly lower HDL, so that could be detrimental, but I don't think that was really substantial. Um, both total T4 and free T4 were lower on the armor than on the levotheroxin, because remember I said armor doesn't have that much T4 in it. If they did MP thyroid, it might be better. So they probably could have done better if they were given a little bit extra T4 or given the visa or uh MP thyroid. And the RT3 was higher in the levothyroxid replacement group, which may be detrimental. Uh, most importantly, 49, this was a blinded study. So 49% of the patients on armor preferred the armor, 19% preferred levotheroxin, and 33% felt better. So you want people to like what they're taking. That means they're feeling better. So it was substantially three times as many people basically did better on the armor. Um so they didn't know what they're taking, and it shows that there was some improvement in how they're feeling with the armor that wasn't picked up in the surveys. They lost more weight. Um, the people that preferred the armor lost more weight. They lost four pounds on the armor if they liked it. So those are the people that probably really needed it. They had a better sense of well-being and their thyroid symptoms were significantly better with cognitive uh function on armor compared to the legotheroxin. And this suggests that patients need armor and would do better on it than the legothoroxin. None of them really seem to like, you know, did do poorly. You know, there was a few people, but 19% in one out of five liked the legotheroxin better. Um, so these people may be poor converters from T4 to T3. They may have high reverse T3. There may be a lot of reasons, but in general, most people did better on the armor. There was no side effects, there's no increase in heart rate of pulse. They included that the improvement with armor was not detected by the relatively insensitive uh methods used in the study. They also included that once a day desiccated thyroid in place of levothyroxin caused modest weight loss and possible improvements in symptoms and mental health without side effects. So, my thoughts on this article was that it was a well-designed, well-executed study, done in a good with a good group, published in a great journal. Um, I recommend, I note that they gave armors a single dose. Since it has its T3 and has a short half-life, I think they would, they would, the patient would do much better if they given twice a day. Um and I think if they they would have done better. So I'm gonna talk to Dr. Wang about uh maybe doing a study with twice a day. Um he's reviewing right now my paper on reverse T3, so I want to see what he says about that. And it's clearly refuted that the armor is inferior.
SPEAKER_03You said you're working on that currently. So if they if we were to switch, for example, my daughter's only about eroxy that is right now, it's only supposed to be taken once until it's approved.
SPEAKER_07No, no, you can doctors give it any way they want. I I think they have to give it twice a day, but there hasn't been a study to prove that. But you know, to me, all it makes sense because it has a short half-life, but it really should be given twice a day.
SPEAKER_02This was a small study of seven people, exactly. Not like 17 penals.
SPEAKER_07Right, exactly.
SPEAKER_06Um here.
SPEAKER_01No, I think I'm all right. Thank you. I'm sure I don't know.
SPEAKER_06So a subset of patients did seem to be better.
SPEAKER_07Um, and you want to, you know, as a doctor, you want to figure out who's the one should go on this. So as I said, many people with on level thyroxin alone don't do well. Those people should be offered this as an option, should give it twice a day, and should be monitored to see how they do. And I think most people will do a lot better on this. There was also more thing. There was also, I think, nine, seven, at least seven studies comparing designated fiber to legal thyroxine, including the next one I'm gonna talk about. Every single one of them showed designated thyroid is better, and none of them showed legothoroxin is better.
SPEAKER_02I'm just curious. So if you have a patient who seems to do well on lifethroxin, would you interact with it?
SPEAKER_05Not necessarily, they're doing fine.
SPEAKER_07So, as I say, 15% of people on level throxin aren't doing well. That means 85% are. And you know, if my county patients, there you know, they have so many other problems to worry about, you know, they're they're fine on the level, most of them.
SPEAKER_01Okay, I'm just taking one time a day. When do you do the blood test?
SPEAKER_07So I don't remember one time a day, right? But I still recommend doing the blood test the first thing in the morning before their dose. You know, if you do it after the dose, you almost always have a high 23. It's not that high usually, but it's almost always so I recommend it before. So it's sort of a caveat that it's going to be a little bit higher during the rest of the day than the the you know the mornings of the trough, but you know, I usually look at that.
