It is now time to start to prepare the lectures for Part V, which I start organizing a year in advance. It is also time for everyone to block out October 5-7 on their calendar, so you can attend this year’s WLM symposium. My interest/focus this year will be the brain, breasts, prostate, and mitochondria. And I’m pleased to announce this conference as our 20-year anniversary event. Dana has worked long and hard to make this reunion special. And so have I by organizing a review of the most recent profound literature that we should all be aware of. It is my annual update of literature that I can’t cram into the courses but that we should have command of to better treat our patients.
During my toxicology fellowship we were taught that the best treatment for a poisoning was to prevent the poisoning in the first place. The same concept applies to dementia and Alzheimer’s disease. After 30 years of failure by the pharmaceutical industry to develop a cure for Alzheimer’s disease, we still have no treatment after billions of dollars in research. However, the best treatment still is to prevent the disease in the first place. There is an amazing plethora of data proving loss of hormones is culpable and replacement is protective. Our ignorance is embarrassing when it comes the research showing benefit. “Yea but…the WHI showed…” I hope that I can cram all the articles that I want to show you into 3 hours of lecture demonstrating many different hormones affect the brain. UCLA is one of the outstanding universities that has a special section devoted to treating dementia, with Dr. Bredesen heading that endeavor. Unfortunately, he will not be presenting but Dr. Sharlin will review UCLA’s protocols as well as functional medicine treatments that have been shown to provide reversal of cognitive decline and improvement in symptoms. SPECT scans demonstrate plaque reversal with BHRT but not so with SHRT. It’s impressive. Patients can now go to you for treatment/prevention without having to travel to UCLA.
As you know I used to run at the front of the pack. In the last 10 years I have moved to the back of the pack, choosing not to fight the fight I used to fight, allowing the naïve specialists to have the upper hand. The pendulum has now swung back in the opposite direction. Patients should not have to suffer the inadequacies of their specialists nor should we have to play second fiddle. I’m tired of dealing with physicians that don’t understand why we do what we do or ignore the literature that supports it. It’s time to show and prove to the specialists that which they should know but don’t. Yes, I do pity them because there is no venue for them to learn this information other than WLM. Unfortunately, it is the patient that suffers the consequences of the physician’s lack of knowledge. Thus, I’ve taken on the role of being the patient’s advocate, empowering them to understand an alternative treatment or prevention that is all evidenced based, but that which is going to be rejected by their PMD’s. I now provide articles to patients supporting the important benefits of testosterone in prostate cancer patients, progesterone and testosterone in breast cancer patients, and the safety and efficacy in prevention and treatment of these diseases. I will provide and review all the studies that you should have in your quiver to present to patients and their physicians that reject what we do because the physicians have not a clue. I’m tired of letting the patients endure the consequences of physician ignorance. All new and recent evidence will be presented. Please utilize these studies to provide direction and support to your colleagues and patients.
The diagnosis and treatment of prostate cancer continues to evolve yet remains controversial. Dr. Bernadette Greenberg from Desert Medical Imaging will present the update in diagnosis and treatment as well as the use of genomics to predict outcomes. This will be the most captivating lecture you will ever hear as I have never experienced any lecturer as dynamic as this lady. Be prepared to be blown away by her knowledge and presentation.
We at WLM are pleased to now have a 2-hour presentation before Part I to help attendees “figure me out.” This is presented by Dr. David Kern who has the same sarcasm and insight as I do. He will be presenting all the data on how glucose affects the brain, dysglycemia, and protein glycation.
A new addition to WLM is a separate course on PRP, injection techniques, and the latest literature by Dr. Nacouzi. Unfortunately, the PRP course sells out due to the popularity of this new and easy treatment. We’ll learn why it is so popular and how to incorporate this procedure into your practice.
We have tried to introduce new and promising concepts that we can incorporate into our practices. I know nothing about genetic testing, epigenetics, when to test, and what to do with the results. What I have read in JAMA is confusing and perhaps political. Dr. Stickler will enlighten us as to what, when, and why to test and then what to do with the results.
I also know little about cannabis, cannabinoids, CBD, etc. Are they a safe and effective alternative to opiates now that we suffer from opiate paranoia? I have had many patients request it with excellent results. Now that it is legal in California and other states, pot shop owners know more about cannabis than physicians. So, we have chosen Dr. Felice to enlighten us about what we should know about this alternative for pain and sleep management.
Our resident attorney and business consultant that teaches the WLM business course will provide an update on practice management, compliance, and how to avoid hassles with insurance and regulatory agencies. As far as hormones are concerned I have focused in this course primarily on breast cancer, prostate cancer, and mitochondrial dysfunction.
I would like to focus on the recent literature as it pertains to my personal situation and how HRT has helped me in this regard as well as the medical literature as it pertains to pain. After 30 joint surgeries, joint sepsis, 5 back surgeries, and over 20 IV antibiotics that have played havoc with my gut that resulted in significant inflammation, I’m an expert in pain management and gut dysbiosis. Pain can affect our psyche and sleep cycles. I’ll review the recent literature as it pertains to opiates effects on hormones. Concurrently, hormones have been shown to have a significant impact on multiple nociceptive pathways that result in significant pain improvement. Unfortunately, do to my snips, opiates and cannabis don’t work for me but I’ll present literature and as to what does work and why.
