Bio-identical Hormone Replacement Therapy Patient Education
Benefits and Potential Risks/ Side Effects of Individual Hormones/ Additional Medication
BHRT: Benefits, alternative therapies, controversies, reproduction risks, cancer risks
What Might Occur After A Pellet Insertion ( Female)
What Might Occur After a Pellet Insertion (Male)
Hormone Support/Optimization Nutraceuticals
Nervana BHRT Program FAQ
Bioidentical Hormone Replacement Therapy
Hormones play a vital role in our daily functioning. Everything from your metabolism to the health of your skin is impacted by the balance of hormones in your body, so it’s understandable that hormone imbalances can make daily functioning difficult. At Nervana Medical, we help you implement a hormone therapy program designed to help optimize your lifestyle by easing symptoms of aging as well as hormone-related health problems and offering wellness benefits that can help improve a patient’s life for years to come.
What are Bioidentical Hormones?
From a physiological perspective, bioidentical hormones derived from natural plant sources are identical to those that the body produces for itself, in the right proportions. When we are “replacing” the body’s hormones, we feel it makes more sense to use entities which the body recognizes as its own, rather than hormones from horses, imbalanced versions, or overly potent synthetic versions. The hormones we use are mainly estradiol (E2), estriol (E3), progesterone (Pg), testosterone (T) and DHEA.
What dosage forms are available?
Compounded dosage forms are numerous and variable in nature. Each method has its advantages for use. Usage of specific dosage forms depends on patient compliance, type of response desired and medications involved. Oral capsules, vaginal suppositories, transdermal creams, gels and troches (a lozenge that dissolves between the gum and tongue) are among the variety of dosage forms available to be compounded. Ideally hormone supplementation should be tailored to individual treatment needs.
Will my insurance company cover these treatments?
Although compounds such as these cannot be processed at the pharmacy like mass produced medications, most insurance companies will reimburse a percentage of the cost to the patient. Look closely at your benefit package. If you have a flexible spending account or HSA (Health Savings Account), you may use your account to pay for your consult and/or hormone prescription(s).
How will the provider know what dose is right for me?
Every patient is different! Your physician will take many issues into account: age, weight, symptoms, gynecological history and prior or present use of hormones will all affect the choice of dose and dosage form. Saliva and/or blood spot testing to identify specific imbalances of one or more hormones eliminates physician guesswork when prescribing. Follow up testing and regular monitoring when using hormones allows your doctor to adjust your dose as needed. Testing can be done from the convenience of your own home and mailed to the lab.
How much does it cost?
The Cost of Bioidentical Hormone Replacement Therapy depends on the treatment option you choose. For optimal effectiveness, BHRT must be approached on a case-by-case basis. Each case involves several steps:
Consultation
Hormone testing
Evaluation of deficiencies
Discussion of wellness goals and treatment options
Individualized treatment plan development
Tailored prescriptions from a (compounding) pharmacy
Treatment
Monitoring and repeat testing
Supplementary services related to wellness and lifestyle
Follow-up and additional services as needed (per shifting hormone levels and health changes)
Consultation: $200
This is collected at the time of any labs that Nervana Medical sends a lab requisition form for, or if the patient brings their own labs for us to review, then it will be billed at the time the provider receives the labs
Includes:
● Hormone testing prescribing (*client responsible for lab costs, see info below)
● Evaluation of deficiencies
● Individualized treatment plan development
● Discussion of wellness goals and treatment options
● Tailored prescriptions from a compounding pharmacy
Pellet Prices: Female $450, Male $650
Pellets typically last 3-6 months, with females usually averaging replacement 3-4 times a year and males 2-3 times a year. Duration of therapy depends on absorption, which will differ for every client.
Even if you end up on pellets, not all the hormone deficiencies can be treated with pellets, so you may also have the cost of the prescription medication if you also need replacement of a hormone that is unable to be combined with your pellet
IM / Oral / Creams / Troches / Patches / etc Prices: $200 / quarter
If the patient ends up on any other method other than pellets; (IM, PO, creams, troches, patches, etc.) then they will receive their prescriptions for a duration of 4 months at a time before they will be required to see the provider for another check-up / consultation.
Lab Work
Specific lab work will be checked 6-8 weeks after pellet placement and 3 months after initiation of any other treatment (i.e. oral, cream, etc). If follow up lab results are stable and the patient feels good, then labs will be drawn every 6 months to a year. If the patient has any symptoms that would be concerning regarding current therapy, then labs may be checked as needed. Cash Price Cost for Initial Labs are around $200-$400 should the patient decide to have us send them a “cash client pay” lab requisition form. We utilize multiple lab vendors so if you cannot come into clinic, let us know and we will get you plugged into the multiple other available locations to have your blood drawn at (we will provide you the lab order).
BHRT Patient / Program Flow
Intake Forms:
In order to determine if you are a candidate for bioidentical hormone replacement, we need your medical history forms and hormone symptomatology completed.
Initial Consultation + Lab Draw:
You will then be scheduled with one of our providers for a hormone consultation where they will provide an in-depth educational review of the risks and benefits associated with BHRT as well as the different forms and routes of replacement. At that time, we suggest that you come fasting, meaning nothing to eat and drink (except for water) for the past 12 hours so that labs can be drawn after your appointment.
Lab + Plan Review:
Once your labs are drawn and resulted, your provider will complete your plan of care depending on your lab results and the discussions regarding your initial consultation. Your provider will discuss these results and plan with you once completed; this can be done in the office or via telehealth platform.