SPEAKER_01How does we get until like one o'clock to take onstead to three?
unknownRight.
SPEAKER_01Or later. Now this is a hospital thing for me to say that. So I always thought I was right.
SPEAKER_07You're right, you were right, who was wrong.
SPEAKER_01So I I mean, if it was a hospital, I mean I understand what is the question. So we take that so if I was taking an E ID with my Lavoxel, I would take the Lavoxel and uh Lavoxel could be just one today.
SPEAKER_06Right.
SPEAKER_01And I would take my second A second V I D uh probably two or flour.
SPEAKER_07Yeah, two or three is good. Yeah. Um, so my other comments, the study looked at people, all comers, you know, many of them were doing well. As you said, if they're doing well, then don't rock the boat. If they looked at people that were doing poorly, I think they would have found more people. And, you know, people come to see me. They're not gonna spend the money to see me. You're used to fly out on Zoom. Um, but if you're doing well, you're not gonna bother with that. So it's really the people that um are sick and not doing well that they should go on this. So this was followed up by uh his colleague, um Mohammed Shaker, who's actually an older man in um probably nearing retirement age, real nice guy, um, published also in JCNM um last year. This was a prospective randomized crossover study. 75% of the people completed the study, again, a small study. This one, there's three arms, the desiccated thyroid extract in T4, T3, and T4 alone. It was blinded again, which is a good idea. And they were crossed over for through three arms for 12 weeks and then crossed over. Of the 45% of patients indicated they preferred desiccated thyroid as a first choice, 32% preferred legal thyroxid and T3 as their first choice, and 23 preferred alone. So, again, most people like the desiccated, they liked the T4 least. Um, there was no difference on the questionnaires. On some of the other questionnaires, also, there was no difference. They also looked at the genetic polymorphosism and didn't find any effect. I'll skip a little bit. So, in general, the I think the the studies do show that the desiccated thyroid is more well liked than the T4. Same thing again, give it twice a day, you'd be better. Same thing again. Um, aim for the higher free T4 and free T3 and have a low tooth age is okay. So, in general, for T4, T3, this is sort of what you asked about a little bit. First, take the first thing, first thing in the morning in an empty stomach, but it doesn't have to be that empty. Twice a day, your second dose mid-afternoon, avoid taking with iron and calcium, vitamins that have iron calcium, the protein pump inhibitors like uh amibrazole, caraphate, phosphamax, or lostat, cholesteromine. I would say there's a minor effect of soy, it's probably nothing, not that much to worry about. Proton pump inhibitors, yeah. Try to take them separately if you can't.
SPEAKER_01No, you can it's not really interference.
SPEAKER_07No, it should be okay. Just try to take it separately. Right. Um, selenium increases T4 to T3 conversion and reduces the TPO antibody. Um, and um there is some selenium deficiency, I think, in the United States. Um, I'm not sure it's needed to measure it, but I think it would be reasonable to take uh selenium. Um, however, selenium gives you a higher rate of diabetes. So if you have a family history, if you already have diabetes, I probably wouldn't give it to you have pre-diabetes, but if you don't, you can probably take it. Um growth hormone deficiency also has an increased rate of T4 and T3 version uh conversion. So they might benefit from the selenium, but they would also benefit from being a growth hormone. Okay, next we'll switch to growth hormone, favorite topic here. Um 50,000 adults in the United States have growth hormone deficiency, so it's a large number. Um they have increased mortality. It's again thought to be due to growth hormone deficiency, it has a pretty big role. It has decreased bone formation, increased fat, such as central obesity, decreased muscle mass, lipid abnormalities, increased thickness of blood vessels, increased inflammation markers, impaired quality of life, increased number of sick days, impaired exercise tolerance. Most of these abnormalities are corrected by treatment. If left undiagnosed, adult growth hormone deficiency have increased risk for premature mortality, anxious morbidity, and multiple signs and symptoms, including an increase in body fat, a decrease in muscle mass, weakness and fatigue, osteoporosis, increased rate of fractures, dyslipidemia, cardiovascular disease, impaired sense of well-being, such as isolation, uh, anxiety, and depression. Yes, Karina?
