Physicians Guide - CSS Salivary Hormones

Transcription

1 Physicians Guide - CSS Salivary Hormones REV C

2 From My Perspective From My Perspective... by Jamie Wright DO, FACOOG, ABAARM Dr. Wright is an expert in hormone therapy and metabolic medicine and has shared some brief examples of how he uses our hormone test panels. Although there is no right way to use these tests, we hope that you benefit from his perspective and extensive clinical experience with hormone therapy. We look forward to supporting you with future educational programs as you seek to enhance your clinical expertise to help your clients achieve wellbeing! - Cell Science Systems, Corp. 1. Female Cycle Profile (12 tubes) 12 x E2, 12 x Progesterone, 4 x Testosterone Clinical: Endometriosis; PCOS; severe or atypical PMDD; complex patient with unpredictable symptoms throughout her cycle. Remember, hormone imbalance can affect the NeuroEndocrine- Immune Axis, therefore, multiple body systems may appear to be involved. Use the hormone data in context of other laboratory data such as ALCAT food sensitivity testing, comprehensive thyroid testing, and other modalities that you may have experience with. Clinical Vignette Mary is a 37 year old G4P4 who has been experiencing a variety of symptoms. She believes that she may be experiencing hormone problems. Her menstrual cycle is days, no significant changes over the past 3 years. She does not have substantial clotting or pain with menses. She notes that her libido has declined markedly since the birth of her fourth child at age 34. Fatigue has been worsening over the past 2 years and has become quite profound in the past 6 months. She has also begun to experience periodic episodes of depression and anxiety, insomnia, increased abdominal adiposity, bladder frequency and urgency, and occasional pain with sexual intercourse. Her physician has done a workup and determined that she is normal. Although she is unable to relate symptoms to a particular timing of her menstrual cycle, a detailed history reveals that she had similar, more mild, episodes of dyspareunia, dysuria, and anxiety in her late teens and early 20s. ese symptoms seemed to improve with pregnancy and breast feeding. Considerations is case history does not fit any particular clinical scenario, but considerations can be made for endometriosis, adenomyosis, fibroid uterus, interstitial cystitis, and premenstrual dysphoric disorder. I would recommend a Female Cycle Profile primarily because of the lack of clear timing of her symptoms with the menstrual cycle and the wide variety of symptoms she is complaining of. It is essential that the patient record pelvic, bladder, and mood symptoms (in detail) by menstrual day throughout the entire saliva collection. is will allow you and your patient to potentially correlate the hormone results with her symptoms, or rule out certain symptoms as being likely related to hormone imbalance. You don t want to focus on hormones when they may not be the driver of the problem. 2. Menopause Evaluation Profile (3 tubes) 3 x E2, 3 x DHEA-S, 3 x Progesterone, 3 x Testosterone Clinical: pre-hrt or managing HRT, experiencing typical peri-menopausal symptoms, post-menopause, or patient with a predictable symptoms of hormone imbalance Clinical Vignette Stephanie is a 44 year old business owner and peak performer. Over the past year she has noticed more fatigue and brain fog than she would expect. Her menstrual cycle length is 31 days and unchanged for years. She is experiencing heavier menses and some clotting, which are not particularly troublesome for her, although she would like to improve this if possible. e most problematic symptom that she is experiencing is a major mood shift during the second half of her menstrual cycle. In gathering more detail, she typically experiences increased energy and vitality around cycle day 12-16, then fatigue from cycle day 17-21, then a very dark mood cycle days She improves some until the onset of her period. She wants your advice: Could this be my hormones? Considerations Yes, it could very well be your hormones! Stephanie is in a very vulnerable time hormonally. Post-ovulatory (luteal phase) progesterone production may not be as robust as in prior years. e effects of stress demand on progesterone for synthesis of cortisol are likely to have a larger impact on her menstrual cycle, mood, and bleeding patterns than in prior years. Why? Her symptoms are quite predictable so we can time the ~ 1 ~

