Dr Fatiha Arhbal MBBS, FRACGP,DCH,DRANZCOG Board Certified Anti Ageing Physician
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Natural chemical regulators of cell physiology Secreted into the blood by specialised glands and act at a distance on one or more target organs Mechanisms-Peptides and proteins act at cell membrane -Steroids enter nucleus and regulate genes
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Pituitary Pineal Thyroid Adrenal
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Sex Steroids Male
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Female
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Growth Hormone Melatonin TSH, T4, T3, rT3 Cortisol, DHEA, Pregnenolone, Aldosterone Testosterone, DHT, Oestrogens, DHEA, Progesterone Oestrogens, Progesterone, Testosterone, DHEA, DHT
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age because our hormones decline, our hormones don’t decline because we age Youth – ANABOLIC Ageing – CATABOLIC Getting old is natural, feeling old is optional
To prevent the morbidity of ageing To prolong the healthy disease free lifespan Compress morbidity to as few years as possible To treat subtle hormone deficiencies as well as severe ones so that disease can be prevented and QOL maintained Traditional medicine seeks to treat outcomes of ageing, not change the process.
Supplementation should be with the same hormone that is deficient “Bio-identical”- identical structure to the hormones produced by the human Some bio-identical hormones are available through pharmaceutical companies Some hormones must be compounded for the individual Synthetically produced
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Prepare the substance required from an individualised prescription Hormones can be made into capsules, creams, gels, troches
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Produced by Pineal Gland Highest as a child, declines in adulthood. At 80, the levels are 80% less Promotes sleep, sleep wake cycles, REM sleep Deep muscle and nerve relaxation Antispasmodic for GIT Mood Body Temperature regulation Immune system Antioxidant Reproductive Health
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Sleep disturbance- a superficial, agitated sleep with a lot of anxious thinking Easily waking during night Restless legs Fatigue Premature Ageing Tense muscles at night Difficulty falling to sleep Poor dreaming Anxiety Lack of peace of mind Depression, irritability
Improved quality of life, better sleep, calmness Improved health Improved secretion of releasing hormones from brain Increased longevity No known side effects
Peak secretion at 3am Test saliva between 10pm to 12am Usual doses 0.5mg- 3mg sublingual 10- 20 mg has been shown to increase longevity and survival in some cancers Increase naturally by bright sun in the morning, dark bedroom 5HT, SAMe, B6, phosphatidyl serine
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Major hormone with prominent roles Anabolic hormone Responsible for growth in childhood and puberty Growth of brain, skin, hair, muscles, bones, internal organs In adults, maintains the volume and tone of the skin, muscle and tissues Low GH causes accelerated ageing Function and repair of muscles, heart, lungs, liver, kidneys, joints, nerves and the brain Mental and emotional impact as it stimulates parasympathetic nerves (calming) Calming, inner peace, increased QOL, relieve depression, anxiety
Highest in the first 3-4 hours of sleep Secreted by pituitary gland Peaks in adolescence Declines from age 30 at 1-3 % per year IGF-1 is produced by the liver under the influence of GH and protein intake, and mediates GH effects Measure IGF-1 as it is more stable than GH
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Sparse thin hair, thin skin Droopy eyelids, sagging cheeks, thin lips, thin nose pointing downward, thin jaw bones Loose skin folds under chin Thin muscles, small shoulders Droopy triceps Hands- thin muscles, thin fingers, vertical lines on nails, small muscles Prematurely aged, obese body Fat droopy abdomen, stretch marks Hunchback, increased subscapular skin, sagging back muscles Sagging inner thighs, fatty cushions above the knees Flat feet Lack of inner peace, reduced QOL, feel unwell, low self esteem, social isolation, excessive emotions, poor stress tolerance, exhaustion with poor recovery, can’t recover from poor sleep, light sleep , excessive sleep, feeling of rapid ageing
Diseases that maydevelop more easily in people who are GH deficient Cardiovascular disease- high cholesterol, heart failure, atherosclerosis, HT Obesity Type 2 Dm