SPEAKER_03My daughter actually took her off the time. And that one, I think it was talking, she was like 10. So I asked her recently um if we can put her back on in which it's a good now.
SPEAKER_07You say all these problems here. So there's two types of growth hormone deficiency in kids. I don't really specialize in kids, specialize in adults, but adults used to be kids. Um so um if you have what's the spituary surgery, traumatic brain injury, something structural, you probably need growth hormone the rest of your life. If you just happen to be short and fail your stem test, then you're probably okay once you get older and you're not growing growing anymore to stop it. So maybe that's her case. But if she has hypothyroidism and cortisol deficiency, then yeah, you're right, then she probably needs to never come see me.
SPEAKER_06Both, I don't know. Probably your daughter. I don't think I can help the endocrine, it's probably too far gone.
SPEAKER_01Stop and if you have stopped and um I noticed before when I was seeing on my um hormone doctor after I had my team to deliver in the box. Um I I was seeing having HR and I tried um I tried somorolin. And yet I felt wonderful. I really felt wonderful. And um all of a sudden, after this, after I started having this uh central thyroid, I the somoralin does nothing to me, but it gives me a little bit of energy and a massive headache on the second day.
SPEAKER_07So again, let's um let's focus on things that for everybody here is okay? No problem. And um you can you can come see me. Um if left undiagnosed, a grid growth hormone deficiency leads to mortality, morbidity, all these conditions here. So most people I think need to be on growth hormone against the first hormone affected. I don't see why you can say these are all the reasons why she stayed your daughter should stay on it.
SPEAKER_06The uh I'm sorry, just high cholesterol. High cholesterol.
SPEAKER_03You know, yeah. Where were you? Where were you before?
SPEAKER_07Still here, I was always around. Um this gentleman over here said he heard me talk. Um, this gentleman here, what was it? Heard me talk one of you guys over there 20 years ago. So I think I've been taking speaking.
SPEAKER_03And I just realized you live in California and I'm in California.
SPEAKER_07Doesn't matter. I do zoom, you know, based on appointments anyway.
unknownOkay.
SPEAKER_07Okay, so um these things are related to growth hormone deficiency, obesity, dyslip lipidemia, trouble with your cholesterol, imperi glucose, oxidative stress, pro-inflammatory cytokines, endophilic dysfunction, um, and you're also the risk factor, more importantly, for heart disease and strokes and black cocks also. So you can't measure growth hormone. Growth hormone is pulsatile. This you can be in the top of pulsating the bottom. It's useless to measure random growth hormone. People who do it don't know what they're talking about. So you start with an IGF one. Um, if it's in the top of the more than 50%, it's unlikely. So on average, you know, each lab is different, and each lab is based on your gender and your sex. If we say greater than 150, give or take, but you know, they have a z-score, the z-score is zero, means you're right in the middle. So if your z-score is above average, your your level is above average, it's unlikely. If it's really low, it's likely, and it's sort of in the gray zone near the bottom, is when you do the STEM test. Especially if you have a history of head trauma, headaches, low blood pressure after delivery, the Sheehan syndrome, history of pituitary surgery, radiation, or pituitary tumor. Uh those are all reasons to have growth hormone deficiency. If it's really low, like less than 75, it's worth, it's likely. If it's sort of the bottom of the normal range, you should do a STEM test. I would test it at zero. But you know, it depends on the symptoms and things like that, also, but probably zero will be cutoff. Um general, I do the growth glucagon stimulation test. Um, the insulin tolerance test is very hard to do, and people feel horrible. Um, the cutoff for the growth hormone, I would say in both of them, is probably three. Some endocrinologists are trying to say if you're overweight, it should be one. I think you're overweight because you're growth hormone deficient, not I shouldn't exclude it. So I use three. Um, sometimes people are at sort of the three to five, sort of in a borderline area. Um, there is a test called a maclin test. I'll talk about that in the next slide. The macron is very hard to get insurance to cover it, it's very expensive. So, growth hormone deficiency, you know, the IGF one is a screen, it's helpful, but you can see there's a lot of patients in the normal range. There's the women in red and the men in um purple, or I guess that's sort of bluish color. There's a lot of people in the normal range and still have growth hormone deficient, and the range goes down with age.