Procedure Appointment (if applicable):
If you are a pellet candidate, then you will come back to the clinic to have your pellets placed.
6-8 week follow up:
After initiation of any hormone replacement therapy, you will receive a follow up symptomatology intake form to be completed; this should be filled out based on your CURRENT symptoms as this is usually when your hormones are starting to peak. You may or may not also have labs to be repeated. Typically Labs will happen on an initial consultation (more comprehensive), 6-8 weeks after (less comprehensive panel) and then annually thereafter, unless your provider feels it is necessary to obtain again for either a dose change or symptom management reason.
Additional Follow Up Visits:
Pellet Patients will be re-pelleted at at the following intervals:
Women: 3-4 months
Men: 4-6 months
All other routes of replacement will need follow-up appointments every 4 months for prescription renewals and plan review/symptom check ins.
BHRT Medication Routes: Patient Education
Bioidentical hormone replacement therapy (BHRT) is a treatment approach that aims to restore hormone balance in individuals experiencing hormonal imbalances or deficiencies. BHRT can be administered through various routes, each with its own pros and cons. Here's a breakdown of the pros and cons of the commonly used routes of BHRT medication administration:
Oral Administration:
Pros: Convenient and easy to take.Familiar method for most patients.May be more cost-effective compared to other routes.
Cons: Hormone metabolism in the liver can result in variable hormone levels, increased risk of liver-related side effects, limited dosing flexibility as the liver can affect hormone potency (this is why we do not offer certain hormones this route such as testosterone because it can cause liver damage).
Topical Administration (Creams, Gels, Patches):
Pros: Absorbed directly through the skin, bypassing the liver and reducing liver-related side effects.Steady and controlled hormone delivery over a specific duration (if applied correctly and consistently). Dosage can often be adjusted easily to suit individual needs.
Cons: Application can be messy or inconvenient. Skin sensitivity or allergic reactions to the delivery system may occur.Absorption rates can vary between individuals, affecting hormone levels. There have been some reports of transferring the medication/hormone to small children, would recommend caution in those who are rubbing up against others in where this can become problematic. In effort of avoiding iatrogenic transfer to others, we recommend avoiding contact with others by allowing 4 hours before contact or exposure once applying. Applying at 7AM and 7PM is best. Wash hands to avoid transference to others and cover application site.
Sublingual Administration:
Pros: Hormones are absorbed directly into the bloodstream through the mucous membranes under the tongue.Bypasses the liver, reducing the risk of liver-related side effects.Allows for more rapid absorption and potentially quicker symptom relief.
Cons: Taste or texture of sublingual medications may be unpleasant for some individuals.May require frequent dosing due to faster absorption rates.Hormone levels can still fluctuate significantly if labs are not drawn accurately or if the compliance has been inconsistent.
Pellet Implants:
Pros: Provides a long-lasting and steady release of hormones over several months.Reduces the need for frequent dosing or application.Mimics the body's natural hormone secretion patterns more closely.
Cons: Requires a minor surgical procedure for implantation.Potential for infection or other complications associated with the insertion site.Difficult to adjust dosages once the pellets are implanted.
Injections:
Pros: Consistent/reliable dosing if compliance and labs are done correctly
Cons: Can be painful, usually needs twice a week injections to avoid roller-coaster effects, testosterone injections can adversely affect HDL/cholesterol
It's important to note that the pros and cons of BHRT routes of administration may vary depending on individual circumstances and preferences. Our providers who specialize in hormone therapy can help determine the most suitable route for your specific needs, taking into account factors such as hormone levels, medical history, lifestyle, and personal preferences.
Benefits and Potential Risks/ Side Effects of Individual Hormones/ Additional Medication
Testosterone
A prescription hormone given by subdermal pellet, injection, troche, or transdermal cream.FDA approved to treat symptoms of andropause/diagnosis of hypogonadism when 2 separate tests show levels < 300 ng/dl.**May qualify through insurance for treatment ***If this is the case, we recommend additional testing to further diagnose if deficiency is secondary to hypothalamic failure (seen in conditions such as a pituitary adenoma) vs. primary testicular failure. Not FDA approved as an “anti-aging”- However, over 90% of prescriptions are written for off-label use studies that demonstrate a decrease in morbidity and mortality over time. Treat symptomatology.
Potential benefits include increased libido and clitoral sensitivity, energy strength and endurance, decreased hot flashes, increase in muscle mass which maintains metabolism and decrease in visceral fat, improved insulin sensitivity, improved lipid panel which can lead to a decrease in cardiovascular disease, decreased risk of dementia, decreased bone loss,decrease in wrinkles, fat deposition, and cellulite, increases collagen and skin thickness, leading to improved skin texture, improved cognition and memory, breast cancer protection
We use the lab tests to demonstrate improvement above baseline and for no other reason (optimals are different than standard lab values). Most studies demonstrate very supraphysiologic levels to be therapeutic, and there is no standard or guide on how high one should go which makes testing nebulous.Some women may require high doses to see benefits, while others need lower doses.
Risks of testosterone replacement may include, but are not limited to: an increase in red blood cells (erythrocytosis/secondary polycythemia; which we will typically send for therapeutic phlebotomy if a hematocrit increases above 54%/or at customized provider threshold) reduced insulin requirements in insulin-dependent diabetics, increased estradiol levels, edema (fluid retention) and feeding hormone responsive cancers.
