The Hormonal Balancing Act

1. The Hormonal Balancing Act Presented By: Craig Batagowski, PharmD, IACP Created By: Lauren Kuta, PharmD Candidate Edited By: Paraj Patel, PharmD Candidate Jameel Khaaliq, PharmD Candidate Sergio Zermeno, PharmD Candidate

2. What are Hormones? hormone /hor·mone/ (hor´mōn) a chemical substance produced in the body which has a specific regulatory effect on the activity of certain cells or a certain organ or organs. Hormones control things like: • Metabolism • Sexual function • Reproduction • Mood • Growth & Development

3. Checking Your Hormone Levels Sometimes the body can under produce or over produce hormones. Your doctor can check your levels via: Based on levels and symptoms, doctors can then prescribe medications and hormones to get your numbers where they need to be.

4. Comparing Tests

5. How Can MARK DRUGS Help? • Drug manufactures do make hormonal medications which can be filled at a community pharmacy. • A problem with mass manufactured medications are they only come in certain strengths. • Prometrium (2 strengths available) • Estrace (1 strength available) • These strengths may be to much or too little for you to properly correct your levels. This is where we come in…

6. We can work with you to make a specific strength tailored to your needs. • We can combine certain hormones into one dosage form. Reduces amount of medications • In short-we are here to make your life easier and to ensure you receive the best care possible.

7. We Compound: Regulates sexual & reproductive function • Estrogens • Progesterone • DHEA • Testosterone Regulates metabolism • Thyroid Regulates pregnancy • hCG

8. General Facts About Hormones • They are interconnected • Which is why too much or too little of different hormones can share the same side effects • They can have an effect on multiple organs or receptors at once • They are derived from cholesterols • Which is why eating a completely fat-free diet or being on statin therapy can be harmful

9. Hormonal Cycle (non-pregnant) ESTROGEN PROGESTRONE HCG Follicular Phase Ovulation Luteal Phase

10. Potential Therapy Options Estrogens

11. Hormone Chart

12. The 3 Types of Estrogens Estrone (E1) (rarely used) Estradiol (E2) (most potent) Estriol (E3) (least potent) ***Pregnancy category X • Reasons for usage: • Atrophic vaginitis • Dysfunctional uterine bleeding • Hot flashes • Menopause • Hypogonadism • Oophorectomy • Osteoporosis prophylaxis • Ovarian failure • Palliative treatment of breast cancer • Prostate cancer • Urethritis Estrogens Progesterone DHEA Testosterone Thyroid HCG

13. Symptoms • Deficiency: • Vaginal dryness • Painful intercourse • Bladder infections • Hot flashes • Night sweats • Memory problems • Lethargic depression Excess: • Puffiness and bloating • Rapid weight gain • Mood swings • Anxious depression • Insomnia • Abnormal Pap smear • Breast tenderness • Monitor • Heavy Bleeding • Migraine headaches • Foggy thinking Estrogens Progesterone DHEA Testosterone Thyroid HCG

14. Ways Supplied/Administration Estrone (E1) - usually not in therapy Estradiol (E2) 50 20 Estriol (E3) 50 80 • Cream • Most commonly used • Capsule • not recommended due to 1st pass effect • Injection • Usually reserved for transgender patients Estrogens Progesterone DHEA Testosterone Thyroid HCG

15. Progesterone

16. Hormone Chart

17. Progesterone • In the beginning stages of Menopause, progesterone is the first hormone to drop dramatically • Too much progesterone can actually block estrogen • Reasons for Usage: • amenorrhea • contraception • dysfunctional uterine bleeding • estrogen replacement therapy • infertility Estrogens Progesterone DHEA Testosterone Thyroid HCG

18. Symptoms • Deficiency/Estrogen Dominance • PMS • Early miscarriage • Unexplained weight gain • Anxiety • Insomnia • Painful and/or lumpy breasts • Cyclical headaches • Infertility Excessive: • Tired • Dizzy • Weight gain • Menstrual cycle changes • Fluid retention Estrogens Progesterone DHEA Testosterone Thyroid HCG

19. Ways Supplied/Administration • Capsule (10-400mg) • Slow release • Cream (10- 200mg/mL) • Lozenge (50-200mg) • Injection • Fertility or maintenance for pregnancy • Suppositories (25-200mg) Estrogens Progesterone DHEA Testosterone Thyroid HCG

20. DHEA

21. Hormone Chart

22. DHEA • “DHEA” stands for Dehydroepiandrosterone. • It is a precursor of both androgens and estrogens, and is referred to as the “father hormone” • Reasons for Usage • Andropause • Erectile dysfunction • Libido • Muscle wasting • Menopause • Systemic lupus erythematosus Estrogens Progesterone DHEA Testosterone Thyroid HCG

23. Symptoms • Deficiency: • Fatigue • Weakness • Nausea • Anorexia • Low blood pressure • Low blood sugar Excess: • Acne • Oily Skin • Increased facial hair • Deepening of the voice • Mood swings Estrogens Progesterone DHEA Testosterone Thyroid HCG

24. Ways Supplied/Administered • Capsules (1-60mg) • IR (OTC) • SR (Rx) • Cream (3-100mg/mL) • Sublingual Spray (5mg/spray) • Biosom (Metagenics) Estrogens Progesterone DHEA Testosterone Thyroid HCG

25. Testosterone

26. Hormone Chart

27. Testosterone • Often blood work is preferred to dose • HRT regimens for woman often include testosterone Reasons for Usage: • Delayed puberty • Hypogonadism • Palliative treatment of breast cancer • Andropause • Erectile dysfunction • Libido • Muscle Wasting Estrogens Progesterone DHEA Testosterone Thyroid HCG

28. Symptoms Excessive • Acne • Weight gain • Fluid retention • Male hair growth patterns • Exaggerated moods • Aggression • Impatience • Frustration • Deficiency • Low or absent libido • Depression • Lethargy • Weakness • Foggy thinking Estrogens Progesterone DHEA Testosterone Thyroid HCG

29. Ways Supplied/Administered • Capsules • Women only • Gel/Cream • Lozenge • Injection Estrogens Progesterone DHEA Testosterone Thyroid HCG

30. What’s the Controversy All About? • In the early phases of HRT (hormone replacement therapy), women were finding great relief from menopause symptoms. • After years past, reproductive cancers were found to be predominantly in those woman who used HRT. • Studies confirmed that not all hormones are created equal. • Higher chance of cancers with progestins • Very low chance of cancers with progesterone

31. Thyroid

32. How Does the Thyroid Work? T3: liothyronine (x10 more active than T4) T4: levothyroxine (more secreted) Ratio T3:T4 / 1:4 disperses through the body to different organs to regulate metabolism Estrogens Progesterone DHEA Testosterone Thyroid HCG

34. Ways to Test Thyroid Estrogens Progesterone DHEA Testosterone Thyroid HCG

35. Symptoms: • Overactive • (Hyperthyroid) • Sudden weight loss • Rapid heartbeat • Nervousness • Anxiety • Tremor • Sweating • Changes in menstrual patterns • More frequent bowel movements • Difficulty sleeping Underactive (Hypothyroid) • Fatigue • Increased sensitivity to cold • Constipation • Pale, dry skin • Puffy face • Unexplained weight gain • Muscle aches • Heavier than normal menstrual periods • depression • brittle fingernails and hair Estrogens Progesterone DHEA Testosterone Thyroid HCG

36. Causes Overactive Thyroid (Hyperthyroid) • Graves’ Disease • Toxic adenoma • Toxic multinodular goiter • Thyroiditis Underactive Thyroid (Hypothyroid) • Hashimoto’s • Radiation therapy • Medications (lithium) • Pregnancy • Congenital disease • Pituitary disorder • Iodine deficiency Estrogens Progesterone DHEA Testosterone Thyroid HCG

37. Medications for Hypothyroid • Liothyronine: synthetic T3 (Cytomel) • Levothyroxine: synthetic T4 (Synthroid) • Armour/Nature thyroid: supposed to be most human like with ratio of T4/T3. Made from pig thyroid glands • Mark Drugs Compounds • Compounded porcine thyroid • Compounded synthetic T3/T4 • Both can be IR or SR Estrogens Progesterone DHEA Testosterone Thyroid HCG