SPEAKER_01It's not exactly exactly.
SPEAKER_07No, but it's helpful, but not exactly. So the test to people do the instant tolerance test, the glucagon stimulation test, the macaroline test. The maculin is potentially the shortest, it might be the easiest, but it's again hard to get coverage of it. They all have side effects in their um the IV uh ITT is two hours, glucagon is four hours, macrolin is one and a half hours. So we do the glucagon test. I think the glucone is the most accurate. I think it gets uh too many people are can be missed it. The macron, a lot of people have it and miss it. I think glucagon is the best. It's hard to find places that do this. The glucone itself is quite expensive, so a lot of people don't want to do it because of that. We offer it on Tuesday night and Sunday afternoons. You do need to fast for eight hours. Um, so I came up with this idea, and I think this is a good idea here. Between cortisol deficiency and growth hormone deficiency, everybody jumps on treating cortisol deficiency. Um, but nobody seems to treat growth hormone deficiency. And like you said, your daughter gets taken off of it. So um why would you treat growth hormone deficiency versus risk? You always medicine look at risk benefits. Um growth hormone deficiency, you have symptoms of fatigue, poor sleep, joint pain, psychological issues. It helps with bone density, body composition, carotid entimal thickness, cardiovascular markers, lipids. Uh, what's the risk of treating? Um, not much. Um, you can get joint pain and swelling. Um, you can it's easy to stop, it's not addicting. On the other hand, cortisol deficiency, mild, yes, you may present a adrenal crisis, but if you're mild, you're not going to get that that often. It may help with fatigue, joint pain, abdominal pain, and not diarrhea, but it checks down the old adrenal gland for making its own cortisol, making it hard to stop or taper off. And it gives you weight-a-in infections and um potentially osteoporosis. So, to me, there's a higher risk-benefit ratio of treating growth hormone deficiency in cortisol, but most people feel the other way around. So, my approach is to do the stimulation test. You don't need it just for body weight in adults. Um, all estrogen, so we'll talk about this a lot, um, is um inhibits the action of growth hormone in the liver, leading to lower growth hormone and higher and lower higher growth hormone, lower IGF 1 levels. Okay. Okay. Um, women need a higher dose. Yeah. I think I'll be okay. Women need a higher dose than men. You start at 0.4 milligrams a day in women, 0.2 milligrams a day in men, you give it night. Um, the final dose varies and can't be predicted. Some people need the one, you know, 1.6 milligrams a day, some people 0.2 milligrams. I titrate basically IGF 1, titrate every one to three months. The likeness is sort of the upper range of normal, sort of around 200-ish area. And some people you don't get much better until they're in there. So oral estrogens and birth control pills block the action of growth hormone at the liver. So you get a high growth hormone, a low IGF one. High growth hormone can lead to diabetes, low IGF one is your main problem. You're trying to treat their IGF 1. So I would say you should never use oral estrogens or birth control pills in somebody with growth hormone deficiency. Um, so I try to treat people with growth hormone deficiency with growth hormone. However, there's a lot of shortages nowadays. Insurance companies can be quite difficult. Um, it's not as expensive as it used to be, but insurance companies are still going to be very difficult. And then if you have a shortage and you have the pharmacy benefit manager wants you to be on one growth hormone, but that one's out, it's very hard to switch to the next one. You think they would automatically substitute it, but they don't. And they play a lot of games with you. Um, so there are some cash paid options. The one I use the most is called Zomactin, it's from University Compounding Pharmacy or Ocean Breeze Pharmacy. It's about $250 a month. Um, not too bad. Um, they use different amino acid blends. I like this supplement called Otropin from Morenda. It's uh it's droplets of uh amino acids by liposomes. I think it helps some. It's not that expensive. Yes, it's disagree to God. And then there's another one called Ceravital. It's available at Ceravital.com or Costco. It's $94 for a 40-day supply, so it's also not that bad either.