Male Specific: There is a risk of infertility/sterility in males as it can cause a decrease in sperm production and a decrease in testicle size. While there are ways to mitigate this risk, we do not recommend any man who wants to preserve his fertility to initiate hormone optimization. With any testosterone treatment, men will produce less endogenous testosterone from testicles and if they stop replacement, they may experience a temporary decrease in natural testosterone production.Compliance with additional pharmaceuticals as prescribed is imperative to ensure best success for to eventually begin reproduction but understand that this will likely fall back to pre-treatment levels and the symptoms endured pre-treatment will likely return. It is imperative to comply with provider ordered labs, we recommend you have at least one annual PSA to help screen for prostate cancer (1 in 7 men will get prostate cancer regardless of testosterone therapy but testosterone therapy can feed/grow hormone responsive cancers.)
Female Specific: Premenopausal females MUST use birth control.Testosterone is a known teratogenic and should not be used in pregnant females or those planning to become pregnant as it can also cause virilization of a fetus (masculinize a female fetus)
Side effects may include, but are not limited to: enlarged clitoris, hormonal acne or back acne, temporary water retention, acne,irritability, hirsutism (facial hair) These are mostly dose related and usually resolve with reduction in dose or addition of spironolactone; however, it can take up to 6 months for hirsutism and acne to resolve. Insulin resistance/ PCOS can also cause acne/hirsutism as they often cause low SHBG which can cause or worsen hirsutism. If this is the case, we aim at treating the insulin resistance to raise SHBG will also help improve these symptoms. It can also cause “PMS” type symptoms such as mastalgia (nipple tenderness) which can be improved with medications such as an aromatase inhibitor (anastrozole) or nutraceuticals to decrease estrogen levels such as DIM or by decreasing the dose. Natural testosterone does not equal synthetic testosterone. Synthetics raise cholesterol and lowers HDL, as opposed to natural testosterone which lowers cholesterol and raises HDL (opposite of synthetics). We will monitor lipid levels annually/as seen appropriate by the provider to ensure that if synthetic testosterone is utilized, this is being monitored and treated accordingly. Of note, a recent study published by the New England Journal of Medicine states that there is NOT an increased cardiovascular risk with synthetic testosterone! Some patients may be on additional medications to help improvement in other hormone related issues such as hair loss or benign prostate hypertrophy; medications that are commonly used to treat these conditions such as finasteride or dutasteride can affect important lab results. If I am on any additional medications, I will ensure that these are fully disclosed to ensure best and safest care.
Contraindications:
Active prostate cancer; men who do not want to risk their fertility should not use testosterone. Men who want to preserve their fertility should consider banking sperm prior to treatment or consider HCG or Clomid which does not affect fertility; these should also be used in conjunction with testosterone to help endogenous production not be affected by the negative feedback system.
Estradiol:
A prescription hormone, given by subdermal pellet, oral tablet, cream, patch, or troche.
Indications: For use in menopause only; not for use in premenopausal women. Menopause is defined by either FSH levels or absence of a period for longer than 12 months.
Potential benefits includes increased libido, sense of well-being, increased energy, decreased hot flashes/night sweats, temperature dysregulation, decreased vaginal dryness,vaginal atrophy, urinary incontinence, UTI’s, decreased risk of cardiovascular disease and stroke when started in the first years of menopause, decreased risk of dementia, decreased bone loss/osteoporosis, improved cognition and memory/alzheimer's disease, help with sleep issues, helps with urinary incontinence.
Contraindications: History of breast cancer; if history of blood clots, should use transdermal route.
Side effects may include, but are not limited to: increased body fat, bloating, breast swelling/tenderness, fluid retention and uterine bleeding.These side effects can typically be resolved with dose adjustments/balancing of the three main hormones. Progesterone will help decrease high estradiol levels. It is not uncommon for postmenopausal women to have a period after starting BHRT, however, if persistent bleeding or spotting may warrant additional work up; including labs, a vaginal ultrasound, and possibly an OB-GYN referral if any of the results come back abnormal or if the bleeding persists despite hormone balancing.
Progesterone:
A prescription hormone, given orally or by transdermal cream.
Potential benefits include protection from estrogen's effect on the uterus and breast thereby reducing risk of endometrial (uterine) and breast cancer, treatment of irregular menstruation/PMS,, improved sleep quality, and improved anxiety and can improve postpartum depression when used at high doses.Reduces fluid retention, bloating, headache, bleeding, and fibroids.Can decreases headache, cyclical migraines, and bloating associated with menstruation when used in high doses.
Side effects can include; drowsiness with oral form due to first pass effect (ODT form does not cause drowsiness),; therefore, only take oral at bedtime, one hour before sleep. Breast or nipple tenderness with oral form, switching to a sublingual form will resolve. Do not recommend a transdermal approach as monitoring is too unreliable and benefits will likely never be obtained due this way as it is not very effective.
Dehydroepiandrosterone - DHEA:
DHEA is classified as a dietary supplement given orally or by transdermal cream.DHEA is a hormone secreted by the adrenal glands. This hormone is a precursor to other sex hormones. In addition to having its own hormone effect, it results in a shift to an anabolic or protein building state.
Potential Benefits: It reduces cardiovascular risk by increasing lipolysis or breakdown of fat. It also may improve adrenal fatigue/exhaustion, restores sexual vitality to improve erectile dysfunction, improves mood, decreases cholesterol and body fat which may help decrease cardiovascular risks. Recent studies point to DHEA as an anti-stress hormone, reversing the effects of stress on the immune system by acting on T cells.
Contraindications : avoid in patients with a history of hormone responsive cancers.
