Part IV in the BHRT Workshop Series
MASTERING THE PRACTICE FOR HORMONE OPTIMIZATION
Mastering the Protocols for Optimization of Hormone Therapy
One would think that 3 courses on HRT would be all that is needed to adequately practice BHRT. However, attendees have requested that they want more, but with more complexity and problem solving as opposed to didactic. Hence Part IV.
Although there are new articles, research, updates, literature critiques, and sarcasm (of course), the majority of this course will be problem solving, case management, mistakes to avoid, and tricks of the trade. The audience will consist of those with significant experience, questions, and issues that make for an excellent experience for both me and participants as we all learn from patients and ourselves. Extensive literature review in Parts I, II, & III have not allowed me to present all the interesting and complicated cases and situations that I have encountered in the last 15 years of practice. I have included 60 of my most complex and problematic cases from the last 15 years but it will require you to have masterful understanding of Parts I, II, and III in order to understand the reasoning behind the treatment and management of these problematic cases.
First, we will review the latest NAMS recommendations. It is a step in the right direction. However, I will use the medical literature to, of course, prove to them what they should have said and done as opposed to their sole reliance on the WHI trial. It should be the summation of all available data that should dictate our treatment, not just one study. We will then review the evolution from testosterone causes prostate cancer to maybe it protects against cancer to now where we prescribe it to men with active cancer. Although commonly (incorrectly) thought to cause prostate cancer, estrogen has been a mainstay to treat and protect against prostate cancer. In fact, it may be through aromatization that testosterone can protect against prostate cancer. We will also review at what level of estradiol results in a flip of the lipids that then become cardio-protective. Although it has been customary and fashionable to utilize aromatase inhibitors to block aromatization of testosterone to estrogen, the most recent study demonstrates using an AI increases gynecomastia, visceral and subq fat, cholesterol, and sexual dysfunction.
Please read the agenda and course outline for a more complete synopsis of topics and objectives. So, bring your tough cases, comments, thoughts and ideas and have another fun weekend with your talented peers. This will be a collection of the most talented and experienced physicians in this industry. Caution: Part IV will be thought provoking, intense, and very complex.
This course is offered as in-person and via live stream, choose your preference during the registration process. We will also post the recording each evening for that day. The recording will be available till Thursday of the week after the event to re-watch or catch anything you may have missed. It will NOT be available after this time.
Upon completion of this workshop the health care professional will be able to:
1) Review prognosis and complications for radical prostatectomy, proton gun radiation therapy, brachytherapy, cryotherapy, HIFU, laser ablation, as well as costs.
2) Review management strategies and importance of testosterone utilization in prostate cancer survivors as well as literature support, in addition to the various mechanisms of estrogen’s ability to stop prostate cancer growth.
3) Evaluate the association of testosterone and estradiol levels and the risk of developing prostate cancer. Should we raise, block, or administer estrogen based on the literature?
4) Recognize that optimal thyroid levels are best as recent studies determine that high TSH levels are associated with increased arterial stiffness and plaque thereby increasing CVD risk.
5) Review the recent NAMS position statements that further distinguish the emerging differences in the therapeutic benefit-risk ratio between ERT & HRT at various ages and time intervals from onset of menopause.
6) Recognize high testosterone levels in women are associated with an increased risk of breast cancer. Also understand that studies show testosterone administration is protective against breast cancer and is apoptotic to cancer cells. This demonstrates that association does not prove causation and one should not extrapolate them to be the same.
7) Recognize high estrogen levels in men are associated with increased cardiovascular risk. However estrogen administration in men protects against heart disease and prostate cancer. This demonstrates another example where association does not imply causation.
8) Evaluate and discuss my 50 most difficult management cases involving HRT, in addition to evaluating abnormal lab tests and various symptoms in complex and confusing cases.
9) Identify current approaches to manage vaginal bleeding, DUB, and endometrial hyperplasia as well as reviewing the dosing and administration of Tranexamic Acid to stop your patients from bleeding.
10) Identify how Traumatic Brain Injury affects quality of life by pituitary dysfunction: When and how to test and not miss it.
11) Evaluate recent literature demonstrating the mechanism by which synthetic progestins increase breast cancer development through the production of the RANKL protein.
12) Utilize dual intravaginal therapy to maximize the effect on atrophic vaginitis, chronic UTI, incontinence, and sexual dysfunction as well as how to treat the vagina with pills, patches, ring and things.