SPEAKER_03No, because it's a program that we're gonna have would be if they would be willing to pay legal compared if like in channels for that.
SPEAKER_07Um so now there's a once-a-week growth home analog. I think this is also a game changer. It's called Segroya or Semapacitin. It's made by Nova Nord, it's the same country that makes um uh Zempic. And it's approved for the FDA for adult growth hormone deficiency, became available in 2023. It's a long-acting growth hormone. So again, it lasts once a week. Um, it's uh more stable. Um, you know, it's a lot easier to take a shot once a week than once a day. So it's really an important one. They did a study of 96 patients, they were very similar in tolerability, IGF1 scores, and the patients liked it better. Um, so I what I do is I take the daily dose and multiply by seven, give that the weekly dose. I don't see the reason why you should do something differently, but the company seems to suggest giving less to start with. Almost every when I give less, I have to go back to the regular dose.
SPEAKER_01It's a lot more expensive.
SPEAKER_07If it's not covered by insurance, but if it's covered by insurance, it's it's not expensive. And there's much less shortages of this.
SPEAKER_06Okay.
SPEAKER_03So do you think if she would have back on the both homes, then she didn't have to do the logobi?
SPEAKER_07Possibly, you know, sometimes they work well together.
SPEAKER_03Oh, you could do both.
SPEAKER_07Yeah, sure. So with the shortage of the daily, this is a good option here. Okay, now we're gonna talk about some of the lesser-known uh hormones. Uh, diabetes insipidus, it's now called arginine vasopressant deficiency because people got confused between diabetes mellitus, which is diabetes, and diabetes incipitous. Um, so the hormones called ADH or AVP, it's maybe the posterior pituitary. If you're a defect, if you have a defect in that, it can lead to excessive urination in thirst. And I think there's a lot of cases with this. It's mild, maybe it's not so bad, but you know, you have to wake up two or three times at night to go to the bathroom, then you don't sleep that well, and then you feel tired the next day. Um, so I think it's worthy of treatment. Um, if you have a lot of urination, it's back for your blood or your kidney. So I ask people how many times they're waking up at night. If it's like more than two or three, I would certainly test to. Yes.
SPEAKER_03Is it how true if I picture enough to, because my daughter's on the AV, right? Do you have to wait for it to, for example, um, like for her urine to be clear to be able to give something?
SPEAKER_07No, so I think that's overrated also. So in general, I give one dose a night, which is usually pretty easy to do. I think it's it's not that hard to give us. I used to think it was harder to do, but you know, most people take one pill at night, and the pills I think are better than the um um the shots.
SPEAKER_03Yeah, yeah.
SPEAKER_07So that's usually what happens during the day you urinate a little bit more. You do I don't like people to urinate that much at night. I don't want people to wake up. So you usually have them take a pill or two at night. Sometimes they take it during the day. You could do a 12, you can look at the urine volume if it's greater than three liters. I'm suspicious. And you I do have them do a 12-hour fast with no water. Everybody forgets this. They have a little water in the morning with their pills, any water makes the test invalid. Collect an 8 a.m. serum and urine osmolality, you can get an ADH level or ABP level. You want to have a high serum osmolality, but that's not really part of the cutoff. I usually use the urine osmolity of 600 as a cutoff. If it's less than that, then it's consistent with diabetes insipidus greater than it's not. Most of the time, the ABP is levels low, even to normal people. But if it is, if it's not low, then it's probably not, they don't have that. You must avoid all food fluid in foods. And this is sort of a replacement of a formal water deprivation test that people don't do anymore. Um, I usually give D D A B pills, usually at night, prevent waking up at night. They should have some breakthrough urination, as he said, usually in the evening of the next day. I think it's pretty benign. I think there's probably some other benefits of ABB. It's an important hormone. If you're missing this for your diabetes insipidus, it also regulates um cortisol, some. So I think it's probably people we're gonna do some more studies. I think it's gonna be important.
SPEAKER_03So if my daughter still she takes the BBP in the morning in the night, but I've noticed at night she's still awake. So could you have like different doses?