Side effects of DHEA replacement are generally dose related and may include but are not limited to: acne or oily skin, hair growth on the face, arms or legs, acne in women, prostate enlargement in men, male pattern baldness, decreased HDL cholesterol, fatigue, mood changes, weight gain and insomnia. If there are any side effects there is no push to continue for patients under age 40.
Spironolactone
Pharmacological Category: Antihypertensive; Diuretic, Potassium Sparing; Mineralocorticoid (Aldosterone) Receptor Antagonist
Use: (FDA Labeled Indications): Ascites due to cirrhosis, Management of edema in cirrhosis of the liver unresponsive to fluid and sodium restriction. Heart failure with reduced ejection fraction: To increase survival, manage edema, and reduce need for hospitalization in patients with heart failure with reduced ejection fraction and New York Heart Association class III to IV symptoms; usually administered in conjunction with other heart failure therapies. Hypertension, chronic: Management of hypertension unresponsive to other therapies. Primary hyperaldosteronism
Use: (Off-Label): Acne vulgaris, females, moderate to severe; Hair loss, female pattern; Heart failure with preserved ejection fraction; Hirsutism, females; Hormone therapy for transgender females (assigned male at birth); Post myocardial infarction, complicated by reduced ejection fraction
Pros: Spironolactone has some unique properties that make it useful for specific conditions.
One of the main reasons doctors prescribe spironolactone is to help regulate the balance of fluids and electrolytes in your body. It works by reducing the amount of water and salt reabsorbed by the kidneys, which can help you get rid of excess fluid and prevent your body from retaining too much water.Spironolactone is commonly used to treat conditions such as high blood pressure, edema (swelling caused by excess fluid buildup), and certain hormonal imbalances. In particular, it is known for its ability to block the effects of a hormone called aldosterone, which can cause your body to retain too much salt and water. For women, spironolactone can also be prescribed to help manage conditions such as polycystic ovary syndrome (PCOS), hirsutism (facial hair) and acne. In these cases, the medication can help reduce the production of androgens, which are hormones that can contribute to acne breakouts and other symptoms of PCOS.
Cons: It's important to note that spironolactone may take some time to show its full effects (up to 6 months at times for androgen improvement) ! Your doctor will typically start you on a low dose and adjust it as needed to find the right balance for your condition. It's crucial to follow your doctor's instructions carefully and take the medication as prescribed.
Potential side effects/risks: increased urination, dizziness, stomach upset, and changes in electrolyte levels if dehydrated. It is essential to let your doctor know about any other medications or supplements you are taking, as spironolactone can interact with certain drugs, including some blood pressure medications and potassium supplements. It is also essential that you stop taking this medication if you feel dehydrated and notify your provider if this occurs for further instruction.
NP Thyroid
NP THYROID® (thyroid tablets, USP) is a prescription medicine that is used to treat a condition called hypothyroidism from any cause, except for cases of temporary hypothyroidism, which is usually associated with an inflammation of the thyroid (thyroiditis). It is meant to replace or supplement a hormone that is usually made by your thyroid gland. NP THYROID® is also used in the treatment and prevention of normal functioning thyroid goiters, such as thyroid nodules,Hashimoto’s thyroiditis, multinodular goiter, and in the management of thyroid cancer.
Risks: Drugs with thyroid hormone activity, alone or together with other therapeutic agents have been used for the treatment of obesity. In euthyroid patients, doses within the range of daily hormonal requirements are ineffective for weight reduction. Larger doses may produce serious or even life-threatening manifestations of toxicity, particularly when given in association with sympathomimetic amines such as those used for their anorectic effects.
• Do not use NP THYROID® if you have hyperthyroidism, overactive thyroid, uncorrected adrenal problems, or are allergic to any of its ingredients.
• Tell your doctor about any other medical conditions you may have, especially heart disease, diabetes, blood clotting problems, and adrenal or pituitary gland problems. The dose of other drugs you may be taking to control these conditions may have to be changed while you are taking NP THYROID®.
• Tell your doctor immediately if you experience chest pain; increased pulse rate; rapid, strong, irregular heartbeat; excessive sweating; or any other unusual event.
• If you have diabetes, check your blood sugar levels and/or the glucose in your urine, as ordered by your doctor and immediately tell your doctor if there are any changes.
• If you are taking oral anticoagulants, blood clotting status should be checked often by your doctor.
• Partial loss of hair may be experienced by children in the first few months of thyroid therapy,but this will usually go away on its own.
• Tell your doctor if you are allergic to any foods or drugs, are pregnant or plan to become pregnant, are breastfeeding or are taking any other drugs, as well as prescription and over-the counter products.
• Use NP THYROID® only as ordered by your doctor. Do not stop or change the amount you take, or how often you take it, unless told to do so by your doctor.
BHRT: Patient Lab Education
To ensure accurate and efficient testing, please follow these instructions:
Fasting Instructions: Some tests require fasting, Fasting only needs to be for 12 hours prior to collection. Please check with your healthcare provider or refer to the specific test requirements provided by your physician during your lab order visit. Fasting means no food or drinks, except for water, during the specified fasting period. Avoid any beverages, including coffee, tea, juice, and soda, as they can affect test results.