Suspect in brain injuries Head injuries Cranial irradiation PPH GI haemorrhage Hypopituitarism Normal IGF-1 levels do not exclude AGHD
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IGF-1 fasting in the morning Men- 39-46 Women 29-40 Treatment can be with injections of GH 0.5-2 IU at night Lifestyle and diet Testosterone, Oestrogen, Progesterone, Thyroid hormone, Melatonin all increase GH levels; high cortisol reduces GH Secretagogues- Arginine, Ornithine, work best in the young: L- Glutamine 2g at night works in all ages
“Extensive studies of the outcome of GH replacement in childhood cancer survivors show no evidence of and excess of de novo cancers, and more recent surveillance of children and adults treated with GH has revealed no increase in observed cancer risk” Jenkins PJ et al. Clin Endocrinol (Oxf). 2006 Feb; 64(2):115-21
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Low dose GH treatment combined with dietary restriction resulted not only in a decrease of visceral fat but also in an increase of muscle mass with a consequent improvement of the insulin resistance observed in obese type 2 patients Nam SY et al. Int J Obes Relat Metab Disord 2001 Aug;25(8);1101-7
DB randomised treatment 20mcg/kg/day >75 years old, IGF returned to 50 year old levels Return to pre fracture living 94% vs 75% Statistically significant, well tolerated Van Der Lely et al. Eur J Endocrinol 2000 Nov; 143(5): 585-592
50 yo man, obese, hyperinsulinaemia, fatigue, depression, low motivation, low muscle mass 3 years ago had oesophageal bleed which left him in a coma for 4 weeks in ICU IGF-1 nmol/l <3 (12-33) Treatment 1 IU GH daily Improvement in mood and energy
Two major thyroid hormones, T4 with four iodine atoms and T3 which has three T3 is the most active and the most widely distributed in the body T3 the main hormone within the target cells T4 the most abundant in the blood, and is a precursor hormone that must be converted to T3
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Increase blood flow, heart rate, heat production, metabolism, energy production and consumption, speed of thinking, intestinal motility, thirst, urination, HDL cholesterol, immune defense against infections and cancer Decrease LDL, diastolic BP, fluid retention
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T4 80-100 mcg and T3 20 mcg secreted by thyroid gland T3 35 mcg is from peripheral conversion of T4, mainly in the liver High calorie diets, fruit and vegetables increase thyroid activity Sugar increases thyroid, but temporarily Eating too much protein or too little calories, lowers thyroid activity by reducing T4- T3 conversion and reducing hormone production by the thyroid gland
Levels decrease with age 10-20 % from age 2575 and T3 by 25% RT3 is an isomer of T3 which can block T3 activity at receptor sites RT3 is increased under stress Conversion of T4- T3 requires adequate zinc and selenium, reduced by old age, decreased calories, inflammation, illness, trauma, post op, increased cortisol
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Prone to ENT infections Prone to easy weight gain, difficult to lose Overweight Swollen Morning fatigue and fatigue when taking a rest Feels best in the evening or when physically or mentally active Lethargy Intolerance to cold Intolerance to heat, inability to sweat Snoring Difficult to get out of bed in the morning Poor appetite Excess coffee Decreased thirst and urination Dry hair
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Hair loss Headaches Tinnitus Hoarse voice in the morning Dry skin Brittle nails Bloated abdo, slow digestion, constipation Muscle and joint stiffness in the morning Muscle aches Leg cramps at night Carpal tunnel syndrome Low back pain Depression Poor memory Slow thinking Easily distracted
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Associated with development of cardiovascular disease, premature atherosclerosis, infertility, obesity, diabetes, depression, memory loss, Alzheimerâ&#x20AC;&#x2122;s disease, ENT infections, and possibly cancer
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Testing lacks sensitivity TSH is not the best test Free T3 the best clue Look at the patient TSH >2 indicates a high probability there is hypothyroidism or it will develop TSH >4 premature atherosclerosis Optimal TSH 1 RT3 <400 Thyroid antibodies often positive, but may be positive in general autoimmune disease, can act as “thyroid blockers”
Reduce by Eliminating physical and mental stress Treating with thyroid Growth hormone Selenium Iodine
