Hormone Replacement Therapy

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I know, it sounds taboo. Images of dingy gym locker rooms, Raider great Lyle Alzado and Tour de France cyclists come to mind. This is the stigma, particularly as it relates to testosterone. For this and other reasons, mainstream acceptance of bio-identical HRT has lagged behind other less promising, yet better advertised, Pharma-backed treatment options.

There is money in disease, not health.

What has to be realized early on is that each one of us is stricken with a disease in our late 20’s to early 30’s, one that essentially primes the playing field for other health problems. It is the disease of aging. You may be thinking, “Aging is not a disease.” Well, if it’s not, why does this non-disease kill 100,000 people per day? Two-thirds of the death toll worldwide is due to age-related disease. So what is considered an age-related disease? Let’s see… cancer, diabetes, heart disease and Alzheimer’s disease. All are age-related, non-communicable diseases.

Problem #1: therefore stems from an overt lack of education. Did you know that the vast majority of cancers are environmental and therefore potentially preventable? They are not at base level due to genetic defects as was once thought. Type II diabetes? Preventable. Heart disease too. The treatment of heart disease is neither bypass surgery nor angioplasty. In fact, these procedures have fallen under much scrutiny recently. Similarly, the treatment for Alzheimer’s disease is neither Namenda nor Aricept. It is prevention.

Enter problem #2. Money.

The population is aging and acquiring disease, preventable disease, right? In the case of Alzheimer’s disease, the most common form of dementia, patients are prescribed medications like Namenda and Aricept. The disease invariably progresses and with good intention, doctors prescribe additional medication. Money by the boatload is dumped into Big Pharma’s coffers. Reeling in the loot, pharmaceutical companies are de-incentivized to find a “cure” for aging or age-related disease. It’s akin to shooting themselves in the foot.

Keep in mind too that the above drugs are only modestly effective in treating the symptoms of Alzheimer’s disease. Yet we continue to treat the symptoms not the disease process itself, AND BY VIRTUE, LINE THE POCKETS of Big Pharma.

Remember, there is money in disease not health. Don’t believe me? Take a look at the efficacy of some of the cancer “treatments” offered today. What a joke! One has to wonder who is benefiting. Patients? Think again... Big Pharma. Drug trial data are often skewed, statistically manipulated, to demonstrate efficacy of chemotherapies and downplay side effects (Vioxx anyone?). Billions of research dollars are at stake should the trials fail.  There are claims of “fabricated diseases,” Adult ADHD for example, to mitigate loss.

Are you simply "getting older?" or...

Interestingly, one of the so-claimed diseases is “Low T,” or what physicians refer to as “hypogonadism.” Hypogonadism is the syndrome associated with age-related decline in sex hormone levels, namely testosterone, estrogen and progesterone. Andropause (in men) and menopause (in women) fall under this heading. But unlike “statin deficiency,” “circadian dysrhythmia,” and “spectrum disorders,” low T has its basis in biology. And in your serology. Yes, we can measure the faltering hormone levels! 

hormone cascade chart

Regardless of the underlying mechanism (i.e., genetic or vascular) to which the phenomenon of hormonal decline is attributed, levels fall as we age chronologically. This may be associated with a cluster of well-described, sex-specific symptoms.

  • Males for example may develop fatigue, increased body fat (adiposity)/reduced muscle mass, sleep disturbances, reduced libido and inattentiveness to name a few.
  • Females: hot flashes, reduced muscle mass, headaches, vaginal dryness coupled with waning sex drive, depression and…
Andropause and Menopause

Heard enough? Do these complaints strike a chord? Ultimately, the vast majority of us will experience symptoms of andropause or menopause. At what age?  Everyone’s different. Truth be told however, the changes albeit subtle at first, begin for both men and women in the early 30’s (and rarely earlier).

In women, contrary to what you may have been told, progesterone production begins to wane firstly, not estrogen. This is associated with headaches, painful and irregular menses and insomnia to name a few. As progesterone levels falls, estrogen becomes disproportionately dominant. This state of imbalance is associated with a myriad of disease processes, breast cancer being on of them.

Interestingly, as males age, testosterone levels tend to decline and estrogen levels increase, again a state of estrogen dominance. Do you have “man boobs” or florid gynecomastia? Such breast tissue growth is induced by estrogen, and more specifically elevated levels of estrogen in the context of low testosterone. Similarly, an estrogen dominant state is associated with increased body fat (adiposity) particularly around the abdomen, hips and thighs. Pear anyone?

Subsequent to the decline in progesterone, testosterone levels fall. The prevalence of “low testosterone” (arbitrarily defined as a serum level < 300 ng/dL) increases in the aging male; at least 50% are stricken by age 85. Certainly however, many more men are suitable treatment candidates than those so dictated by blood levels in isolation. In fact, only 5-35% of hypogonadal males actually receive treatment. [Seftel A. Testosterone replacement therapy for male hypogonadism. Part III. Pharmacologic and clinical profiles, monitoring, safety issues and potential future agents. Int J Impot Res. 2007; 19:2-24.] Testosterone levels must be interpreted in the context of the clinical picture. I always tell patients that, “I operate on people, not MRI’s” as they pore over reports of the interpreting radiologist, having been referred to me for multiple “disc herniations” in their neck. Reality? The “herniations” are often nothing more than spondylosis or degenerative disease, always best left untouched if the patient is asymptomatic. Imaging studies (or laboratory data) therefore cannot be interpreted in isolation.

The clinical picture is always the most important.

Why am I telling you this? Because you may be suffering from the symptoms described above, aware of the fact that something is “not right,” and have been denied treatment only by virtue of a number, a lab value. That said, I’m not recommending treatment for all individuals in frank disregard of their labs. What I am saying is that hormone levels should always be used to corroborate the clinical findings.

Treatment similarly should be guided, albeit not dictated by hormone levels. A hormone level of ‘X’ may generate a robust clinical response in one individual and prove inefficacious in the other. Often times therefore, hormone dosage and frequency is tailored to “best-fit” the patient, clinically. This requires open communication lines between patient and physician, something that cannot be understated. We at the clinic pride ourselves on the open access afforded to patients in this regard.


Hormone replacement therapy after all, is a direct manipulation of one’s biochemistry. In the case of thyroid replacement for example, metabolic pathways are being reignited. Patients experience distinct phenomena in the wake of hormonal reintroduction. Side effects, while infrequent, may occur and are not to be dismissed. It is imperative in fact, that these are brought to our attention expeditiously. This will allow us to make the necessary changes in your medication regimen, in essence righting your path immediately.

In addition to providing this critical feedback, for like reason, you will undergo scheduled lab reassessments. Initially, blood is drawn every 6-12 weeks; thereafter at 3-6 month intervals depending upon your clinical response. Keep in mind that hormone replacement therapy is lifelong and unceasing. You will not be “cycling steroids” with on and off stints, as do professional bodybuilders. This has absolutely nothing to do with bodybuilding in fact. Yes, you will be a leaner you by virtue of all the applied modalities, HRT being one of them. Still, the physical gains are merely a “side effect” of optimized internal biochemistry, not the cyclic usage of synthetic hormones and their myriad of associated side effects.

At the clinic, we utilize only bio-identical hormones.

Synthetic hormones (i.e., progestins) are dangerous, plain and simple. The fact that progestin was utilized in the WHI study (as opposed to bio-identical progesterone) was an overt flaw in the study design, which ultimately deprived many women of the potential benefits of HRT. Progestins are not progesterone. Do you know any women who have developed “blood clots” from birth control pills? Progestins at work.  

Bio-identical hormones, unlike synthetics, mimic the structure and action of native bodily hormones and by virtue have a better safety profile.They are not for everyone for example individuals with hormone-sensitive cancers, but can make a dramatic difference in those who qualify. Do not underestimate the roles that hormones play in your biochemistry, and more specifically, in your well-being. Progesterone exerts very important effects on the nervous system for example. In fact, it is being used successfully as a neuroprotective agent in head-injured patients, in both women and men. Both women AND men! Yes, men too need progesterone. Some researchers have even proposed that Alzheimer’s disease is in part due to progesterone deficiency. Surprised? You shouldn’t be. Restoring a youthful hormone profile not only has the potential to make you feel great, but also may impede the aging process and slow the progression of age-related disease.

The question still remains, do our hormone levels decline as we age, or do we age as a result of our declining hormone levels? Chicken or the egg? My bet is on the latter…

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