Medication Compliance: If you deviate from your provider's medication orders since your last appointment or had labs drawn but were not following exactly what was prescribed by your provider for 6-8 weeks prior to drawing your labs, your lab results can be inaccurate. Please ensure you inform us of any compliance issues with what we prescribe/plan so we can adjust labs and treatment plan accordingly
Take your regular medications as prescribed; I.E. If you are having hormones tested, it is imperative that you are on your dose consistently for at least 6-8 weeks; if you are on injections, you are having your labs drawn mid week injection schedule;etc..).If you deviate from your provider's medication orders since your last appointment or had labs drawn but were not following exactly what was prescribed by your provider for 6-8 weeks prior to drawing your labs, your lab results can be inaccurate. Please ensure you inform us of any compliance issues with what we prescribe/plan so we can adjust labs and treatment plan accordingly
*For our Hormone Patients*
Recommended Lab collection timing for best results:6-8 weeks post initiation or dose changes and :
- Creams- 12-24 hrs post dosing
- Oral-12-24 hrs post dosing
- Patches- 1 -2 days post dosing
- Pellets-no specific timing
- Injections: Midpoint between injections (i.e. If on IM Testosterone every 7 days, specimen should be collected on day 3-4
Lab Assay Interferences:
Some medications can affect lab results. It is imperative that you refrain from the following:
-No biotin for 48 hours (if greater than 5000 mg/day)
- High Dose Vitamin C (anything greater than 15 g;hold for 1 wk)
- Any vitamin testing should be done after being off of supplements for at least 3 days, preferably 1 week
*If receiving a prostate lab; it should be drawn prior to receiving a digital rectal exam.
Results and Follow-up:
Your provider will discuss the results of your labs once they receive them and have the chance to review them in combination with the symptomatology form that you will fill out to give you appropriate guidance and recommendations based on these findings.
Note: It is crucial to follow the instructions provided by your healthcare provider or the laboratory staff accurately. Deviations from the instructions may affect the reliability and accuracy of the test results. If you have any questions or concerns, please contact our laboratory or consult your healthcare provider for clarification.
BHRT: Benefits, alternative therapies, controversies, reproduction risks, cancer risks
You have sought treatment for symptoms that correlate with hormone deficiencies and recognize that we strive to “optimize” your overall health and wellness and improve your symptoms of hormone deficiencies to help you feel and live your best life. You may potentially benefit from hormonal supplementation. Your provider has recommended treatment with BHRT which consists of either progesterone and/or testosterone and/or estradiol.
You need to be sure you understand the reason that this therapy is being prescribed, the potential risks of therapy and the potential risk of declining treatment. We also feel it is important that you know there are significant controversies regarding the best method to diagnose and/or treat symptoms related to hormonal treatments, the best methods of treatment, and the most appropriate way to monitor therapy. This is especially true when “standard” blood tests look “normal”. Thus, you may consult another doctor who does not agree with the therapy.
This document provides extensive information that will be summarized by your provider so that you understand the basis for the diagnosis, the treatment method, and the potential risks and benefits of treatment and declining treatment. Do not undergo therapy until you have reviewed this document with your provider, thoroughly understand the potential risks and benefits of treatment, and have all your questions answered.
The diagnosis and treatment used may be considered nonconventional, complementary or alternative. Other physicians may disagree with the need for treatment, the method of treatment and dosing, and/or the methods of monitoring. You agree to undergo testing as recommended by your provider and report any potential side effects immediately.
Therapeutic Basis: Many individuals have inadequate hormone levels despite technically “normal blood tests''. There are limitations to “measuring” hormone levels as it reflects what is in the serum or saliva only rather than inside the cell. Some individuals suffering symptoms related to fluctuations in their hormones such as perimenopause, menopause, and declining testosterone levels may benefit from these therapies. Bio-identical hormone replacement therapy can be used to augment hormone levels in a number of conditions where diminished hormone levels are evident or clinically suggestive based on symptoms. The providers at Nervana Medical may prescribe these hormones at dosages designed to achieve a pharmacologic effect to reduce the symptoms of hormonal decline. The diagnosis and treatment will involve many components including your symptoms, confounding medical issues or medications, blood levels, physical exam, response to therapy, possible side effects, individual reaction/response to therapy, and other information. Your blood levels may fall into “normal” lab reference ranges, which may not in our opinion, reflect your deficiency. We also feel it is important that you know there are significant medical differences of opinion/controversies regarding the best method to diagnose and treat low hormone levels, whether or not blood tests are needed at all, the best methods of treatment, and the most appropriate way to monitor dosage and therapy. This is especially true when “standard” blood tests are “normal”, meaning that the result is within the normal laboratory reference range for the test. The diagnosis and treatment used may be considered non-conventional, complementary or alternative. Other physicians may disagree with the need for treatment at all, the method of treatment, dosing and/or the methods of monitoring. Thus, you may consult another doctor who does not agree with our diagnosis or therapy.
Expected Benefits of Hormone Replacement Therapy may include:
Control of symptoms associated with declining hormone levels.
May help prevent, reduce or control physical diseases and dysfunction associated with declining hormone levels.
Alternatives to Hormone Replacement Therapy
Include, but are not limited to: Leaving the hormone levels as they are and doing nothing. Risks may include, but are not limited to: experiencing symptoms of hormone deficiency, and increased risk for aging-related diseases or dysfunction resulting from declining hormone levels. This alternative may result in the need to treat diseases or dysfunctions associated with declining hormone levels. Treating the symptoms of declining hormone levels as they develop with non-hormonal therapies such as SSRI’s (antidepressants), sleeping pills, and herbal therapies, essential oils, lifestyle modifications such as weight loss, stress reduction, yoga, etc. Many of these hormones are used “off-label”, which means they are not FDA approved. Many of these hormones are made by a compounding pharmacy. Off-label refers to use of, relating to or being an approved drug legally prescribed for a purpose for which it has not been specifically approved. Seeing another provider who believes in using non-bioidentical synthetic hormones such as Premarin and Prempro or other therapies FDA approved therapies for menopause (synthetic hormones have extensive research suggesting numerous risks of therapy, remember, bioidentical hormones and synthetic hormones are DIFFERENT).