13) Evaluate when to use estrogen in premenopausal women and when not to use it: Anovulation vs. amenorrhea.
14) Identify different types of estrogen and progesterone and when to prescribe each.
15) Review various scenarios that dictate when to switch to alternate forms of HRT, based on history, BMI, risks, and compliance.
16) Discuss Hair loss in women: Current approach to reverse hair loss.
17) Describe various alternatives in testosterone administration in women.
18) Discuss the current approach to preventing CVD in women with Syndrome W (X)..
19) Discuss HRT review, myths, updates, alternatives when the usual routine doesn’t work and review management strategies for estrogen intolerance and progesterone intolerance.
20) Identify current recommendations from NAMS for HRT and ERT and how they differ from past recommendations.
21) Review the history as to why the world believes testosterone causes prostate cancer.
22) Review further data demonstrating that E2 is the best estrogen but not the safest.
23) Discuss the most recent FDA BBW for testosterone as it pertains to MI, CVA, and DVT and literature review of Spironolactone and its BBW.
24) Engage in discussions among conference participants on how these topics are used by physicians and nurses working in a clinic or independently. In addition, include pharmacists and their experience working with providers for hormone therapy to ensure synergy in prescribing, monitoring and adjusting
Neal Rouzier, MD
Dr. Neal Rouzier is a pioneer in the bio identical hormone replacement field, practicing almost since its inception in the early 1990’s. He has dedicated his life’s work to uncovering the medical literature that supports safe and effective protocols for unique and personalized patient care. He is the Director of the Preventive Medicine Clinics of the Desert, specializing in the medical management of aging and preventive care for men and women. He has treated more than 2,000 patients with natural hormone replacement therapy and is recognized as a renowned leader and expert in the field. Additionally, Dr. Rouzier is the author of Natural Hormone Replacement for Men and Women: How to Achieve Healthy Aging. He has over 16 years of experience as an educator and practicing physician, and 29 years of Emergency Medicine experience at Queen of the Valley Hospital in West Covina, CA.
7:00 – 8:00 am
Section 1: 35 Q & A
- Risks of PCOS and treatment to prevent complications.
- Relative risks of P4 and clotting.
- Effects of oral P4 on estradiol levels and effects of SL P4 on weight.
- Relative risks of estradiol levels and prostate CA.
- Appreciate a literature review of which type of estrogen to use in which circumstances and why. Oral vs transdermal, risks vs. benefits, and recent NIH studies.
- Evaluate the most important literature summary chapter on estrogen and progesterone that you will ever read proving the harm of estrogen deprivation and the benefit of replacement = a must for everyone’s library.
- Review all the long-term studies demonstrating the effect of estrogen on morbidity and mortality and the pathophysiology behind it all.
- Determine how to assess studies of association that do not prove causation in contrast to RCT’s that prove causation through interventional study.
- Do not extrapolate to prove a theory as one must intervene to prove causality.
10:15 -11:15 a.m.
Section 2: 39 Q & A:
Estrogen in men for CVD protection and that cause CVD.
- Understand the risks of estrogen deprivation in men and importance of SHBG.
- Learn the importance of fatty acid esters in CVD protection and how to increase them.
- All hormones provide CVD protection in the correct form.
11:15 – 12:15 p.m.
Estrogen in men: Good, bad, or indifferent?
- Review the studies demonstrating estrogen is associated with an increased risk of heart disease and cancer in women as well as heart disease in men = an association.
- Review the extensive literature on the beneficial effect of estrogen in men in the treatment and prevention of prostate cancer and heart disease = proves benefit= causation.
- Understand the various methods for raising estrogen in men and consequences of each.
- Evaluating the literature and understanding the difference between cause and effect and how it pertains to hormones.
- Discuss how association does not prove causation and to prove this requires the need for RCT’s to differentiate.
- Practice HRT according to the EBM and not confabulation = don’t lower estrogen.
- Learn how to increase visceral fat, decrease libido, increase lipids, and increase dementia through aromatase inhibitors as per NEJM.
12:15 – 1:15 p.m. Lunch
1:15 – 2:15 p.m.
Section 3: 43 Q & A:
- Methods to increase risk of depression and how to avoid it.
- Amenorrhea vs. anovulation, work-up, diagnosis & treatment.
- Breast proliferation markers and how to reduce them with HRT.
- Treatment of endometrial proliferation. Easy Treatment made easy for “no man’s land.” Evaluating the various effects of SHBG in HRT.