Lastly, and most disturbingly, is a topic that I must address but with grave reservation and frustration, and that is our legal environment. It is a complete system failure, from the process of medical board complaints, to medical board handling of complaints, to reliance on completely inappropriate endocrine guidelines as if they were case law. I will review all the cases (with fake names, case scenarios, and circumstances of course) that I have had to deal with so that history doesn’t repeat itself. More importantly, I will discuss my solution to the issues and how everyone can help. This will be an audience participation time, Q & A, discussion by Dr. Kadambi (esteemed endocrinologist that totally gets it), and how we can all help each other through this process. Number one on my current bucket list is to educate the medical boards to the literature as well as stop using worthless and outdated guidelines to sanction physicians that only make their patients better. WLM attendees should be the experts that review these cases, not a specialty that has no understanding of the literature and current studies. I will enlist everyone’s assistance in doing so. We will spend an entire evening addressing these issues and concerns.
Last year’s Beyond Hormones conference at the Lied Lodge will be hard to beat. However, we are going to try to make this anniversary celebration better than last year with great food and entertainment at a fabulous resort in Tucson. I’m looking forward to a great reunion this October and hope to see everyone there.
Kindest regards, Neal
Neal Rouzier, M.D.
When planning a weekend-long course to learn and incorporate a significant clinical advancement such as PRP, it should be thought of carefully. The presented material and exercises need to be clinically relevant, succinct, and applicable.
After attending many PRP-specific conferences, I recognized that the same contents and formats were endlessly being recycled. The hands-on exercises often left me wanting and in the worst cases, left me questioning the clinical experience of the instructors. As presented, to try and apply these experiences the next day in my own practice would be unreasonable, if not unsafe.
There needed to be a format that would allow attendees to easily apply the information they were presented. Thus, after performing over 2500 procedures in our office, I decided to put together a course summarizing the up-to-date thinking on PRP along with a way to establish confidence in those performing some of the most common procedures encountered.
As a result, my colleagues and I have summarized the majority of our experience thus far with PRP. We have read and abridged hundreds of articles regarding preparation, dosage, activation, and implementation of PRP into an easily applicable format. We then developed a system of reference for each step of implementation, including: functional diagrams, planning methods, safe zones, dosing, adjunct product use, pearls of injection, caution zones, follow-up, and discussion of relevant challenges encountered.
In addition, we will share the intricacies and important modifications needed for PRP preparation. The latest recommendations and reasoning proposed by leading European and international researchers.
In order to make the most of our time together, we will substitute more long-winded pathway lectures with hands on need to know material, and the complete reference material will be distributed to attendees in advance for their conference.
Every slide in our program will be relevant material aimed to benefit attendees in their own practice. As such, we will have two one-hour open discussion periods based on the questions asked at registration. The hands-on-lab will offer over ten live cases to participate in and will include the application of neuromodulators (Botulinum A toxins), Hyaluronic filler injections, facial volumetric remodeling, and other relevant procedures. In addition to our hands-on-lab, 5 conference attendees will be able to volunteer for 5 independent procedures guided by myself and my colleague.
We welcome you to our conference.
Dr. Nacouzi, MD
NEAL ROUZIER, M.D.
You will find a new level of confidence as you move from the basics of Part I to the advanced protocols in Part II. The Part II course provides the experienced practitioner with training that is essential for mastering complex cases. The course will serve as a short refresher, but will highlight new important therapies, clinical pearls, tricks of the trade, controversies and everything that I could not cram into Part I that you still need to know. The field of age management medicine continues to grow at a rapid rate, and we only seem to get busier, making it difficult to stay abreast of all the changes. This is why we’ve condensed an inordinate amount of material into 2 ½ days—in fact, there are over 1,300 slides of information (Yikes! I’ll talk fast).
My favorite part of this course are the informal discussion and question and answer session at the end of the day where we discuss anything that you want to discuss. This is one of the most interactive ways that new attendees expand their clinical knowledge by learning and sharing experiences, audience discussions, difficult cases, controversies, legal issues, suggestions, medical board issues, trials and tribulations from other seasoned attendees. I’ve yet to find anywhere else where can one go to participate in such a gathering and meeting of HRT practitioners that share their successes and challenges. This discussion is a wonderful prelude to the topics covered throughout the remainder of the weekend:
Antiaging, definitions of, and why we call it that. This is a review of the medical literature articles that shows us why we refer to BHRT as antiaging and provides credence for why we do what we do.
Longevity medicine and which hormones have a proven record of extending health, wellness, and longevity. Yes, optimization of HRT does extend life.
Making sense out of the many HRT studies, the critiques, and the rebuttals. Putting the pieces together will make you an expert on all the ifs, ands, and buts. It is the knowledge and command of this scientific literature (that your colleagues will never know) that makes you the expert.
The positive and negative articles on BHRT. Laying to rest estriol as the worthless metabolite it is. What the literature shows we should use and shouldn’t use, and disproving what many others are teaching without any basis in fact, ie estriol is safe.
“There are no studies that prove BHRT is different than synthetic HRT.” Baloney! Many studies contrast the BHRT with SHRT.
A literature review proving that HGH, testostereone, estrogen, progesterone, DHEA, and melatonin protect against cancer. The perfect solution to Obamacare.
This section is “R” rated for language and me acting out: Optimization of progesterone and case examples, multiple studies that prove transdermal cream is worthless and harmful, and saliva testing for monitoring therapy is fraught with error. Scientific studies prove where your levels should be for maximum protection, and where they should not be if one wants to protect against cancer. Case studies with labs show the good and bad.
New and different methods for raising testosterone in men and women besides creams: Oral, SQ, IM, HCG, Clomid, which are the cheapest and which are the best.
Oral vs. transdermal estrogen, relative risks for both, safest vs. most beneficial. Which, when, why and how the ESTHER study guides us.
