WorldLink Medical

Hormone Q&A: Round 2 of BHRT Guidelines and Takeaways

Due to an overwhelming number of responses from the 1st Q&A session, we decided to host another live web conference. But really, I think it has to do more with the fact that Dr. Rouzier has an addiction he cannot get away from- his willingness to go over the time limit to ensure all questions are answered. Get real HRT guidelines from this truly enlightening presentation.

The following questions were answered during the web conference:

  • What is your usual starting dose of hormone replacement in perimenopause and menopause. If a woman has family history of breast cancer would you change your course of treatment?
  • What would be your typical dose of testosterone cream in perimenopause?
  • If a woman develops bleeding on treatment how would you adjust the dose?
  • Any specific time of the cycle you suggest to check serum hormone levels in perimenopausal lady, or random test?
  • A young woman with PCOS not obese, gained weight on Progesterone p.o and Metformin. Can progesterone cause that? Metformin should promote some weight loss so could it be Progesterone 100 mg qhs?
  • After attending Part 1, I have been doing full thyroid work ups and have found a lot of low, non-optimized free T3’s. Some of my patients are on levothroid/synthroid. What is the best course, increase the synthetic, add Armour and how much, or switch to Armour alone.
  • Please discuss your treatment protocol for providing estrogen and progesterone in a lady who is 5 years out breast cancer?
  • Can you discuss your treatment recommendations for patients who you believe would benefit from HgH but fearing prescribing this medication?
  • I can’t get around the problem of bleeding that happens in the early menopausal female who starts BHRT. Also the perimenopausal female who may not bleed for 6 weeks then gets heavy menses. I’ve tried pushing progesterone up to 400 mg daily but did not resolve.
  • I have a pt on armour thyroid 60 mg daily. Her repeat thyroid labs show a suppressed TSH, with a low Free T3 (2.7) and Free T4 (<1). She did 4 point cortisol testing and this showed mild adrenal fatigue. Could this be the reason? How would you proceed?
  • Would you start HGH on a very physically active 53 yr old male with hypothyroidism, hypoandrogenism and pre metabolic syndrome, who has had DHEA, Testosterone, and Thyroid optimized, who been on a low glycemic high protein diet, but he remains frustrated with little improvement on abdominal and visceral adiposity. IGF -1 values baseline 129 and most recently 151.
  • I have many hypo gonadal male patients who experience dramatic improvement in mood, body composition and libido during the first four months of testosterone supplementation but these benefits seem to taper off after 9 to 12 months even though their hormone values have been optimized. Is this a reset of their expectations, receptor saturation or are they secretly not as rigorous in their diet and exercise routine.
  • Would supplementing a 45 yo man with transdermal testosterone in addition to HCG affect fertility?
  • A 48 year old male symptomatic of hypo gonadism with a free testosterone 74, still wanted to have children. I placed him on HCG 500 IU SQ QD with a repeat level in 8 weeks. My question is titrating the HCG up and how much. What are the risks of depressing spermatogenesis if I add Testosterone cream to the HCG?
  • With long standing insufficiency especially in elderly what is exp. with rate of replacement?
  • Why would the DHEA be high in someone on no hormonal supplements as yet? Does that effect my choice giving other hormones that may be DHEA precursors?
  • What is the best plan for a perimenopausal woman whose goal is to loose visceral fat?
  • How do you increase the increments of the hormonal dosing?
  • Nipple tenderness is a side effect of which hormone? How is it treated?
  • Bleeding is a side effect of estrogen only, correct?
  • If you place a woman on pregnenolone for memory improvement, would you see an increase in DHEA, progesterone, testosterone, or estrogen?
  • Which pharmacy do you recommend for the best price on Testosterone Cypionate 200mg/ml . Is it safe to use Testosterone that appears coagulated or crystalized upon delivery?
  • Are concerns or suggestions for women currently on Mirena IUD that are interested in starting BHRT. Please advise.
  • What labs, markers, and functional tests would you consider the nominal baseline for a new client? Vit. D? Full thyroid panel? VAP cholesterol? DXA, IMT, VO2 Max, EKG? Saliva cortisol?
  • My internist would not renew my T therapy started elsewhere unless I underwent a Stress Echo [14.5 minutes out of 15] and an IMT [negligible plaque], probably because I had elevated cholesterol numbers and a family Hx of CAD. Cholesterol is not the defining factor I know, but would you want these baseline exams anyway in someone over 55?
  • What baseline labs do you draw to screen for thyroid?
  • How do you treat an elevate rT3?
  • What are your thoughts re bio identical HRT after breast cancer with positive estrogen receptors in DCIS? Are there clinical studies to support use of this type go HRT for this patient type?
  • What are the ideal levels of estradiol for men on HRT?
  • What are the most rationale strategies to combine HCG and Testosterone injections in patients?
  • Using Armour thyroid, I’m getting levels all over the map. I test at 11:30 am which is 6 hours after the dose. I’ve used bid dosing as well as larger am doses and I’m still getting a lot of variation. Words of wisdom?
  • I have a 52 yo male who’s testosterone level at 100mg bid, 150mg bid or 200mg bid is always below 500 (i.e., his latest level is 300 and that is on 200mg bid!?! Is he cheating, not taking it day of test, or is it possible that he just can’t absorb it?