39. Thyroid Supplementation • Iodine • Selenium • Zinc Estrogens Progesterone DHEA Testosterone Thyroid HCG

40. Thyroid Supplementation • Iodine • The body uses iodine to make thyroid hormone • Low levels can cause goiter • Usually found in your diet • Common sources include: • Dairy • Table salt • Saltwater fish • Shellfish • Seaweed • Multivitamins

41. Thyroid Supplementation • Selenium • Antioxidant function • Supports conversion of T4 to T3 • Regulates thyroid hormone levels • Also found in diet • Common sources include: • Sunflower seeds • Pinto beans • Halibut • Sardines • Multivitamins

42. Thyroid Supplementation • Zinc • Supports conversion of T4 to T3 • Supports T3 receptors • Also found in diet • Common sources include: • Poultry • Red meat • Oysters • Beans • Whole grains • Multivitamins

43. hCG (Human Chorionic Gonadotropin)

44. Reproductive hormone • pregnancy tests pick up this hormone • can be found in blood 11 days after conception • Levels of hCG in weeks from last menstrual period (LMP): • Three weeks LMP: 5 to 50 mIU/ml • Four weeks LMP: 5 to 426 mIU /ml • Five weeks LMP: 18 to 7,340 mIU /ml • Six weeks LMP: 1,080 to 56,500 mIU /ml • Seven to eight weeks LMP: 7,650 to 229,000 mIU /ml • 9 to 12 weeks LMP: 25,700 to 288,000 mIU /ml • 13 to 16 weeks LMP: 13,300 to 254,000 mIU /ml • 17 to 24 weeks LMP: 4,060 to 165,400 mIU /ml • 25 to 40 weeks LMP: 3,640 to 117,000 mIU /ml • non-pregnant females: <5.0 mIU /ml • postmenopausal females: <9.5 mIU /ml Estrogens Progesterone DHEA Testosterone Thyroid HCG

45. How Supplied 10,000 - 12,000 Units ???????? 62.5-90 Units Homeopathic drops-take under the tongue Injection-into subcutaneous fat or intramuscular Nasal spray-1 spray in each nostril Estrogens Progesterone DHEA Testosterone Thyroid HCG

46. What is HCG Used For? Weight Loss! • How it works… • It has been found that pregnant women from 3rd world countries are able to retain muscle mass and a healthy pregnancy, regardless of poor nutrition and hunger • This has been attributed to the high levels of HCG • The idea behind HCG weight loss: • Decreased calories + HCG= weight loss without losing muscle Estrogens Progesterone DHEA Testosterone Thyroid HCG

47. Plan Breakdown: Estrogens Progesterone DHEA Testosterone Thyroid HCG

48. What Can You Eat? • Protein: 100 grams of the following: • Beef, Buffalo, Veal, Boneless/Skinless Chicken Breast, Sea Bass, Flounder, Halibut, Sole, Lobster, Crab, Shrimp, Albacore (Not tuna) • Vegetarian options: egg whites, cottage cheese (may affect weight loss) • Veggies: Only 1/meal, no mixing: • 2 cups: Spinach, Lettuce, Asparagus, Cabbage, Cucumber, Chard, Beet Greens, Red Radish, Celery, Chicory Greens • 1 cup: Tomatoes, Fennel • 1 small: Onion • Fruit: 2 per day, 1 per meal: • Apple, Orange, ½ grapefruit, 6 strawberries • Bread: Not recommended • 1 Grissini or 2 Melba Toast • Other: • Coffee, Green/Black tea, Stevia sweetener, 1 tbsp of milk, juice from 1 lemon, lots of water, vinegar, mustard powder, plain spices Estrogens Progesterone DHEA Testosterone Thyroid HCG

49. Most Common Concerns • Constipation • Hair loss (reversible) • Leg cramps • Menstruation • Headache • Heartburn/Bloating • Sore Throat • Dry skin • Rash or Acne Breakouts Estrogens Progesterone DHEA Testosterone Thyroid HCG

50. Positive Effects of HCG diet • About 10% body weight reduction in 30 - 40 days • Reduction in the amount of unhealthy cholesterol • Decrease and stabilization of blood sugar levels • Reduction in the appearance of cellulite • Decrease in food cravings • Increase in energy levels during maintenance phase • Deeper sleep • Decrease in blood pressure • Possible decrease in medications Estrogens Progesterone DHEA Testosterone Thyroid HCG