A literature update of thyroid for cardiovascular protection and osteoporosis protection. So you think you know thyroid? More literature backing for why we do what we do.
What can you do to prevent and treat weight gain and bloating as far as hormones are concerned?
Cardiovascular disease protection, cardiac markers, eicosinoids, diet, EFA’s, insulin, inflammation.
Cardiovascular case studies with management beyond statins.
Diagnosis and treatment of the most common premenopausal endocrinopathy that everyone fails (misses) to diagnosis, and it’s relation to CAD, breast CA, and uterine CA.
Treatment of osteoporosis beyond biphosphonates: E2, D3, Vit K, strontium, & ipraflavone. Measuring and monitoring NTX & CTX. Estrogen metabolites- do they or do they not predict breast cancer and should we waste money on testing? 2OH-E1 vs. 16αOH-E1?
Importance of optimization of estrogen in men too and the harm of suppression. The harm of giving progesterone to men that increases inflammatory cytokines and ED (what are they thinking)?
Cortisol for fatigue and CFS, how and when to use it, how to monitor it, and test it with ACTH.
Complex cases, labs, adjustments, fun and interesting cases, and lots of WWND (What Would Neal Do?)
Hormones and cancer, cause or protection? The myths & controversies of the oncogenic effects of hormones. Literature review showing protection against cancer by optimization of hormones.
Last hour is 100 pertinent questions and answers with discussion.
See you all in Houston!
Over the past 12 years of teaching HRT courses I have tried to modify the content to be what I thought best as far as practicing HRT. Part I begins with the didactic, evidence-based approach to demonstrate what we do and why we do it, based on the medical literature. Day two is designed to get you started on prescribing, monitoring and adjusting hormones based on symptoms and laboratory data. When I ran out of time and space, then Part II was developed to complete the Part I course. Part II consisted of finishing what I thought to be important facts, papers, and labs that I felt you should know but could not cram into Part I. Finally, we reviewed chronic fatigue, PCOS, hair loss, skin, osteoporosis and new lab markers. The most important section of Part II was demonstrating the anti-cancer benefit of our hormones, which most physicians and academicians have never read or seen. I had hoped to lay the groundwork for everything there is to know, based upon our literature, to have a firm understanding of preventive medicine. Unfortunately the sections on clinical pearls, tricks of the trade, and difficult and interesting cases I've accumulated were eliminated. Hence, Part III.
All 3 courses are in constant evolution. New to this Part III is the importance of SHBG, which is the most important and least recognized serum protein for predicting cardiovascular disease in both men and women. The literature demonstrates the importance of optimizing this protein. The literature also weighs in on which estrogen is best for long term health and it’s the opposite of what most are doing. Recent literature purports that testosterone has a longevity effect on men with treated prostate cancer. Unbelievably, some doctors are now treating men that have active prostate cancer with testosterone with no ill effects except improvement in longevity and well-being. We will also look at prevention and treatment of prostate cancer with estrogen, completely the opposite of what other academies are teaching. We’ll review how SHBG protects against cancer and how testosterone raises SHBG?
Part III involves new material and studies to further shape why we do what we do. However I have the most fun when we utilize the medical literature to debunk what other groups commonly teach and believe which is why I focus so much on evidence based teaching. Even though many theorize that estrogen is harmful in men, the literature entirely supports the opposite. In fact, recent literature supports estrogen’s role in treating and preventing prostate cancer, CAD, DM, osteoporosis, and dementia. We will review the literature to decide which estrogen to use in men, when, how much, and which ones to avoid. I will present the many cases of active prostate cancer that I have been treating for 10 years with only estrogen! Many practitioners are still being taught that estrogen causes prostate cancer despite estrogen having antiangiogenic and proapoptotic properties against prostate cancer. As for women, we will also review which vaginal estrogen to use, which ones to avoid, how much, when and why, which ones are absorbed systemically and which ones are not. In addition, the new treatment of choice for prostate cancer is HIFU and the best diagnostic test is the MRI-S. We should only biopsy the prostrate after we produce a mapping of the prostrate under MRI guidance. And if no tumor is seen, then no biopsy should be done.
At what level should a man’s serum estradiol level be maintained for optimal health? What estradiol level should be maintained to suppress the growth of active prostate cancer? This is counter to the teaching of A4M and AMMG, yet they have no scientific evidence to back up their unsupported claims that estrogen causes prostate cancer which is contrary to the studies showing the success of estrogen in treating prostate cancer. Let’s see who wins in this court of medicine. The pendulum now swings in the direction that optimal testosterone levels, with the resulting optimal estradiol levels, may be protective against prostate cancer. Lastly we will look at the literature supporting estrogen in the treatment of prostate cancer and review the cases where I have successfully treated prostate cancer with estrogen administration throughout the last 15 years.
The local osteoporosis expert can't get NTX levels below 50. He is baffled as to how I get them below 20, then raise vitamin D levels to above 60, and get all DEXA scans to improve. He believes that I use toxic levels of vitamin D whereas studies prove what levels are toxic and the side effects associated with these toxic levels. The cardiologist wonders how I can lower cholesterol, triglycerides, lipoprotein and CRP levels, and get HDL up that high. And a local fertility expert is frustrated that I have made two of his patients pregnant whereas he could not (don't go there!). It was simply due to the effect of Femara in blocking excess estrogen, maintaining adequate progesterone, thyroid, and metformin levels throughout pregnancy in patients with PCOS. The literature tells us how to prevent and treat post-partum depression. Fun and interesting cases will be reviewed that I did not have time to review in Parts I & II. There will be many cases involving “what to do when this happens,” that we couldn’t cover in the prior courses. Let’s see how you do with the 50 menopausal cases that review every type of problem you could possibly encounter in a menopausal woman. The amount of data and study that is available to support this therapy is amazing and I love to share and decipher these studies that are so important yet missed by most physicians and academies. As you know by my passion, this medicine is absolute fun!
The prescribing of HRT is relatively straightforward and that was very repetitiously covered in Parts I & II. However, it is that 10% of patients that have problems and complications that will challenge your knowledge and expertise. So, Part III is designed as a course that reviews tricks of the trade as it relates to problem cases, many ifs, ands, or buts, complications, and what to do and say to patients and their doctors when they challenge you. As in keeping with our tradition, more supportive and interesting articles from our literature will be analyzed to support our unique style of medicine. Following this letter will be a small sampling of questions that may pique your interest. After completing Part III you should feel confident in calling yourself an expert in preventive medicine and hormone replacement therapy.
So bring the Provigil and coffee and get ready for an intense 2.5 day board review type of course. Past attendees have commented that it was the most fun course of the three because of the discussions. If you have signed up for the certification, WLM will present the third part of the certification test upon completion of Part III. In preparation for this we will review 500 questions and cases of clinical pertinence to understand the most difficult, interesting, fascinating, and controversial cases. In addition there will be an hour potpourri of interesting articles that don’t fit into any particular topic yet are so pertinent to our science. I hope to see you all soon in Park City, UT!
Has there been any progress on new reference ranges on progesterone? My patients are coming back with levels of 2-5 ng/mL which was confusing to me until I read on the forum about the reagent. I’d appreciate any update.
Based on looking at many recent tests, I think the new range should be at least >2. Still working on that with LabCorp. Again it is completely arbitrary and nebulous. Unfortunately the manufacturer of the new reagent, nor LabCorp Executives, have recommended a certain level of normal or optimal to shoot for. Just goes to show how these numbers are picked and how they should be used as only a guide.
The consensus meeting of OB/GYNS in Europe last year felt that a level of 10 ng/dl was adequate for endometrial protection. Unfortunately that number was established using the old reagent but has now been discontinued. Ultimately the number that will be decided on will be based on negotiations between me and a few pathologists at LabCorp. Now how scientific is that? Hard to believe that LabCorp would suddenly start using a new reagent without reference ranges and without alerting the public as to their doing so.
Use the number as a guide but keep an eye on bleeding or spotting. Based on doing this for 20 years, I still feel that the doses we prescribe (100mg SL or 200mg PO) should be adequate for most women. The OB/GYN community does not follow levels like I do, so a lot of their dosing is based on the studies that show 200mg PO is protective, which in our experience results in P4 levels of at least > 10ng/dl. In my experience, about 20% will require more progesterone to prevent endometrial proliferation. Use your clinical judgement as well as inform the patient to be alert for any abnormal bleeding/spotting which would then require an endometrial ultrasound/biopsy and dosage increase of progesterone. So we never will truly know the exact or best level to shoot for, however with time and experience we will eventually come to know what level to shoot for in most women, with a few outliers requiring more. Remember all women are like snowflakes, all are different and will respond differently depending on cellular sensitivity to progesterone and intestinal absorption.
We hope this preliminary information is helpful, please comment as we all work collectively to resolve this issue. Thanks to many of you for reaching out with your initial concerns, it has helped us to better figure out what is happening as we reach out to LabCorp to re-establish some starting guidelines. As soon as we have more definitive information Dana will send along an update.
In addition to learning about dysbiosis and all the effects that probiotics play on health and wellness, I thought that it would be interesting to learn and review from an expert all that we should know about gut flora, health and wellness. I personally have been on 8 different potent IV antibiotics since January and have completely messed up my intestines, only to be saved by gut healing supplements and probiotics. Dr. Dirk Parvus will review how he assisted me in recovering. Eric Serrano sent a care package to my home with all of the necessary elements to heal my leaky gut and put me back to normal. What a tough road it’s been, but I’m finally back to normal thanks to these docs. I’ll review their treatments that led to my healing when nothing conventional worked. And I’m sure you’re interested in hearing where I’ve had stem cells injected, why, and the results. Although you may never administer stem cells, we feel it is extremely important that you become aware of the modality, what it can be used for, and when you should utilize it. Dr. Herman Pang will enlighten us with everything you should know about stem cells and where to refer your patients for the various treatments with PRP and stem cells, as well as where I sent my own patient that had an ejection fraction of 15% with class IV CHF.
The administration of growth hormone has always been complex and confusing, and many practitioners and zealots still try to convince everyone that growth hormone is illegal to prescribe based on their misinterpretation and misunderstanding of some law they say applies to growth hormone. Fortunately, it’s up to the law makers to enact laws and the courts to interpret them, and NOT the FDA or pundits that claim to. We’ll review case law on legalities of HGH and put the false claims to rest that are intended to scare practitioners away from prescribing HGH. If it is illegal to prescribe HGH, then I know about 10,000 doctors that are breaking the law. Really? Are all of us breaking the law? Nope, not to worry, I’m not going to turn you in because you prescribed HGH. However, I will discuss the various cases that I’ve had to defend (medical board cases), issues regarding the use of HGH, and how to prescribe and document so that you will never have any concern with prescribing growth hormone for medical reasons. Don’t make the mistakes that others are making.
We will review 100 studies on diagnosing, prescribing, monitoring and troubleshooting HGH. Old landmark articles will be reviewed, as well as the most recent literature showing benefits. We’ll review tricks to maximize response and raise IGF-1 levels. We’ll also review various types, costs, where to go to prescribe for best cost, alternatives to HGH, and the important facts that you need to document when you prescribe growth hormone for off-label use. Ever hear of ipramoralin, tesamorilin, or ibutamorin? We’ll review both injectable HGH and PO secretagogues, which ones work and for how long. The use and clinical utility of pharmaceutical secretogogues and the lack of efficacy of non-pharmaceutical secretogogues will be reviewed. Recent evidence proves significant protection against Alzheimer’s disease by HGH and various secretagogues. Just how illegal is it to prescribe growth hormone? I’ll review the reasons why I don’t prescribe growth hormone, as well as the reasons why I DO prescribe growth hormone. We’ll review supply and demand, cost and availability, andeverything else you need to know before prescribing growth hormone, including the necessary verbiage for documenting and defending its use. It may take me several hours to get through the material, but I hope to cover everything of importance that I feel you should know about HGH. And of course, it goes without saying: WWYLYLTB?
Five years ago, I put together a lecture on the brain that I gave at AMMG. Three years later I added a second lecture that consisted ofnewer articles not included in the first lecture. Earlier this year I put together a third lecture from all recent data that addresses the various treatments for dementia and Alzheimer’s disease. It is thoroughly amazing that the experts who write the articles on Alzheimer’s disease and dementia have no understanding of the pathophysiology of hormones on the brain. They just don’t get it. However, you will by the time I finish the third lecture. I will convince you of how bad estrogen is for the brain, and the same goes for testosterone. Then, in my usual style, I will show you all the bad effects of not using hormones to protect the brain. Recently there have been several studies proving the harm of estrogen in older women, as well as demonstrating the harm in having high baseline levels of estradiol that have been associated with an increase in Alzheimer’s disease and dementia. That is absolutely true as you can’t argue the results, only the extrapolation. But in fact, their conclusion couldn’t be further from the truth. Unfortunately, researchers still don’t understand that association does not prove causation. We will review the medical literature that demonstrates protection of the brain with various hormones for both men and women. After 20 years and billions of dollars of research we are no better off in treating Alzheimer’s disease. Aricept and Namenda have been disappointing in treating symptoms, and no drug reverses the disease process as it progresses. We will review all the EBM that medical academies and pharmaceutical companies ignore, which instruct us on how to prevent dementia as opposed to treating once the disease becomes established. Can/should we treat Alzheimer’s disease with estrogen? Yes, absolutely, if you want to reverse the disease process. Unfortunately, the pharmaceutical industry fails to read and appreciate all the data for the various hormones in preventing the disease in the first place. There is definitive evidence that CEE≠E2 and MP≠MPA, particularly when it comes to the brain and this is demonstrated in SPECT scans. Finally, there is only one drug that reverses (removes) beta amyloid plaque from neurons, which is what the pharmaceutical industry has been searching for to treat AD. Well, we found it, but we are going to keep it a secret! It doesn’t make me any less sarcastic, but it does make me think clearer so that I can be even more sarcastic.
Recently while in China, I read about another promising Alzheimer’s disease drug that failed to improve AD or reverse beta-amyloid plaque deposition. After 50 years and billions of dollars spent, there is no successful treatment or preventive drug therapy for AD. And now we have good data to show the harm of HRT which logically calls for yanking out ovaries, heuvos, and your pituitary gland. Fortunately, those are all observational studies that suggest harm of hormones, in contrast to RCT’s that show and prove protection. This then leads us to another section where we will learn how to evaluate medical journal articles and interpret their results, which are usually the opposite of what the real data shows. We will review a multitude of studies whereby the ultimate results are different than what the authors originally claimed. I hope to make you better students by teaching you how to interpret and review studies for bias, political correctness and economic agendas.
I have also invited two hormone experts, both internationally recognized, that have completely opposite opinions on HRT. You will find their debate on hormones enlightening and be amazed how two experts can have completely different views of HRT. Listening to them both will give you a new perspective on life.
Lastly, I have found the most profound article on BHRT that I have ever seen or read. Finally, someone has published exactly what I have been teaching and preaching on thyroid administration for the last 20 years. In spite of the fact that it’s in the bible of endocrinology not to suppress TSH, endocrinologists, ENT surgeons, and psychiatrists suppress TSH with impunity, but you can’t. Regardless of this right of certain physicians to suppress TSH, a landmark study reviewed why and how we came to fear suppression of TSH. Unfortunately, all of the studies that showed harm of TSH suppression were from extrapolation from Grave’s disease which causes harmful effects due to an autoimmune disorder and not from elevated levels of thyroid hormone. Years of studies of suppressing TSH by endocrinologists, psychiatrists using high doses of T3 for depression, and ENT surgeons suppressing TSH for treatment of DTC, none showed any harm. We will review this study and recent other studies showing the benefits of thyroid optimization and lack of harm with TSH suppression. In fact, proper treatment involves TSH suppression. I could not sleep after reading this article and I’m sure that you will feel the same.
We’ll review all the articles that review PCV vs erythrocytosis, as well as review outcome studies. High hematocrit is predictive of stroke and heart attacks but only in patients with PCV, not erythrocytosis. Got that? Well most don’t got it and here’s why. Fifty years of study prove no harm to physiologic erythrocytosis. Don’t assume and don’t extrapolate but everyone does because they don’t get it. However you’ll get it. Need studies, documentation that erythrocytosis is harmless, need to understand why checking a CBC is in the endocrine guidelines? No I don’t go by (incorrect) endocrine guidelines.
We’ll review the physiology of erythrocytosis that the hematology world doesn’t comprehend, and look at how and why they confuse PCV with erythrocytosis. The mechanism and physiology of erythrocytosis is thoroughly amazing and none of my hematologists know or understand the physiology behind normocytosis, erythrocytosis, and extreme erythrocytosis, as well as when, and when not, to phlebotomize each. I’ve saved interesting cases of PCV with lab reviews.
How to analyze a medical study: Examples of studies that state one thing and prove another. Review and critique a study before even reading it. DBRCT’s, RCT’s, prospective studies, retrospective studies, observational studies and confabulation. How to design a study to prove or disprove anything that you want by using sensitivity, specificity, relative risk vs. absolute risk, number to treat, underdiagnose and overdiagnosis. We’ll make it fun!
Hope to see you in October!
Sarcastically yours, Neal
P.S. I just heard from Einstein and he’s coming all the way from Tokyo.
IS OUR THERAPY EVIDENCE BASED?
Hormone Facts You Should Know But Probably Don’t
By Neal Rouzier, MD
Recently the medical community has undergone criticism for journalistic articles and medical studies that promote one drug or treatment over another. There are often political or economic gains behind the purpose or results of the studies, which leads to inappropriate and biased conclusions or recommendations in these articles. This has negatively impacted the credibility of some authors and journals. Some medical journals provide a study rating score so that the reader may be able to discern any bias of a study’s treatment or product. In addition, medical journals and textbooks now use the term “evidence-based medicine” (EBM) in order to assert credibility for a medical treatment based on peer-reviewed studies or meta-analysis. The purpose of this introduction is to prevent the reader from being led astray by the political and economic bias from paid authors of medical journal papers with misleading agendas.
Many treatments, suggestions, lab tests and information presented in lectures, books and age management seminars do not follow foregoing standards of evidence-based medicine either. Exposure to these non-peer-reviewed teachings and conclusions has led me to perform extensive literature searches. I have discovered significant literature that refutes many teachings and conclusions of these anti-aging academies. For example, the trend to lower estrogen in men is contrary to scientific literature that supports the opposite. Estrogen is touted as harmful to men, causing an increase in prostate cancer; however, the literature has demonstrated a beneficial effect of estrogen in treating prostate cancer, and estrogen loss in men leads to an increase in Alzheimer’s, coronary artery disease and osteoporosis. A recent article in the NEJM proved that lowering men’s estrogen with aromatase inhibitors increases cholesterol and body fat and lowers libido and sexual function. Yet I constantly hear lecturers recommend that physicians prescribe aromatase inhibitors to men in spite of the lack of EBM to support this and the EBM that demonstrates harm of doing so.
Physicians who misunderstand the scientific literature also con- tinue to prescribe estrogen for women in a transdermal cream to prevent the thromboembolic complications of oral estrogen, the increased incidence of which is only 4/10,000 (as per the WHI for CEE). The loss of cardiovascular protection would be negatively realized in a substantial number of women if transdermal estrogen was preferred over oral estrogen. Every NIH study and recent European studies demonstrate the cardiovascular protective effects of oral estradiol over transdermal estradiol, a fact that most physicians fail to appreciate. However, the transdermal estrogen would be expected to protect only a few women from DVT, or 4 per 10,000, but in turn lose the cardiovascular protection afforded by oral E2. The majority of cardiovascular protective benefits are attained only from oral and not transdermal estrogen. Using a transdermal estrogen prevents the cardio- vascular protection provided by oral estrogen and puts 90% of women at increased risk of cardiovascular mortality, certainly devastating in comparison to protecting 4 out of 10,000 from venous thrombosis (again for CEE). Every study to date (KEEPS, EPAT, WEST, CORA, DANISH, ELITE) where oral estradiol (E2) was utilized, the relative risk (RR) for DVT has been < 1.0 indicating no risk of DVT with oral E2, which is contrary to what everyone believes. True, there is a risk of DVT with oral es- trogen, but that is seen only with oral CEE, and not oral E2. As a result, millions of women lose the most protective cardiovascular benefits of oral estrogen because physicians fear an increase in DVT that does not exist for oral E2, only for oral CEE (and that risk is not statistically significant). Still, I continuously hear that we should use only transdermal E2 over oral E2. This is why the most powerful ongoing RCT (ELITE) uses only oral E2 and not transdermal E2.
This concept also applies to testing hormones levels. Physicians are typically taught that if a serum level of a hormone is within a normal range, then that is all that is required. However, the medical literature refutes that concept as many patients, both men and women, will feel and function better when their levels are raised or brought to optimal levels rather than normal levels. Understanding this requires review of studies that prove a receptor site resistance, or cellular hypofunction, as is commonly understood with insulin resistance but is also present with other hormones as well. The literature provides evidence that normal is an average of a population whereas optimal is what the medical literature proves is best for you. Physicians must be taught to recognize the difference between normal and optimal hormone levels and the benefits of optimization as demonstrated by cur- rent medical studies.
Most compounding pharmacies have begun dispensing newer, cheaper yam-based estrogen (as opposed to soy-based), but physicians fail to test serum levels of hormones and thereby cannot guarantee a therapeutic serum level of estradiol, not realizing that yam sources of the estrogen prevent attaining a therapeutic level due to poor absorption and lack of micronization. Also, using a transdermal E2 that does not provide adequate serum levels, or using estriol in preference to E2 that provides no in- creased level of E2, will forego all of the protective musculoskeletal and cardiovascular benefits of estrogen. Many physicians promote the use of transdermal progesterone that does not provide adequate therapeutic serum levels for breast and uterine protection as per some peer-reviewed studies. Other hormone levels such as progesterone are also critical to maintain at optimal levels. In fact, the only substance shown to prevent breast cancer is progesterone, but only if high optimal serum levels are maintained. Failure to maintain these serum levels puts women at risk for breast and uterine cancer—and it must be serum levels that we optimize and not saliva levels. Many studies demonstrate that therapeutic levels of progesterone in saliva are worthless in protecting breast and uterine tissue.
Progesterone is also being promoted and used by some pharmacists and physicians for prostate protection in men, whereas there no basis in fact for its use in men. On the contrary, medical literature shows that progesterone use in men has been a successful “salt peter” and increases instances of erectile dysfunction and loss of libido. Prescribing progesterone to men has also demonstrated increased vascular inflammation and risk of MI and CVA, which is the opposite of the effect seen in women. The “Y” chromosome seems incompatible with progesterone, making it harmful to men in spite of the protective benefits seen in women. Unfortunately, most physicians and pharmacists remain unaware of the phenomena associated with the various sources, forms and levels of these and other hormones. Pharmacists, physicians, and patients alike trust that all hormones dispensed are beneficial and therapeutic. However, when serum levels are tested and significantly low levels are found; this can attest to the failure of some compounded hormones to provide any benefit in spite of all the claims, which is also why ACOG and NAMS caution against BHRT.
The goal of my lectures and teaching seminars is not only to provide the physician with evidence-based literature to guide our therapy, but also to provide research that discredits commonly accepted but misguided therapies. This provides confidence and credence for the therapy the public is now demanding. To assure benefit, they must conform to the scientific standards set forth in our literature. Do not assume that any bioidentical hormone prescribed provides protective levels or is of any benefit. Physicians must ascertain that the compounding pharma- cy they recommend to their patients is a quality PCAB accredited pharmacy. The only method of assuring adequacy of compounding pharmacies is to brazenly ask questions about quality standards and processes. In addition, the only method of assuring adequacy or benefit of a therapy is by measuring biologic endpoints, or serum markers, as is carried out in the NIH trials. Monitoring therapy and assuring adequate replacement that conforms to FDA standards should be a priority of every physician and pharmacist in order to make this therapy credible. Whatever protocol one might choose, one should then follow those research protocols that support the validity of our therapy, and then copy it to assure therapy efficacy.
Through my continuous, intensive search of the scientific liter- ature, I’ve been able to design the BHRT lectures and courses to encourage rethinking our customary practice due to data or studies that support the opposite of what some academies practice or teach based on misleading articles and studies. The lectures and seminars that I teach are a potpourri of fun and interesting articles from the top peer-reviewed medical journals without bias or hidden agenda. The intent is to provide evidence-based literature to challenge our thinking, guide our practice, and prove that commonly prescribed therapies dispensed by many physicians may be harmful or lack efficacy and should be changed to conform to industry and peer-reviewed standards. The physician reviews that follow further explain the intensity of the courses and past experiences of attendees.
My Fellow Colleagues, The agenda, schedule, faculty, location and amenities for the new Worldlink Medical Course have finally come to fruition. Many of you asked for a Part V and many others asked for different topics related to lifestyle, preventive medicine, vitamins and supplements, and perhaps something beyond just hormones. So Dana Burnett has put together a faculty to do just that.
Welcome to our newest course: Beyond Hormones for 21st Century Wellness Medicine
Attending the BHRT series is NOT a requirement to attend this course, and it includes all-new material that we are excited to bring you. As the Faculty Chairman for this event we combined new topics on the gut, the microbiome, and inflammatory issues that oftentimes not only prevent hormones from doing their job, but also wreak havoc on many other body systems. Dr. Dirk Parvus will explore what to look for, how to diagnose and treat, and how to prevent inflammatory conditions that we so commonly see but don’t understand how to treat. And no discussion would be complete without the evidence-based research to support what we do, as has always been our mantra in the past.
As for me, I get to spend time on fun stuff (topics) I never seem to get to in Parts I – IV, namely growth hormone and everything you could possibly want to know about this important hormone. HGH will be split into diagnosing, treating and adjusting with complex case studies. There is a plethora of medical data that demonstrate benefits we should all be aware of. We will look at the attempt of the FDA and AACE to limit and restrict use of HGH based on extrapolation of a law that does not apply to physicians, but is often quoted as to make everyone think that HGH is illegal to prescribe. We proved in court that is not the case and we will review those legal proceedings.
Speaking of legal issues, they are most uncomfortable for physicians to deal with and dissect. I would prefer to just pretend that I will be lucky enough to avoid legal issues. Although it is painful for physicians to review, we all should be aware of the legal arena surrounding HRT and how best to document and prepare our practices to be bullet proof, both for legal defense and, more importantly, to use to teach our colleagues a scientific method rather than what they heard or were taught. That still may not prevent lightning from striking so I will review the most common cases now making the rounds, and how I have defended them using the medical literature provided during this review. We must use science and literature to defend how we practice and protect the lives of our patients despite the legal profession using recent guidelines to bring suit. Plaintiffs’ attorneys wish they would have never met me! Important issues pertaining to HRT commonly addressed by opposing attorneys (which I will counter in the medical literature review) are concerns about AACE guidelines which restrict use, concerns that testosterone causes blood clots that polycythemia is harmful, and that estradiol levels should be monitored and lowered to prevent the harm of elevated estrogen. Each one of the aforementioned is so important that I will provide separate lectures on each.
• Levels are meaningless for symptom improvement and diagnosis.
• More in depth review of polychthemia and lack of harm of erythrocytosis.• More review of articles on estrogen in men.
• How I used the articles to prove to a jury that the hematologist was wrong.
Next, let’s get really good at interpreting the medical literature. I find it so fascinating that physicians can continuously misinterpret medical studies and the results of those studies. I hated statistical analysis taught in my training. However, we will make it fun to analyze and critique studies before looking at the conclusions. Almost every study has an agenda, a bias, and a purpose for being published which makes me leery of any study, thereby making it necessary to understand the methods and bias before even reading a study. The more we review and understand medical literature, the better we are able to extract meaning and purpose of our science. We should all be able to speak and defend our therapy with confidence and this review will better enable us to confidently defend the work we do as we look to grow this field. I for one cannot do this work alone. You all play a vital role in how we take care of root causes and provide preventive care to our patients.
Finally, no 21st Century medical discussion would be complete without an update on stem cells. I am the proud recipient of several stem cell injections and will share my knowledge along with Dr. Herman Pang’s experience with stem cells.
I am so excited for this debut event and hope you plan to join us October 7-9, 2016, in San Antonio, TX. Let’s make it a reunion event! I hope to have dinner discussions featuring those of you who wish to tell us unusual and profound success stories. Dana needs to know numbers early, therefore she is offering a super early bird discount of $895.00 if you register by March 31st, See you all later this year for this inaugural Worldlink Medical event.
If you want to think, feel, act, respond, perform, heal, exercise, and function the way you used to, then hormone replacement (HRT) is your answer. If you want to improve your skin, aesthetics (maintain muscle and burn fat), and look the way you used to, then HRT is your only option. If you want to regain strength, energy, endurance, and recovery, then HRT is you only hope. If you want to improve health, wellness, longevity, quality of life, then HRT is a must. If you want to improve libido, sexual response, erectile function, and orgasmic ability for both you and your spouse, then you both need to be on hormones. If you want to live a longer, happier, healthier life with less morbidity (increased health span), then HRT is for you. If you want to offer these same quality of life benefits for your patients, then you need to incorporate this into your practice. If you want to get it back again, then you must optimize all of your hormones. Sound far-fetched? Not according to the medical literature. There is tremendous scientific support in our medical literature demonstrating the benefits of hormone optimization which is termed anti-aging, age management medicine, or simply preventive medicine. This medical information is in so much demand by the public, yet it is ignored by physicians.
This presentation reviews the importance of HRT. What it is, what it isn't, and what it does from a scientific standpoint. Peer reviewed medical research is extensively reviewed to demonstrate all that is known in our literature, yet not embraced or utilized by most physicians and medical academies. This new trend in medicine will be reviewed and analyzed as to the validity of the claims and to enable you to understand the importance of this therapy for both you and your patients. There is no better compliment to your practice. Dr. Rouzier will explain how the practice of age management medicine has changed his practice of medicine, his life, the lives of his patients, and the lives and medical practice for so many of past course attendees.
1) Review the new trend in medicine of optimal hormone replacement therapy.
2) Review the co-morbidities associated with low hormone levels.
3) Discuss the scientific basis behind optimal hormone replacement = life extension = anti-aging = preventive medicine = age management medicine.
4) Discuss the patient and consumer demands as well as awareness as to how any physician can incorporate age management medicine into their medical practice.
5) Evaluate medical studies as they pertain to optimizing thyroid, estrogen, progesterone, DHEA, and testosterone and the resultant effects on health, wellness, debility, obesity and longevity.
6) Interpret labs, establish protocols and manage cases.
7) "Monday morning ready" to start treating your patients.
Neal Rouzier's Interesting Case Studies
These interesting and informative Case Studies were pulled and submitted by Neal Rouzier.
Questions will by typed out and just hover over the "answer" text to see what Neal has to say.
Doctor I’m bleeding!
A 45 year old pre-menopausal woman presents with prolonged periods and heavy bleeding. Ultrasound shows no fibroids or polyps. Endometrial stripe is normal and endometrial biopsy is negative. Any endometrial pathology has therefore been excluded. What is the treatment to diminish bleeding acutely?
1) BCP's 2) Progesterone in high doses 3) Mirena 4) IUD 5) Tranexamic acid (Lysteda) 6) Uterine (endometrial) ablation
Question: Amenorrhea vs. Anovulation
Your 21 year old daughter, a track star, has had no period for 2 years. No symptoms, hot flashes or night sweats or hormonal complaints. Recent OB-GYN tested DEXA and found T-score of -2.4. PMD gave her BCP’s to protect her bones. She doesn’t wish to take and refuses BCP’s. How would you treat your daughter? If it was you, how would you treat yourself?
Question: An 80 year old female presents with history of vaginal bleed and endometrial proliferation. The endometrial stripe measures 0.9 cm: biopsy is negative. Patient can’t stop estrogen due to vasomotor symptoms and osteoporosis. She did not tolerate Provera 5mg by PMD. What is the treatment plan?
Question: A 52 year old female presents with severe hot flashes. Her FSH = 56 and her estradiol = 210. What is the treatment plan?
Question: A 44 year old female on BCP’s for PCOS, present with PMS, fatigue, headaches and no libido. Her total testosterone = 90 (high) and her free testosterone = 0.2 (low). What is the treatment plan?
Have other interesting cases, feel free to send them along. Hope this is helpful and hope to see you soon at another Worldlink event.
– Neal Rouzier, MD
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