Importance of compliance regarding recommended screenings:
Hormone Responsive Cancers: Patient has been educated regarding BHRT and its potential to "feed" potential "undiagnosed hormone responsive cancers" as well as alternative therapies to BHRT. Patient understands and accepts the risk. * Patient was educated of the importance of staying up to date on preventative exams as recommended by CDC/WHO for age.Reproduction Risks have been outlined and explained in detail to patient; more details can be seen under Medication education.
What Might Occur After A Pellet Insertion ( Female)
A significant hormonal transition will occur in the first four weeks after the insertion of your hormone pellets. Therefore, certain changes might develop that can be bothersome.
Infection: Is possible with any type of procedure. Infection is uncommon with pellet insertion and occurs in <0.5 to 1%. If redness appears and seems to worsen (rather than improve), is associated with severe heat and/or pus, please contact the office. Warm compresses are helpful, but a prescription antibiotic may also be needed.
Pellet Extrusion: Pellet extrusion is uncommon and occurs in <5% of procedures. If the wound becomes sore again after it has healed, begins to ooze or bleed or has a blister-type appearance, please contact the office. Warm compresses may help soothe discomfort.
Itching or Redness: Itching or redness in the area of the incision and pellet placement is common. If you have a reaction to the tape,please apply hydrocortisone 2-3 times per day to the rash.If redness becomes firm or starts to spread after the first few days, you will need to contact the office.
Fluid Retention/Weight Gain: Testosterone stimulates the muscle to grow and retain water which may result in a weight change of two to five pounds. This is only temporary. This happens frequently with the first insertion, and especially during hot, humid weather conditions.
Swelling of the Hands + Feet: This is common in hot and humid weather. It may be treated by drinking lots of water, reducing your salt intake, or by taking a mild diuretic, which the office can prescribe.
Breast Tenderness or Swelling: This usually occurs most commonly in the first round of pellets but does not usually continue thereafter.DIM 1 capsule daily is helpful in preventing this, but the dose may be increased to 2-3 daily, if needed. Evening primrose oil (available in our office) is helpful as is Iodine+if this occurs.
Mood Swings / Irritability / Anxiety : These may occur if you were quite deficient in hormones. These symptoms usually improve as hormone levels improve. 5HTP can be helpful for this temporary symptom and can be purchased at many health food stores.
Elevated Red Cell Count (most common in men): Testosterone may stimulate growth in the bone marrow of the red blood cells. This condition is called erythrocytosis. Erythrocytosis may also occur in some patients independent of any treatments or medications. If your blood count goes too high, you may be asked to see a blood specialist called a hematologist to make sure there is nothing worrisome found. If there is no cause, the testosterone dose may have to be decreased.
Hair Loss: Is rarely due to pellets but can occur in some patients who convert testosterone to DHT. Dosage adjustment generally reduces or eliminates the problem. Prescription medications may be necessary in rare cases. Workup for other causes may also be needed.
Facial Breakouts: Some pimples may arise if the testosterone levels are either too low or rise rapidly. This lasts a short period of time and can be handled with a good face cleansing routine, astringents and toner. If these solutions do not help, please call the office for suggestions and possibly prescriptions.
Uterine Spotting / Bleeding / Irregular Periods: This may occur in the first few months after an insertion, especially if you have been prescribed progesterone and are not taking properly: i.e. missing doses, or not taking a high enough dose. Please notify the office if this occurs. Bleeding is not necessarily an indication of a significant uterine problem.
Hair Growth: Testosterone may stimulate some growth of hair on your chin, chest, nipples and/or lower abdomen. This tends to be hereditary. Fine vellus hairs or “peach fuzz” often occurs but is not thick nor coarse. You may also have to shave your legs and arms more often. Dosage adjustment generally reduces or eliminates the problem
What Might Occur After a Pellet Insertion (Male)
A significant hormonal transition will occur in the first four weeks after the insertion of your hormone pellets. Therefore, certain changes might develop that can be bothersome.
Infection: Is possible with any type of procedure. Infection is uncommon with pellet insertion and occurs in <0.5 to 1%. If redness appears and seems to worsen (rather than improve), is associated with severe heat and/or pus, please contact the office. Warm compresses are helpful, but a prescription antibiotic may also be needed.
Pellet Extrusion: Pellet extrusion is uncommon and occurs in <5% of procedures. If the wound becomes sore again after it has healed, begins to ooze or bleed or has a blister-type appearance, please contact the office. Warm compresses may help soothe discomfort.
Itching or Redness: Itching or redness in the area of the incision and pellet placement is common. If you have a reaction to the tape,please apply hydrocortisone 2-3 times per day to the rash.If redness becomes firm or starts to spread after the first few days, you will need to contact the office.
Fluid Retention/Weight Gain: Testosterone stimulates the muscle to grow and retain water which may result in a weight change of two to five pounds. This is only temporary. This happens frequently with the first insertion, and especially during hot, humid weather conditions.
Swelling of the Hands + Feet: This is common in hot and humid weather. It may be treated by drinking lots of water, reducing your salt intake, or by taking a mild diuretic, which the office can prescribe.
Breast Tenderness or Swelling: This usually occurs most commonly in the first round of pellets but does not usually continue thereafter.DIM 1 capsule daily is helpful in preventing this, but the dose may be increased to 2-3 daily, if needed. Evening primrose oil (available in our office) is helpful as is Iodine+if this occurs.
Mood Swings / Irritability / Anxiety : These may occur if you were quite deficient in hormones. These symptoms usually improve as hormone levels improve. 5HTP can be helpful for this temporary symptom and can be purchased at many health food stores.
Elevated Red Cell Count (most common in men): Testosterone may stimulate growth in the bone marrow of the red blood cells. This condition is called erythrocytosis. Erythrocytosis may also occur in some patients independent of any treatments or medications. If your blood count goes too high, you may be asked to see a blood specialist called a hematologist to make sure there is nothing worrisome found. If there is no cause, the testosterone dose may have to be decreased.
Hair Loss: Is rarely due to pellets but can occur in some patients who convert testosterone to DHT. Dosage adjustment generally reduces or eliminates the problem. Prescription medications may be necessary in rare cases. Workup for other causes may also be needed.
Facial Breakouts: Some pimples may arise if the testosterone levels are either too low or rise rapidly. This lasts a short period of time and can be handled with a good face cleansing routine, astringents and toner. If these solutions do not help, please call the office for suggestions and possibly prescriptions.
Aromatization: Some men will form higher-than-expected levels of estrogen from the testosterone. Using DIM 2 capsules daily as directed may prevent this. Symptoms such as nipple tenderness or feeling emotional may be observed. These will usually resolve by taking DIM, but a prescription may be needed.
High or Low Hormone Levels: The majority of times, we administer the hormone dosage that is best for each patient, however, every patient breaks down and uses hormones differently. Most patients will have the correct dosage the first insertion, but some patients may require dosage changes and blood testing. If your blood levels are low, results are not optimal and it is not too far from the original insertion, we may suggest you return so we can administer additional pellets or a “boost” (at no charge). This would require blood work to confirm. On the other hand, if your levels are high, we can treat the symptoms (if you are having any) by supplements and/or prescription medications. The dosage will be adjusted at your next insertion.
Testicular Shrinkage: Testicular shrinkage is expected with any type of testosterone treatment.
Low Sperm Count: Any testosterone replacement will cause significant decrease in sperm count during use. Pellet therapy may affect sperm count up to one year. If you are planning to start or expand your family, please talk to your provider about other options.
Pellet aftercare instructions
Aftercare instructions:
Your insertion site has been covered with two layers of bandages.
Remove the outer pressure bandage any time after 24 hours. It must be removed as soon as it gets wet. The inner layer (usually a steri strip) should be removed in 7 days.
Do not take tub baths or get into a hot tub or swimming pool for 7 days.
You may shower, but do not remove the bandage or steri-strips for 7 days.
No heavy lifting or major exercises for the incision area for the next 7 days, which includes running, elliptical, squats, lunges, etc. You can do moderate upper body work and normal walking on a flat surface.
The sodium bicarbonate in the anesthetic may cause the site to swell for 1-3 days.
The insertion site may be uncomfortable for up to 2 to 3 weeks. If there is itching or redness you may take Benadryl for relief (25 to 50 mg orally every 6 hours). Caution: this can cause drowsiness!
You may experience bruising, swelling, and/or redness of the insertion site which may last from a few days up to 2 to 3 weeks. If the redness worsens after the first 2-3 days, please contact the office.
You may notice some pinkish or bloody discoloration of the outer bandage. This is normal.
If you experience bleeding from the incision, apply firm pressure for 5 minutes.
Please call if you have any bleeding not relieved with pressure (not oozing), as this is NOT normal.
Please call if you have any pus coming out of the insertion site, as this is NOT normal.
We recommend putting an ice pack on the area where the pellets are located a couple of times for about 20 minutes each time over the next 4 to 5 hours. You can continue this for swelling, if needed. Be sure to place something between the ice pack and your bandages/skin. Do not place ice packs directly on bare skin.
REMINDERS:
Remember to have your post-insertion blood work done 6 weeks after your FIRST insertion. If you are not feeling any better by 4 weeks, however, please call the office to have your labs drawn early.
Most women will need re-insertion of their pellets 3-4 months and men 4-6 months after their initial insertion. If you experience symptoms prior to this, please call the office.
Please call as soon as symptoms that were relieved from the pellets start to return to make an appointment for your next insertion.
Hormone Support/Optimization Nutraceuticals
EstroDIM - Orthomolecular
Indole-3-Carbinol (I3C) 200 mg -Diindolylmethane (DIM) 100 mg- Vitamin E 33.5 mg
• Supports Estrogen Balance
• Supports Proper Estrogen Metabolism for Women and Men
• Improves Estrogen Detoxification Pathways
• Provides Cellular Antioxidant Support for DNA Stability
Makes estrogen metabolize down the 2 hydroxy estrone pathway, which reduces the level of undesirable estrogen metabolites. Frees up bound testosterone allowing for higher levels of Free Testosterone in the bloodstream. Prevents conversion of Testosterone to Estrogen. A supplement that combines the synergistic benefits of the cruciferous vegetable metabolites indole-3-carbinol (I3C) and 3-3’-diindolylmethane (DIM) to support balanced estrogen metabolism. Formulating I3C and DIM together creates the ideal combination of beneficial metabolites that work together to support estrogen balance, breast and prostate health.Additionally, both I3C and DIM have been shown in vitro to decrease aromatase expression, the enzyme that converts androgens to estrogen.
Adapten-All - Orthomolecular
OR
TruAdapt Plus (Adapten All + Immune support) - Orthomolecular
This unique blend of nutrients, herbs and adaptogens supports normal adrenal function during occasional stress and fatigue.
Improves Stress Resilience
Supports Healthy Energy Levels
Strengthens the Body’s Stress Response
Improves Mental and Physical Performance
Helps Maintain a Balanced Cortisol-to-DHEA Ratio
Stress is defined as any disturbance—extreme cold or heat, psychological stress, sleep deprivation, work overload, physical trauma, as well as toxic exposure—that can trigger the stress response. The body’s stress response system consists of the hypothalamic-pituitary-adrenal (HPA) axis. Prolonged stress triggers the HPA axis and consists of three stages: stage 1: alarm; stage 2: resistance; and stage 3: exhaustion. The initial, short-lived phase (the alarm phase) is the body’s normal fight-or flight response to danger which is characterized by elevated cortisol levels. The next phase, the resistance phase, allows the body to continue buffering extended stress exposure, long after the initial fight-or-flight response has dissipated. Hormones released by the adrenals, such as cortisol and DHEA, help support the "resistance" reaction. However, extended periods of stress not only burden the system, creating an imbalance in cortisol and DHEA production, but can result in mental and physical fatigue, nervous tension, irritability and poor memory- all of which are characteristic of stage 3.
Adapten-All provides a unique blend of botanicals and micronutrients that support the adrenal glands, as well as the body’s ability to respond to and counteract the negative effects of stress and strengthen the body’s stress response and support healthy energy levels. Adapten-All provides targeted amounts of vitamin C, pantothenic acid and other B vitamins that are critical to adrenal gland function. Adapten-All also provides a unique blend of "stress adapting botanicals" which help increase the body’s resistance to fatigue and maintain balanced cortisol and DHEA levels.
MitoCORE - Orthomolecular
OR
MitoCORE Protein Blend (Lemon or Strawberry) - Orthomolecular
Contains key mitochondrial micronutrients and a smart combination of alpha lipoic acid, N-acetyl cysteine, and acetyl L-carnitine to boost cellular energy production.
Recharges Cellular Energy Production
Supports Immune Function
Increases Antioxidant Protection
Supports Detoxification Capacity
The body’s cells and organ systems depend on an adequate supply of energy to function optimally. The mitochondria, known as the powerhouse of the cell, contain nutrients and enzymes that are important for cellular energy metabolism, including those that convert food to usable energy in the form of adenosine triphosphate (ATP). ATP functions as the key source of energy for all cells. In order to increase mitochondrial output, there must be adequate fuel supply for combustion and abundant antioxidants to scavenge free radical by-products. Preserving our energy reserves and increasing energy output is a critical part of maintaining optimal health.
Lack of sleep, too much stress, poor nutrition, and prescription medications can draw on energy reserves, using them up faster than they can be replenished. Even the vital biologic systems can create an energy deficit that needs to be restored.
MitoCORE is scientifically formulated, based on published research, to boost mitochondrial reserves and recharge cellular energy production. MitoCORE includes the powerful antioxidant trio of alpha lipoic acid, N-acetyl cysteine and acetyl L-carnitine, all shown to recharge cellular energy production and the primary cellular antioxidant pools of vitamins E, C and glutathione. MitoCORE also includes key micronutrients and phytonutrients, including green tea, broccoli seed extract and resveratrol, to protect the mitochondria and continually renew the cycle of energy production.
*****Pair with NAD+ Injections or IV Infusions for optimal mitochondrial support****
Vitamin D (recommend 50,000 iu/wk)
In addition to supporting bone health, vitamin D plays an important role maintaining cardiovascular health and immune function, and promoting an overall sense of well-being.
Maintains Bone and Dental Health
Increases Calcium Absorption and Balance
Boosts Immune Activity
Supports Cardiometabolic Health, Blood Sugar Balance Already Within Normal Levels, and Weight Loss
Helps Increase Musculoskeletal Strength and Comfort
Vitamin D is a steroid hormone that is part of a group of fat-soluble prohormones best known for the role they play in supporting bone health and aiding in the absorption of calcium and phosphate from the gastrointestinal tract. A growing body of research highlights vitamin D's important role in supporting other body systems, including cardiovascular and blood sugar balance, musculoskeletal strength, and neurological and immune function, enabled by vitamin D's ability to target over 200 different genes throughout the body. Vitamin D deficiency can lead to a decreased testosterone production by as much as 25%!While it has long been assumed that the majority of the population achieves adequate levels of vitamin D through exposure to the sun, the biosynthesis of the nutrient is affected by time of day, seasons, location, smog/pollution, clothing and sunscreen. Depleted levels of vitamin D may interfere with the normal development of teeth and bones, normal cell growth, and contribute to poor regulation of immune and nervous systems.
DHEA (25 mg) - Orthomolecular
Promotes Healthy Hormonal Balance
Supports Mood Regulation
Balances the Stress Response System by Improving Cortisol-to-DHEA Ratios
Maintains Healthy Aging and Normal Inflammatory Balance
Supports Bone Health
DHEA is a precursor to estrogen and testosterone. In addition, DHEA may also have physiological actions unrelated to its function as a hormone precursor, as DHEA receptors are also present in human muscle cells. Clinical studies using oral doses of DHEA have demonstrated its ability to maintain hormonal balance. In a study that included 20 women (ages 50-65 years) receiving 25 mg/day for 12 months, DHEA promoted hormonal balance as soon as three months after beginning DHEA administration. As indicated by serum concentrations, DHEA helped support healthy levels of testosterone, progesterone, estrone and estradiol.