Part IV in the BHRT Workshop Series
MASTERING THE PRACTICE FOR HORMONE OPTIMIZATION
Mastering the Protocols for Optimization of Hormone Therapy
Although there are new articles, research, updates, literature critiques, and sarcasm (of course) presented in BHRT Workshop Series, Part IV, the majority of this workshop will focus on problem solving, case management, mistakes to avoid, and learning more “tricks of the trade”. The audience comprises healthcare providers with significant experience, questions, and concerns, making for a memorable experience for participants who are seeking to learn more.
The workshop will involve several components, including reviewing the latest NAMS recommendations. The medical literature will be used to support decision making rather than sole reliance on the WHI trial. Some of the exciting topics to be discussed include:
- Treatments for common gynecological issues (severe PMS, migraines, endometriosis, and abnormal bleeding, such as heavy bleeding, irregular menses, etc.)
- TBIs and Hypopituitarism – diagnosis and treatment
- Advanced prostate cancer treatment protocols (i.e – BAT therapy, proton gun, external beam radiation, etc.)
- Alternative treatments for vaginal atrophy and orgasmic disorders in women (testosterone, oxytocin, etc.)
- Male orgasmic disorders and treatments (topical testosterone applied to the glans of the penis, oxytocin spray, etc.)
The workshop will also provide an in-depth review of the evolution of opinion on testosterone replacement therapy, from the belief that it causes prostate cancer to its role in possibly protecting against cancer and how it may even be used to treat active cancer in some men and women.
Access: This workshop is offered in-person and/or virtually. You can choose if you would like to be shipped printed educational materials. We will also post a recording for each day that same evening. The recording will be available until Thursday of the week after the event to re-watch or catch up on anything you may have missed, but it will not be available after this time.
Accreditation: 20 AMA PRA Category 1 Credits | 20 Nursing Contact Hours (20 pharmacologic hours) | 20 Hours Pharmacy Credit (knowledge based)
Upon completion of this workshop the health care professional will be able to:
- Review prognosis and complications for radical prostatectomy, proton gun radiation therapy, brachytherapy, cryotherapy, HIFU, laser ablation, as well as associated costs.
- Review management strategies and importance of testosterone utilization in prostate cancer survivors, as well as literature support. Learn the various mechanisms by which estrogen stops prostate cancer growth.
- 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?
- Recognize that higher thyroid hormone levels are best, as recent studies determine that high TSH levels are associated with increased arterial stiffness and plaque thereby increasing CVD risk.
- 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.
- Recognize that some studies show high testosterone levels in women are associated with an increased risk of breast cancer. Also, understand that other studies demonstrate 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.
- Recognizing high estrogen in men is 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.
- Evaluate and discuss Dr. Neal Rouzier’s 50 most difficult management cases involving HRT, in addition to evaluating abnormal lab tests and various symptoms in complex and confusing cases.
- Identify current approaches to managing vaginal bleeding, DUB, and endometrial hyperplasia, as well as reviewing the dosing and administration of Tranexamic Acid to stop your patients from bleeding.
- Identify how Traumatic Brain Injury (TBI) affects quality of life by causing pituitary dysfunction. Also, learn when/how to test for it and how to not miss it.
- Evaluate recent literature demonstrating the mechanism by which synthetic progestins increase breast cancer development through the production of the RANKL protein.
- 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.
- Evaluate when to use estrogen in premenopausal women and when not to use it: anovulation vs. amenorrhea.
- Identify different types of estrogen and progesterone and when to prescribe each.
- Review various scenarios that dictate when to switch to alternate forms of HRT based on patient history, BMI, risks, and compliance.
- Discuss hair loss in women and current approaches to reverse hair loss.
- Describe various alternatives for testosterone administration in women.
- Discuss the current approach to preventing CVD in women with Syndrome W (X).
- Discuss HRT review, myths, updates, and alternatives when the standard routine is ineffective. Review management strategies for estrogen intolerance and progesterone intolerance.
- Identify current recommendations from NAMS for HRT and ERT and how they differ from past recommendations.
- Review the history as to why the medical community believes testosterone causes prostate cancer.
- Review further data demonstrating that E2 is the best estrogen but not the safest.
- Discuss the most recent FDA BBW for testosterone as it pertains to MI, CVA, and DVT, as well as a literature review of Spironolactone and its BBW.
- Engage in discussions among workshop 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 treatment protocols.
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
In support of improving patient care, this activity has been planned and implemented by The Foundation for Care Management (FCM) and Worldlink Medical. FCM is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team
20 AMA PRA Category 1 for CME
20 Nursing Contact Hours
20 Contact hours Pharmacy Credit. Program # XXXX-XXXX-XXX-XXX-X
This activity was planned by and for the healthcare team, and learners will receive (20 hours) Interprofessional Continuing Education (IPCE) credit for learning and change.
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