3 From My Perspective collection of her saliva sample to give us a valid clinical picture of her hormone levels at the time that we choose. I will generally time the hormone samples in an attempt to document and compare hormone balance as well as imbalance, based on the patients symptoms. In Stephanie s case, I would like to collect a sample at the time of ovulation (cycle day 14), during her worst mood day (one collection between cycle day 21-25), and one sample when she has improved, but before the next period begins. ese samples will allow us to compare her hormone balance, correlate it with her symptoms, and create a flexible effective replacement strategy with a reasonable dose at the times of need. Other candidates for the Menopause Evaluation Profile are women who are post-menopausal, transitioning into menopause (peri-menopause), and those on hormone replacement therapy. 3. Male Hormone Profile (4 tubes) E2, DHEA-S, 4 x Testosterone Clinical: male age >35, obese male of any age, male of any age experiencing sexual dysfunction, poor wound healing, recent fatigue, cardiovascular risk factors or vague depressive feelings. Clinical Vignette Mike is a 33 year old male business executive seeking help with preparation for an upcoming marathon. Mike was struggling with fatigue and exercise recovery, although he has successfully lost over 35lbs. in the past 6 months of training. He has a family history of coronary heart disease and hypertension. Mike s fatigue seems disproportionate to his age and activity levels so a more in-depth workup was performed to evaluate his cardiovascular risk, thyroid function, stress and sex hormone production. Considerations Despite his young age, Mike was found to have multiple cardiovascular risk factors as well as both thyroid and testosterone hormone deficiency. In fact, his testosterone levels were consistent with a normal 60 year old male. e Basic Male Profile is appropriate for Mike and will allow us to see how his hormone levels fluctuate during the day. He also collected sample for the Adrenal Stress Profile to evaluate the effects of stress on cortisol and DHEA production. Hormone replacement in a young male should be used cautiously due to fertility considerations and, for every patient, modalities to support normal hormone production should be encouraged. Stress reduction disciplines, gut health, and fitness training targeting stimulation of human growth hormone production will ensure that you are helping the patient craft a lifestyle of wellness, not simply treating a hormone deficiency. Optimal hormone balance is essential for the reduction in risk of cardio-metabolic disease, abdominal obesity, and immune function. Consider hormone testing in men of any age who have signs of chronic stress, poor healing, risk factors for coronary heart disease and glucose intolerance, fatigue, and simple erectile dysfunction (however, nothing is simple!) 4. Adrenal Stress Profile (6 tubes) 5 x Cortisol (optional 6 th ), DHEA-S Clinical: fatigue, chronic fatigue, post-traumatic stress, stress symptoms, chronic disease or recovery from acute illness Clinical Vignette Robert is a 53 year old OB/GYN who has a history of excellent health. Nine months ago he was hospitalized with acute pyelonephritis. He was subsequently diagnosed with a staghorn renal calculus (large kidney stone). Over the course of a 22 day hospitalization he was given prolonged broad spectrum antibiotics and other medications for pain and nausea. He also underwent both extracorporeal shock wave lithotripsy and surgical removal by ureteroscopic removal. His kidney infection and nephrolithiasis have resolved, however he has never fully recovered his energy and stamina. His physician has documented sterile urine and bloodwork is normal. Robert wonders, Am I crazy? Is there anything I can do to improve my energy?! Considerations Fatigue can be a symptom of many underlying metabolic problems ranging from inflammation, auto-immunity, chronic pain, thyroid imbalance, nutritional deficiencies, and prescription drug use. Robert s case is not as simple as one might think. First, he has been a practicing OB/GYN for 20 years and has endured tremendous chronic stress from sleep deprivation and clinical work. Infection, surgical trauma, and emotional stress related to prolonged hospitalization are significant stressors and we should consider post-traumatic stress disorder. Finally, the prolonged antibiotic exposure and dietary changes during his hospitalization certainly will have had an impact on his gastrointestinal tract and hence his immune system. ~ 2 ~

4 I would select an Adrenal Stress Profile to document Robert s HPA axis via salivary cortisol and DHEA evaluation. Due to his age, Robert is also a candidate for the Basic Male Profile, to evaluate the role that sex hormone deficiency may play in his fatigue and immune status. Remember, DHEA is a growth and healing hormone that complements cortisol output during stress and shields against excess negative cortisol in the body. DHEA is also a precursor of testosterone; therefore, chronic stress can limit the availability of DHEA for conversion to testosterone. Consideration for thyroid evaluation and markers of inflammation would be reasonable as well. Stress hormone assessment will allow you to focus your nutritional and lifestyle recommendations toward, or away from, support of stress hormone production. For instance, if Robert had maintained optimal cortisol and DHEA output despite his ordeal, then you would want to dig deeper and focus your treatment strategy on other systems, such as sex hormones and gastrointestinal health. Testosterone ough testosterone is primarily thought of as a male hormone, this steroid hormone is very important for women s health. Testosterone plays a role in the proper functioning of sex drive, lean muscle mass and strength, bone health, mood, cardiac health, and blood production. For perimenopausal or menopausal women, testosterone is becoming a common part of hormone replacement therapies. Evaluation of testosterone levels is rapidly becoming a standard part of female hormone evaluation by physicians around the world. In men, low testosterone levels have been linked to decreased sex drive, impotence, LOW Testosterone Bone loss Decreased motivation Depression and similar mood disorders Erectile dysfunction (ED) Fatigue General aches and pains Lack of well-being Loss of muscle tone Lower-than-normal libido Obesity, especially abdominal inning skin, especially notable around face ELEVATED Testosterone Acne Changes to voice Insomnia Irritability Moodiness Loss of scalp hair infertility, abnormal breast enlargement, fatigue, depression, lowered motivation, irritability, weight gain, and decreased muscle mass and strength. Testosterone levels in men reach their peak by age 20-30, and decline with each passing decade. Low testosterone has also been implicated in decreasing body hair, shrinking of testes and prostate, increased risk for osteoporosis in men, anemia, and thinning of skin with increased wrinkled development. Excess testosterone and its enzymatic conversion to DHT (dihydrotestosterone) may be a concern when there is a prostate cancer present. Testosterone therapy: creams first, pellets, and injections Inhibit aromatase activity if estrogen is elevated via zinc, anastrazole, and chrysin Antioxidants If SHBG is elevated, decrease levels through increased intake of omega-3 fatty acids, increased dietary protein and decreased soy intake. Reduce insulin resistance, through exercise, better diet choices, and certain supplements (alpha-lipoic acid, omega-3 FA, chromium, cinnamon, gymnema, and corosolic acid) Increase SHBG if low (increase dietary fiber, weight loss, and dietary soy) Optimize thyroid function ~ 3 ~