SPEAKER_06Yeah, for sure. Again, most of the time I give it mostly at night. Right because I don't want people to wake up during a higher dose at night.
SPEAKER_02And you can take too much of it, which I learned.
SPEAKER_07You can, right. So you can have a low sodium, fluid overlooked, right? You can take too much, also. Let's go on to oxytocin, it's a famous hormone now. The love hormone is made by the posterior pituitary, like AVP. It's the only one that we don't really test. Um, it's not all replaced. It has a role. I think we're getting more and more literature on this: bonding, intimacy, orgasm, GI issues, trust, generosity, pain, energy. There is a 24-hour urine oxytocin level available at Meridian Valley Labs. I don't think it's great, but it's probably okay. They don't really give that much information on the quality of their assay. And I there's compounding pharmacies that give it. I think it's a reasonable thing to replace if you're low. So I usually do that 24-hour test, give it back, you can give it back by uh troches or uh sprays. And many people have an improvement in their symptoms, especially these sort of bonding issues, weight, some weight loss, some joint pains, uh, decreased social isolation. With my lifestyle medicine talk, we talked about how bad social isolation is. So that's how reasonably treat people. Um, I found that increases cortisol requirements a lot of times in people on cortisol.
SPEAKER_06So if you're one of my patients and you want to be on this, let me know. No.
SPEAKER_07Many times. You know, where we go in cortisol. Okay, uh testosterone, estrogen, and progesterone, the gonadal access is that is gene RHLHFSH and testosterone. Women have lack of ovulation, irregular no periods, hot flashes, poor sleep infertility, vaginal dryness, osteoporosis, decreased libido, poor sense of well-being. So, what do you do if you're trying to get pregnant? First of all, um determine if you're ovulating. There's an important test that's underutilized, also called an AMH level. High is good, low is bad, although P2S patients have a high level, so maybe falsely high. Um, but this is a good test. If it's low, say less than 1.5 or so, it's concerned that your ovarian reserve is not that good. You should see a reproductive endophenologist. If it's okay, you can probably just try um timed intercourse, um, especially if you're ovulating. Um, if you're not trying to get pregnant, replace your estrogen, you should replace your progesterone. And classically we're talking you only need to replace your progesterone if you don't have a uterus. But there's a lot of benefits from progesterone, and I think many people should do get still get it even if they don't have a uterus. Um they can give back testosterone. I can give back testosterone if your libido is low and if you have decreased muscle strength. Um, the best assay for low estrogen is lack of periods or regular periods. If somebody has regular periods, they probably are okay. Um, regular periods is the early sign of torturing dysfunction. The famous studies, the women's health initiative and the HTRS study looked at post-menopausal women. The average age for the women's health initiative that showed some detrimental effects was 63, it wasn't 50, and it was using uh pregnant mare urine, premerin instead of estrogen replacement that we do now by creams and gels and uh patches. So I think younger women are more likely to benefit this, especially a young person. Um, you know, you're missing your years of estrogen, you probably do better on uh on it and higher doses and a younger person, an older person less clear. Um, you know, some people I keep it on until they're 70. Um, some people I stop at 60, depends on how they're doing on it. Um, and then I whether you want to have a period or not, it depends on people's personal preference. But usually younger people want to have a period, just sort of be like your peers if you're in 45 or so, it'd be reasonable to have um a period. So the choice is the pregnant premerin. It's called pregnant bare urine, it's called conjugate estrogen, multiple estrogen compounds. I would avoid that. Um, oral estrogen, estrace, again, you have um that it's not as effective if it's uh oral, blocks the IgF1 effect, blocks the birth home in the IgF1. Birth control pills, I also try to avoid. They also affect your IgF1. They have high dose of progesterone, low dose of estrogen. I think they need people need more estrogen. There's patches, I love them. Climera and bigel, the bible is a little patch, chlimera is a bigger patch, estrogel is quite good, vaginal estrogen is good, compounded estrogen creams, some people like them also, they're compounded. So again, oral estrogen replacement, um, but not other routes, has a first pass effect on liver. It blocks the action of growth hormone of the liver to raise IgF1. Um, so you get uh high