Review the historical perspective of testosterone causing prostate CA or how easily we can be lead astray.
- Understand how Huggins was correct in his assumption but also very wrong in his conclusion. Huggins led us astray with just one patient!
- What level of testosterone is conducive to the growth of prostate cancer?
- What level of testosterone is safest to maintain for prostate cancer protection?
- Is it possible or safe to utilize testosterone in prostate cancer survivors and at what point in time?
- Using testosterone in men with active cancer? What does the literature support and under what circumstances.
- Understand the complexity of the saturation model that is demonstrated in the world’s literature.
- Does testosterone cause prostate cancer or does it not? Well it depends. Yes it does but treatment does not, rather endogenous does but exogenous does not.
- Review of the meta-analysis and world’s expert opinions.
3:15 – 3:30 Break
3:30 – 4:30 p.m.
Section 4: 23 Q & A:
Treatment for high TSH and high Free T3. Really, what is estrogen dominance and is it really IR in disguise?
- Hair loss in men vs. hair loss in women.
- Blood donation with use of HGH, testosterone, finasteride.
- When to use estrogen in premenopausal women and when not to.
- When to measure it and when not to.
4:30 – 5:30 pm
Review the new NAMS recommendations for HRT with comparison of past recommendations- understanding why the change in attitude.
- Evaluate whether they utilize all current literature on which to base their recommendations or are they still stuck on the WHI? My critique and commentary follows.
- Discuss the pathophysiology of estrogen deprivation and biology of estrogen replacement.
- Describe the nonsensical use of long-term of estrogen blockade in women.
5:30 – 6:30 pm
Section 5: 31 Q & A
40 case scenarios requiring alternate types of hormones.
- Which vaginal estrogen to use, when, and why.
- TOC for vaginal atrophy and UTI. Work-up and treatment for vaginal bleeding. Alternative treatment for excessive, non-pathological vaginal bleeding (DUB).
- Vaginal estrogen troche, pills, patches, rings and things to protect the vagina.
8:00 – 9:00 a.m.
Look at the advanced treatment of the vagina and how to make it work better with estrogen, DHEA, and Oxytocin.
- Review of the literature of further treatment of sexual dysfunction, both for women and men using Oxytocin.
Review the diagnosis and treatment of prostate cancer-state of the art with MRI-S and laser ablation.
- Discuss treatment centers, procedures, side effects, and costs of ablation vs HIFU.
- Other treatment modalities for prostate cancer vs. newer treatments not covered by insurance.
- Relative Risks of HRT in comparison with standard drug regimens for other illnesses- HRT is really quite safe in comparison with commonly prescribed medicines.
- Review the detriments of estrogen blockade and benefits of testosterone and estrogen replacement in men.
- Case presentation of before and after MRI laser ablation with lab review. What values to shoot for when treating with estrogen. A virtual reality of lab values when treating with estrogen.
9:00 – 10:00 a.m.
Section 6: 27 Q & A
Interesting HRT cases and how to solve the mysteries.
- Serum sickness from testosterone, diagnosis, treatment, avoidance.
- Treatment of young men with hormones can be life-saving also.
- Alternative testosterone treatments for women and how to reduce side effects and improve compliance.
- Lab review with case management for problems with lab values and how to manage the complicated and confusing cases.
Discuss new insights into thyroid hormone replacement.
- Discuss use of T3 alone and what it does to lab values.
- Review the studies demonstrating genetics (DIO2 gene) predict response to T3 that explains the wide range of responsiveness.
- Discuss the plethora of data from pharmaceutical studies that prove that T3 is worthless and not needed.
- Explain how to design a study to prove that T3 does not work.
- Discuss why athyreotic patients don’t do well on T4.
- Thyroid for ED?
- Review the recent Medco advisory to stop Armour thyroid.
11:15 – 12:15 p.m.
Section 7: 74 Q & A:
Optimal levels of estrogen and progesterone in men.
- Alternative methods of testosterone administration in men.
- The ins and outs of PCOS, harm, prevention.
- HRT cycling?
- HRT and fertility, what to advise.
- Function of inhibin and treatment of loss.
- HGH and mitosis vs. apoptosis.
- Side effects of estrogen and treatment. Use of metabolites and DIM.
- Treatment of erythrocytosis for pre-surgery clearance.
12:15 – 1:15 Lunch
1:15 – 2:15 pm
An entertaining review of HRT literature and the use of statistics to change outcomes or what the investigators should not have done with the numbers.
- HRT-Real Concerns and False Alarms: Understanding statistics of the WHI and how they make no sense on re-evaluation.
- Traumatic Brain Injury and pituitary insufficiency that everyone misses.
2:15 – 3:15 p.m.
- Review the treatment for common side effects/complications of HRT.
- Evaluate different treatment options for heavy menstrual bleeding (dysfunctional uterine bleed or DUB) in pre-menopausal women.
- Discuss work-up and various treatment modalities including tranexamic acid (Lysteda) to decrease fibrinolysis.
- Evaluation and management with laboratory work-up to assist in the diagnosis of postmenopausal vaginal bleed.
- Review complex estrogen lab levels, that don’t make sense and why, and various treatment options.
- Understand the treatment of a man with prostate cancer, both active and cured.
3:15 – 3:30 pm
3:30 – 5:30 pm
How high can one go with estrogen therapy to treat sub-therapeutic levels? Why do you fear it? A lab review with various doses and corresponding estradiol levels.
- Review the latest NAMS article deciphering the safety and efficacy of HRT in comparison with other commonly used medications.
- Understand the difference in mortality when comparing estrogen vs. statins vs. ASA for cardiovascular protection.
- Review which medicines reverse plaque and which ones don’t.
- Evaluate the various studies showing increased breast cancer with statins in comparison with HRT/ERT.
- Review which hormone/med provides the best protection against CVD mortality as well as all-cause mortality and which hormone/med increase mortality.
- Update and evaluate breast markers and MPA vs. OMP.
- Study the mechanism behind Provera and Depo-provera in stimulating the RANKYL protein and the subsequent increase in breast cancer risk.
- Review why and how to block RANKYL with Denosumab.
7:30 – 8:00 a.m.
8:00 – 9:00 a.m.
Final review of the testosterone studies demonstrating testosterone causes an increase in MI. Letters to patients and doctors.
- How to CYA when prescribing testosterone and what to add to your consent forms.
9:15 – 11:00 a.m.
50 complex cases, treatment and management.
Section L: Q & A
Questions and answers with case reviews from articles from Part IV:
- What is the course of action to take when women report weight gain after starting HRT?
- What is the course of action to take when women report progesterone intolerance?
- A patient with an elevated PSA has a (-) TRUS biopsy. So now what?
- So what makes you the prostate cancer expert?
- Your BHRT patient of 15 years suffers an MI which results in her cardiologist taking her off HRT. Should she be off HRT or on HRT? What the PMD won’t understand and doesn’t know.
- At what point can hormones be resumed after a diagnosis of CA prostate, breast, uterus, and ovary?
- What is the appropriate treatment to block progesterone in a patient with a progesterone receptor site (+) breast cancer who is a normally menstruating 45 y/o female on Tamoxifen? What if the chemo resulted in loss of menstruation and ovulation and she developed endometrial proliferation from Tamoxifen?
- Review cases demonstrating when and when not to use oral E2.
- Which E2 does one use in older men with heart disease that also have prostate cancer and are very symptomatic on Casodex and Lupron?
- When to transition from oral estrogen to transdermal and vice versa and whether it differs in men or women?
- Why use oral E2, P4, and testosterone for Syndrome X and not transdermal? Think SHBG, weight gain, and hirsutism respectively.
- Why use oral P4 and oral testosterone in older women? Think about saliva and compliance.
- What is the appropriate treatment for endometrial hyperplasia in postmenopausal women on Tamoxifen?
12 pm: Adjourn
AMA PRA Category 1 Statement
This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the Foundation for Care Management (FCM) and Worldlink Medical. The Foundation for Care Management is accredited by the ACCME to provide continuing medical education for physicians.
FCM designates this educational activity for a maximum of 21 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in this activity.
The ACCME defines a “Commercial Interest” as any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.
Foundation for Care Management is accredited as a provider of nursing continuing professional development
by the American Nurses Credentialing Center’s Commission on Accreditation.
The Foundation for Care Management is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. Program # 0347-9999-20-004-L01-P Objectives appropriate for pharmacists. This activity is 21 Contact Hours Pharmacy Credit. *This CME is Knowledge Based (K). Initial release June 26, 2020
- The Foundation for Care Management cannot provide a statement of credit unless an evaluation form has been filled out online. Please go to fcmcme.org to access the evaluation form.
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