5 Estrogen Estrogen hormones are essential to health and have a significant role in the body. ese powerful molecules have wide reaching affects and are a strong factor in female sexual development, cardiovascular and skeletal health and the nervous system. Estrogen testing determines the specific level of each estrogen which will help to prevent deficiency or excess, ensuring an optimal and balanced estrogen hormone level. LOW Estrogen Anxiety Bone loss (Recommend biennial bone scans) Depression Dry skin Fatigue Headaches Heart palpitations Hot flashes (often extremely irritating) Insomnia Irregular menses (often heavy) Joint and muscle pains (soft tissue pain syndromes) Low libido Memory challenges Mood swings Unpleasant and sometimes painful intercourse, often associated with severe vaginal dryness ELEVATED Estrogen Autoimmune disease Breast swelling and associated tenderness Depression, with anxiety or agitation Edema Fatigue Food cravings, especially sugars and fats Hypoglycemia episodes Hypothyroidism Insomnia Migraines Weight gain Blood clotting Breast, endometrial, and ovarian cancer Cervical dysplasia Fibrocystic breasts Gall bladder diseases Progesterone-deficient conditions Uterine fibroids Heavy menstrual periods e symptoms resulting from estrogen deficiency include hot flashes, irregular menstruation, mood changes and vaginal dryness. In contrast with estrogen deficiency, elevated estrogen may be associated with migraines, breast tenderness, heavy menstrual periods, water retention and hormone-related cancers and other symptoms. Bio-identical estrogen replacement therapy (creams are recommended and some people prefer pellet implantation) If cream is used, rotate sites to decrease transdermal fatigue. Start low and increase slowly, treating to a level of minimal symptoms such as hot flashes or breast tenderness. Calcium D-glucurate (inhibits Beta-Glucoronidase and helps regulate estrogen metabolism and movement out of the body): Detoxification of gut and liver. Recommend pre biotics (FOS (fructo-oligosaccharides), inulin or fermented vegetables): Alpha lipoic acid Burdock Garlic Glutathione Green tea (EGCG) Hops Milk thistle Resveratrol N-acetyl-cysteine (NAC) Superoxide dismutase (SOD) Turmeric and curcumin Diindolylmethane (DIM) Exercise and better dietary choices/weight Loss Indole-3 carbinol Inhibit aromatase activity (anastrazole, chrysin, zinc) Reduce exposure to xenoestrogens (e.g., bisphenol A and similar compounds) ~ 4 ~