Whole Thyroid- from Pig glands “Armour” or compounded equivalent 1 grain/60 mg- T4 38mcg/T3 9mcg T4 and T3 treatment more beneficial than T4 alone T4 and T3 synthetic but bioidentical Treatment with both T4 and T3 has been shown to be more beneficial to patients than T4 alone
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Zinc 30 mg Selenium 200 mcg Iodine up to 12.5 mg- Lugol’s or Iodoral Tyrosine 500- 1000mg “Thyroid formulas” Adrenal support- low thyroid is a stress situation and will cause increased cortisol. When treated with T4 only, and less T3 conversion, the stress response gets worse and leads to adrenal fatigue
“The adrenals first, the adrenals last and the adrenals inbetween” James Wilson Most people have a degree of Adrenal Stress or Fatigue If cortisol is increased, it decreases hormones levels and their activity. The biggest hot spot in ageing
DHEA is the most abundant hormone produced at puberty leading to development of axillary and pubic hair Declines from age 30 Lifelong adrenal cortex deficiency leads to allergies, thin body, inflammation, poor response to stress
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Are present throughout the day Worse with physical activity Moderate fatigue Anxiety and depression Low resistance to stress and noise Decreased libido Dry eyes, dry skin Loss of axillary and pubic hair, lateral calf Poor muscle development
Blood- Optimal level for men 9, women 7 Saliva 20- 25 DHEA orally men 20-55 mg, women 5-30 mg
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Enhances immune system, may have an anti cancer role Reduces risk of age related disorders, including cancer, CVD and osteoporosis Improved BSL and helps prevent diabetes Weight loss and increased muscle mass Important in autoimmune illness, AIDS, chronic fatigue Treat depression, menopause, memory Increase life expectancy
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Stimulates protein breakdown to amino acids Lipid breakdown in fatty tissue Promotes synthesis of glucose in the liver from the above Makes glucose available to the brain by using other tissues Normally, the breakdown (catabolism) of tissues is followed by the building up (anabolism) of androgens (DHEA, TT) As we age, excess catabolic:anabolic hormones develops and this results in the breakdown of organs and tissues, the loss of ability to repair damage This also occurs under chronic severe stress and contributes to ageing
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Stressed/anxious/irritable/nervous Crave sugar and sweets Weight gain Depressed Loss of memory Foggy thinking
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High blood pressure Puffiness under eyes Weight gain easily, especially in the waist Loss of muscle Low sex drive Hair loss Thinning skin Bruise easily
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Lower level of energy/fatigued Difficulty waking up in the morning Fatigued increases late afternoon Resistance to stress is low Resistance to infection is low, prone to illnesses Allergies/sensitivity to chemical Foggy thinking Crave salty foods Crave sugar and sweets Suffer from arthritis, joint pain Excessive sensitivity to pain Nausea Appetite is poor
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Low blood pressure, sometimes orthostatic Conjunctivae reddened Dark circles under eyes Appearance of age spots Wet/sweaty palms Thin, undernourished body Thinning hair Hollow cheeks Dry skin/eczema Brown palmer folds
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Weakness, fatigue GI symptoms Nausea Vomiting Constipation Abdominal pain Diarrhoea Anorexia Salt craving Dizziness Muscle and joint pain
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Weight loss Hyperpigmentation Hypotension Loss of scalp hair Excess facial or body hair Vitiligo
Serum Cortisol in the morning- optimal 500 Saliva cortisol throughout the day- 8am, 12pm, 4pm, 10pm 24 hour urinary cortisol
Cortisol
DHEA
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Eat early and never skip breakfast Have a glass of water in the morning with ½ to 1 teaspoon of salt Avoid sugary fruits (all juices,oranges, citrus, ripe bananas) Avoid starchy foods (all grains, bread, potatoes, rice, popcorn, pasta) Avoid coffee or other caffeine containing beverages Avoid trans-fat (they are in everything processed)
Cardio: 3 times a week for 30 minutes Low weight high reps: This helps improve metabolism and maintain muscle strength and mass Flexibility, improves circulation, reduces stress, and lessens chance of injury Exercise should leave you energized not wiped out
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Stop watching TV and using the computer by7pm No work after 7pm Sleep by 10 p.m. Sleep in as late as possible, and twice a week until you wake on your own Avoid getting over-tired Do the things that you like Laugh several times a day
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Vitamins B complex B-5, once or twice daily Vitamin C 1000mg Magnesium 300mg Adaptogens Siberian Ginseng 250 to 500mg 1 or 2 times daily Ashwagandha (Indian Ginseng)/Withania 250 to 500mg 1 or 2 times daily Rhodiola (Rhodiola rosea) 100 to 250mg 1-3 times daily Glandulars Thorne Cortrex Rest Augmenters Phosphatidyl Serine 100 mg 1-3 tablets at 6pm for sleep L-Theanine 100-200mg 1-4 times daily. Melatonin 0.5-3mg at night
Hormones Progesterone transdermal 3%-6% DHEA orally 5-50mg Pregnenolone 50-100 mg Hydrocortisone 5-15mg at 7am and 2.510mg at noon Fludrocortisone 50-100mcg
A hormone also made by the adrenals Responsible for retention of water and maintaining blood pressure by making the kidneys retain sodium Higher during day when you are upright Higher on low salt diet- able to compensate less as get older Can be very low in adrenal fatigue
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Feel better lying down Need to move around all the time when standing Drowsiness, zombie like feeling when standing Easily distracted Difficulty with vision focus Salt cravings Thirsty and urinate a lot
Pale face, absent minded look Low BP less than 110/60 Blood pressure drops when standing Hollow face, sharp wrinkles Soft eyeballs Dehydrated Tongue indentations
Blood Sodium- optimal 141 low <138 Blood Potassium 4.3 High >4.8 Aldosterone >415 Fludrocortisone 50-200 mcg daily with adequate water and salt
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Pregnenolone is the precursor of all steroid hormones It is made from cholesterol in the mitochondria Functions also as a neurotransmitter, especially in the part of the brain that deals with memory 50% who take > 50mg daily report improvement in memory Anti rheumatic Produced by brain and adrenal glands Declines with age
Poor memory especially under stress Reduced colour vision Reduced artistic awareness Fatigue Dry skin Joint pains Deficiencies of other steroid hormones
Test other hormones “Pregnenolone steal” syndrome occurs under stress Pregnenolone 50-150 mg daily Dementia and Autoimmune disease up to 200-400 mg daily
Oestradiol, Oestrone, Oestriol Progesterone Testosterone
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Oestradiol is the strongest oestrogen and it is converted to oestrone and oestriol Delicate balance between oestrogen and progesterone Have opposite and complimentary effects Oestrogen retains fluid, progesterone is a diuretic Oestrogen increases menstrual loss, progesterone decreases it Oestrogen stimulates SNS increasing alertness, but if no PG , then can get very nervous Progesterone is calming as it stimulates the PNS
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Oestradiol feminises the body Reddens the skin Proliferation of uterine lining Vaginal lubrication Libido Female voice Initiates ovulation 10-200 mcg daily in 18-30 year olds
Prepares the uterus for implantation of fertilised egg Essential for pregnancy 1-2 mg daily (from adrenals)in the first half of the cycle and 20-40 mg (from ovary after ovulation) in the second half
Prolonged physical activity and intense stress can suppress the production Protein and fat increase Sugar and high fibre grains decrease All women become hormonally deficient over time when no good eggs remain at menopause Progesterone usually the first hormone to become deicient
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Fatigue Depression Poor libido Poor memory Hot flushes and night sweats Droopy breasts Menstrual irregularity, light or absent Vaginal dryness Painful intercourse Bladder infections Joint aches
Oestrogen Deficiency
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Nervous tension Irritability, aggression Anxiety, rage Increased sensitivity to pain Insomnia with nervous tension PMT, swollen tender breasts Bloating Heavy periods Fluid retention
Progesterone Deficiency/Oestrogen Excess
Infertility Premature ageing Osteoporosis CVD Alzheimer’s Disease
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Oestrogen deficiency
Breast cysts Breast cancer Ovarian cysts Endometriosis Endometrial cancer Uterine fibroids Enlarged uterus Heavy bleeding Infertility Miscarriage
Progesterone Deficiency
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Blood- “Day 21” oestradiol and progesterone Ratio 5:1 Salivary hormone testing Day 21 Ratio 200:1 Vitex can be a useful herb and has progestagenic effects, esp in younger women Treatment- Biest cream - Oestradiol alone - Progesterone as a cream in the second half of the cycle, or as a troche or capsule
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Osteoporosis, 67 yoa Oestradiol (E2) < 50 pmol/L Anxiety, depression, overweight , 42 yoa Oestradiol (E2) 1041 pmol/L Blood shows bound and unbound hormones, up to 98% of hormone can be bound to binding proteins Transdermal progesterone cream does not show up in serum levels Salivary hormone testing will show transdermal and unbound fraction
Called progestins Progestins are synthetic modifications of the progesterone molecule. Several different ones are prescribed . Progestins are not progesterone. Progestins do not reproduce the same actions of natural progesterone. Progestins worsen cancer risk
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Testosterone important in women for mood and assertiveness Improve bone density, muscle strength and skin oil production Female genitalia- sensitivity Protection against atherosclerosis Production is 20-30 times lower than men Mostly from DHEA 40 yo have half the TT of 21 yo
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Nervous irritable Lack of mental firmness, indecisive Poor memory Depression, anxiety Excessive emotions and sensitivity to stress Ageing appearance, abdominal obesity Muscle laxity Fatigue, low energy Dry skin, easily sunburnt Decreased or absent libido and orgasm Painful intercourse Cellulite
Aim serum TT in upper range Saliva 80-90 TT cream 1mg/g daily Injections Troche
Testosterone Dihydrotestosterone Oestradiol
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The predominant male hormone, converts to dihydrotestosterone, the most potent male hormone If does not convert to DHT, will convert to oestradiol Andropause is more gradual than menopause
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Protects against CAD, decreases BP, thins blood Protects against obesity and diabetes, increases lean muscle mass Maintains reproductive health Supports brain by increasing connection of neurones and increasing blood supply Improves mood and memory and decreases anxiety
Daily production is 7 mg daily Higher in the morning Leydig cells make testosterone and every four seconds, one dies, so when 70, have only a third left cf 18 Over time, become deficient and suffer symptoms
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Ageing appearance Obesity Headache, ear buzzing Palpitations, shortness of breath on exertion Decreased muscle strength and size Muscle pains, poor recovery after exercise Easily sunburned Constipation Fatigue, worry, low motivation Hot flushes, sweating Prostatism Decreased libido, erections, morning erections Lack of decisiveness Depression Excessive emotions Lack of interest in life Social isolation
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Cardiovascular disease Infertility Obesity Type 2 Diabetes Depression Memory loss Alzheimers disease Osteoporosis Poor wound healing
Blood testosterone, SHBG, free testosterone Ideally in upper third of the range depending on size Oestradiol Testosterone gel Injection Implants
Oestradiol (E2) Testosterone SHBG Free Androgen Index Calculated Free Testosterone
213 pmol/L 14.3 nmol/L 73 nmol/L 19.6 % 0.16 nmol/L **
Reference Intervals
Calculated
Testosterone Adult Male 8.0 - 30.0 Pubertal Male 6 - 30 Prepubertal Male <6
SHBG 10 - 45
FAI 30 - 120
FreeTestos. 0.20-0.60
A metabolite of TT The strongest androgen Used in Europe predominantly
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Is a useful aromatase inhibitor and also a 5 alpha reductase inhibitor, reducing the metabolism of testosterone to both oestradiol and DHT
Oestradiol is made from testosterone Abdominal obesity and inflammation increase this conversion Men need some oestradiol for brain, bone, heart and libido Too much will cause gynaecomastia, possibly BPH and prostate cancer Weight loss, zinc, progesterone
Testosterone and prostate cancer HRT and breast cancer Cortisone use Thyroid and osteoporosis
Healthy diet Healthy GIT Healthy detoxification Avoid xeno oestrogens Supplementation and lifestyle THEN appropriate hormone supplementation when required with bio identical hormones Good health doesn’t come from a pill or an injection
www.acnem.org www.a5m.net www.aima.net.au www.worldhealth.net www.a4m.org www.intlhormonesociety.org Also I have a facebook fan page Dr Fatiha Arhbal
Dr Simeon in the 1950’s developed a weight loss programme using the pregnancy hormone human chorionic gonadotrophin Inject small amounts daily Calorie restriction to 500 cals daily Resets weight set point in the hypothalamus No rebound weight gain Can lose up to 15kg in 40 days without exercise!