  • Use of Progesterone in patient on Tamoxifen s/p breast cancer, mastectomy, receptors strongly positive for estrogen and progesterone: Is it indicated? If so, oral or cream? Is it contra-indicated? Her estrogen level is 500, Progesterone 0.5, DHEA Sulfate is 150, T3 is 2.4. Should I be thinking of DHEA or 7-Keto DHEA to optimize her levels?
  • Use of 17keto DHEA? Transdermal vs oral estrogen therapy? Should I treat patients under 40 for low testosterone?
  • Review the pro and cons of PO or cream bio identical hormones.
  • Thyroid: What is the best indicator TSH or Free T3? Pro’s and con’s IM Testosterone vs. SQ and Test replacement with HCG combined.
  • Please comment on hormone replacement in type 1 diabetic, no other risk factors.
  • How do you treat Type 1 diabetes in 41 yo that is very symptomatic and blood sugars are getting worse and are all over the place? She is worried about stroke risk with estrogens.
  • My daughter has PCOS. She is not overweight. Her endocrinologist has her on BCPs. Can she take bioidentical progesterone along with her BCPs? She is 25 years old. She has not taken metformin.
  • My dad is 83 and early Alzheimer’s. My mom is 73 healthy but has a pancreatic duct stent for a stenosis likely resulting from an injury in childhood (Yes, thats what the GI guy says). How does one begin age management rx in an old feeble man and an older woman NOT on any HRT?
  • Is there a way to improve the transdermal absorption of progesterone?
  • In men, do you prefer testosterone in lipoderm or carbogel and why? (HI NEAL)
  • If I want to add progesterone as a treatment for fibromyalgia patients, where would I begin?
  • If a 56 year old post-menopausal woman has been on premarin and provera for 10 years already…is it ok to have her stay on hormones (estradiol and prometrium) now?
  • I have a 50 yo woman with a carotid dissection history, otherwise healthy, going through menopause and her neurosurgeon warns her about HRT because it will increase her risk of strokes. Am I correct by advising her that transdermal estradiol and progesterone replacement are okay. What data do I have to support this?
  • I am constantly adjusting Armour for a female whose eyebrows are diminishing. She is up to 3 Gr. bid after 3 months, and the eyebrows are again starting to decrease. I will measure Iron and ferritin soon, but any other supplements that can help?
  • I am attending the A4M conference for another perspective, and the consensus of the speakers here is to not prescribe any oral post-menopausal estrogen due to the inflammatory component. Their preference is Bi-est. Your comments?
  • How do you assess for adrenal insufficiency/ adrenal fatigue?
  • What is your initial therapy (i.e. hormones and doses) for adrenal fatigue for women and for men?
  • What are the preferred options and doses for transdermal testosterone for initial replacement therapy?
  • Endometriosis- Patient is currently perimenopausal and symptoms are well controlled on BCP. Will changing from BCP to BHRT cause the endometriosis to recur
  • Prostate cancer and testosterone therapy. What parameters do you use to determine if/when safe for testosterone replacement. eg – pt is 2 years s/p proton radiation Rx for contained, gleason 7 tumor. current total psa= 0.5
  • Does spironolactone for acne decrease free testosterone levels?
  • Confusion about progesterone and estrogen use in women who have had breast cancer and the benefits the literature suggests. But they seem to lump all breast cancers and stages together. Can you help me – when to use hormone therapy (estrogen or progesterone) and which what types and stages. I was at the AMMG conference in Vegas and heard your talk 2011 which I found very enlightening.
  • Best time to measure serum testosterone? How many hours after using it transdermally?
  • Can you comment on each of the following determinants of penile blood flow and their contribution to correcting ED: exercise? plant-based diet and it’s favorable effects on Nitric Oxide? Testosterone supplementation? Can you prioritize this list with regards to treating ED?
  • 48 yo patient who has markedly elevated FSH and LH and almost zero estradiol levels but is still having periods, can we start them on estrogen replacement or wait till at least 6 months till no periods?
  • For the perimenopausal patient, is there any advantage of only 2 weeks per month progesterone vs. continuous?
  • Please give pros and cons of route of administration of estrogen especially as some data suggests that transdermal may be the safest route with regards to risk of dvt.
  • Does the “positivity “, estrogen or progesterone receptors of breast cancer cells have any significance in the treatment of a woman post breast cancer?
  • I had the understanding that breast cancer is an estrogen responsive tumor, but not progesterone responsive? Can you clarify?
  • Is it necessary in testosterone replacement, also to use HCG?
  • Is it possible for oral DHEA supplementation in men (50-100mg) to feedback and decrease endogenous testosterone production?
  • WHI showed that in the ERT group the results re: breast cancer were neutral or showed perhaps slight benefit as to reduction of breast cancer. We are also talking about protecting the breast with progesterone from the cancer promoting effects of bio identical estradiol. Is that relating only to endometrial cancer? Or is that being over cautious?
  • Does Braca or receptor status of breast cancer affect decision to give bio identical hormones in a patient after 5 year cure? E+, P+ HER, or triple negative? What about receptor status of breast cancer in a family member. Should that affect our decision making?
  • These questions are coming up from the women’s health practitioners who send me patients for cardiovascular risk stratification, and the patients are more worried about breast cancer risk!

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