growth hormone and low IGF one if you're on oral estrogen. Or prototype pills. That's bad. Raising your sex hormone binding globulin, which could be good because it lowers your testosterone, your free testosterone, but you may not want the low free testosterone. If it's already has hypopoturigism, your testosterone is already on the low side. Studies have shown that the effects of oral estrogens decrease free testosterone levels for up to a year after stopping it. Oral estrogens raise your thyroid binding globulin, it can lead to increase in thyroid hormone level replacement. It makes testing for adrenaline insufficiency difficult, also, and can lead to what looks like higher total levels of cortisol, even though it's not true because the cortisol binding globulin is affected. So again, the common medicine you should never take if you're on growth hormone, estrogen and birth control pills. What type of estrogen is best? There's three types of estrogen, estrogen E1, estradiol E2, and estriol E3. Estradiol is the most abundant. There's slight evidence that the estrone is detrimental. Oral estrogen is averted estrogen, so that's one of the reasons to avoid oral estrogens. I often use the bivalodot patch or estrogel, titrate the estradiol dose. Again, I think it's important to monitor your blood test as well as your symptoms. We like the estradiol level to be in the 50 to 100 range. There are compounded ones. Compounded pharmacies make bias, triest. I don't really like the compounded ones as much, and that the triast has estrone, you know, which is detrimental, so I wouldn't recommend that. Generally try to give a higher dose for the younger patients. Should you take progesterone to get a period, you can either take Provera, five to 10 milligrams, it's synthetic, or Prometrium, which is biodential, for 10 days, it will usually give a period, unless you're quite low. If you take a daily dose, you usually don't get a period. If you take continuous provera or continuous prometrium, you don't. So women less than 40 or 45, I try to get them to psych, I don't have a period. Older than that, I usually don't have them have a period. Progester, I usually give uh certainly if somebody with a uterus, they need to take progesterone. Um, sometimes without a uterus, progesterone may help with sleep, hot flashes, but could give fatigue and bloating, but it's usually not that much of progesterone or prometrium more with Rivera. Okay, we'll go on to testosterone, not just for men. The physiological role of testosterone is understood in women. Um in most there's been very few studies, including that we started a study, we didn't finish it, um, but it seems like there was some effect of testosterone on sexual function, sense of well-being, and variable effects on sort of bone issues. In general, there's thought that uh androgens improve sexual function, improve bone density, improve muscle mass, improve mood and sense of well-being, improve cognitive function, ameliorates autoimmune disease, ameliorates pre-menopausal symptoms, and improves dry eye syndrome. The detrimental effects or adverse effects could include virilization, including enlarging your clitoral size, um, hersitism, which means extra body hair, facial hair, acne, effect on plasma lipids, and effect on behaviors. So, a prior study that women with hypoperism could have increased cardiovascular disease. This could be associated with testosterone deficiency in women, that these persist after normal treatment. Karen Miller did a study with hyperwomen with hypoperturism. They had low levels of both antigen and ovarian production of androgens. The they had lower testosterone and DHES levels than if they just had an ovarian failure alone. And Dr. Miller did a study on replacing testosterone, and they did the patients in general better. But even she doesn't really recommend it for um patients, even though it's a positive effect. Um, so I recommend measuring a bioavailable and total testosterone level in women with hypopertreism. If the bioavailable is low, less than two, I recommend testosterone cream from a compounding pharmacy. It's not commercially available, although some companies have been working on it for a long time. Usually use the 2.5 milligram per mil dose. I start in older women, I might give 1.25 milligrams. Side effects would be facial hair, acne, and hair loss, but it usually works out well. Some people, it's expensive, some people try to do the subcutaneous shots. It's harder to do that. You have to give a real tiny, small amount of that. The dose is very low. And I try to aim for this biodal testosterone to be between three and seven. What about DHEA? There's also confusion on this. DHES is what you measure, DHEA is what you give. Um, you give adrenal androgens. Um, they're often low in hyperplatuidism. They often give a dose between 10 and 25. It may help with energy. Side effects include oily skin, uh, greasy hair, and I find that testosterone in general is more helpful effective than DHEA, but some people do do benefit from both. Okay, next we're going to talk about stimulants, and this is again glad people are staying. It's the most important part of the most important part of the talk. Uh, there's a very nice article called apathy and pituitary disease that has nothing to do with depression. Increasingly, patients with pituitary disease are evaluated and treated cancer centers. In any way, these patients resemble other brain malignancies, although the majority of adenomas are benign. The physical, emotional, and cognitive change that these patients have are on their well-being is malignant. I went on to say there's a greater understanding that these patients may have emotional problems as a result of tumor. Um, the authors present a case, a series of cases in which pituitary disease were diagnosed and treated for depression, showed little response to treatment for depression. When the treatment of pituitary apathy syndrome was considered and implemented, including stimulants, there is a big improvement on apathy and the hypothalamic pituitary organs improved. So, this is, I thought, a very important paper, came out in 2005, um, showing that you can need to diagnose pituitary apathy and treat them with stimulants. So pituitary apathy means no interest in life's pleasures. Most hypopit patients have this. I think it's very under-treated. It's not really depression, they're not sad, they're not crying, they're not blue, they're just apathetic. Football players have this, you know, junior sayo, commit suicide, probably had this. Um, these patients respond to stimulants, not antidepressants. Um, I like Ritalin the best. I find it better than Adderall, so the more available. I usually give Ritalin LA 20 milligrams in the morning. Many patients do better on this. I think most patients should be on a stimulant. Not rare. I think most should be on this. I have had very few patients that say it didn't help them, and very few side effects, including feeling hyper, insomnia, anxiety. Helps with energy focus, weight loss. It's really a great medicine for a lot of people. And it's not really that addictive. You can stop it if you don't like it. There are very few cases of withdrawal. Um, occasionally it happens that people get addicted to it, including one of the family members, but um, for the most part, it's a good medicine. I think it works. Yes, exactly. Undertreated. This works well with broccole and oxytocin. I think those together are a good combination.
SPEAKER_01Okay.
SPEAKER_07Yeah, we can call it less. So treating a patient with adrenaline sufficiency and hypothyroidism with thyroid medicine without treating the cortisol, you get a breakdown of cortisol. So you do need, if they have adrenaline insufficiency and hypothyroidism, you need to treat their cortisol first and then add the thyroid medicine. Treating it with growth hormone can also cause T4 to T3 conversion. So you may have to reduce your T3. Um, you may need um, if you treat it, then you then your T3 may go up. So you may have reduced the dose of T3 if on T3. Growth hormone may decrease TSH, this may amass central hypothyroidism. You may need a higher dose of thyroid medicine once the growth hormone started. Oral but not transdermal estrogen, increase the need for levothyroxin. So if you're on oral estrogen, you have more side effects from that and decrease the need for growth hormone. We talked about stopping oral estrogen, raise your IgF-1. So you can have somebody that can get thrown into a crisis because they're um they're um you may get a I'm sorry, not a crisis, you may get a high IgF1 by stopping the oral estrogen, they get side effects from too much growth hormone, like hand swelling, things like that. Um, you may treat adrenaline sufficiency and maybe amassed diabetes insipitus. Um the growth hormone also causes you to break down cortisol. So it affects an enzyme called 11-beta HSD1. If you treat a patient with hypophyrus with growth hormone, you could decrease, decrease the cortisol and throw them in crisis. So I had a famous patient that was on glucocorticoids, underreplaced on thyroids, not on growth hormone. I thought I was doing her good deed. I gave her more growth hormone, increased her glucocorticoids, and increased her livothyroxin. A couple days later, she had adrenal crisis. So you need to make changes slowly, monitor, frequently, see a specialist. So what's the problem overall? Most patients are on too much cortisol, not enough thyroid medicine, not enough growth hormone, not on the right thyroid medicine, not on testosterone, not on stimulants, not on oxytocin. This leads to uh fatigue, awaking, and depression. Um, just as you get your dose of digestive to come see me, see an expert.