6 Progesterone Progesterone is the other important female hormone. Like estradiol, it is responsible for a normal monthly cycle, and is also important for the health of bone, blood vessels, heart, brain, skin and many other organs. In recent years, we have come to appreciate how important it is to consider this hormone in the treatment of menopausal symptoms, premenstrual syndrome and infertility. Progesterone, like estradiol, plays an important role in mood, blood sugar balance, sex drive and thyroid function, as well as adrenal gland health. Peri and post-menopausal women may monitor the decreasing levels of this hormone that occur with aging and menopause. Cycling women experiencing PMS symptoms due to a hormonal imbalance may also monitor progesterone. LOW Progesterone Acne Anxiety Breast tenderness Depression, especially post-natal Hot flashes Insomnia Joint and muscle pain Low libido Migraines Mood swings Night sweats PMS Pre-Menstrual Symptoms Weight gain Increased Risk Breast disease Infertility Miscarriages Osteopenia and osteoporosis Polycystic ovarian syndrome Vulvar dystrophy ELEVATED Progesterone Breast swelling Candida exacerbations Depression (mild) Drowsiness Estrogen deficiency symptoms GI bloating Inflammation Insulin resistance Stress Progesterone has important functions in men as well. Though considered to be a hormone exclusively in women, progesterone is a precursor for most other hormones important for male health including testosterone, DHEA and cortisol, and even the small amount of estradiol men have. In men, progesterone plays an important role in adrenal gland health, as well as being an important consideration for the health of other hormones. Progesterone supplementation (creams and oral dosing are recommended) Chasteberry (Agnes castus) decreases prolactin and may increase progesterone Decrease relative estrogen levels by decreasing inflammation and by improving estrogen metabolism excretion. (See movement out of the body treatment considerations for elevated estrogen) Decrease cortisol steal syndrome with stress reduction techniques until normalized Adrenal gland support Reduce stress and inflammation If supplementing with progesterone, check levels every six weeks ~ 5 ~

7 Cortisol Cortisol is a very important hormone that is secreted by the adrenal glands. is hormone affects the activity of other hormones such as insulin, thyroid hormones and DHEA. Cortisol is involved in balancing blood sugar (glucose), in protein synthesis, in immune system response and in REM sleep. It also effects bone turnover rate and thyroid function. External stress or disease processes may disrupt normal function of the adrenal gland. Cortisol levels may be decreased, or may be elevated due to stress. Abnormal cortisol levels have LOW Cortisol Risk of Fatigue Inflammation Allergy Symptoms Hypoglycemia Hypotension ELEVATED Cortisol Abdominal weight gain Increasing loss of memory Insulin resistance Type 2 diabetes Compromised immune function Bone loss Skin Conditions been noted in chronic fatigue, fibromyalgia, depression, anorexia nervosa, panic disorders, and many chronic illnesses. In women, normal adrenal and ovarian function is very important for female health. Abnormal cortisol levels may play a role in PMS, infertility, menopause or other female disorders. In men, abnormal cortisol levels have been noted in chronic fatigue, fibromyalgia, depression, impotence, anorexia nervosa, panic disorders, and many chronic illnesses. Stress Management through meditation, deep breathing exercises, yoga, tai-chi, etc. Nutrient or Supplement Intake Minimize refined carbohydrates Maximize adequate amounts of Vitamin C, B complex (with extra B5 and B6), zinc, magnesium Glandular Support Supplements (adaptogenic herbs/licorice root) Low Dose Hydrocortisone (never more than 20 mgm/day in four divided doses Stress reduction through meditation, deep breathing exercises, yoga, tai-chi, etc. Avoid or minimum use of caffeine Maximize adequate amounts of Vitamin C, B complex (with extra B5 and B6), zinc, magnesium Calming Herbs Music Massage erapy Phosphatidylserine supplementation 4-6 hrs. prior to noted elevation Fee Schedule : Available Salivary Hormone Profiles Female Cycle Profile (12 tubes) 12 x E2, 12 x Progesterone, 4 x Testosterone Professional Fee: $229 / List Fee: $309 Menopause Evaluation Profile (3 tubes) 3 x E2, 3 x DHEA-S, 3 x Progesterone, 3 x Testosterone Professional Fee: $139 / List Fee: $189 Male Hormone Profile (4 tubes) E2, DHEA-S, 4 x Testosterone Professional Fee: $99 / List Fee: $129 Adrenal Stress Profile (6 tubes) 5 x Cortisol (optional 6 th ), DHEA-S Professional Fee: $99 / List Fee: $129 Snapshot Profile 1 (1 tube) E2, Progesterone, Testosterone, DHEA-S, Cortisol (AM) Professional Fee: $129 / List Fee: $179 Snapshot Profile 2 (2 tubes) E2, Progesterone, Testosterone, DHEA-S, Cortisol (AM/PM) Professional Fee: $149 / List Fee: $209 Snapshot Profile 3 (5 tubes) E2, Progesterone, Testosterone, DHEA-S, 5 x Cortisol Professional Fee: $229 / List Fee: $319 *Create a Comprehensive Hormone Profile by adding an Adrenal Stress Profile to any Male, Female or Menopause Profile. for an additional $89.00 ~ 6 ~

8 Cell Science Systems, Corp. ALCAT Worldwide 852 S. Military Tr., Deerfield Beach, FL Tel: 800-US-ALCAT ( ) Fax: ALCAT EUROPE GmbH August-Bebel Str. 68, Potsdam Tel: +49 (0) Fax: +49 (0) PreviMedica 850 S. Military Tr., Deerfield Beach, FL Tel: Fax: