NEW AT BIRKEN

News

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Birken Medical Aesthetics Salutes Mom This May

MAY 2008

Birken Medical Aesthetics recognizes mothers everywhere by offering incredible discounts on facial treatments through the end of May. Dr. Randy Birken and his staff are proud to present a 40 percent discount on a Microdermabrasion treatment and Hydration Mask as well as 50 percent off of a photo facial.

Birken Medical Aesthetics serves The Woodlands, Texas and surrounding areas to provide a professional medical alternative to aesthetic physical enhancements. Dr. Birken specializes in Laser Vaginal Rjuvenation, In-Office Laser Liposuction, BioIdentical Hormone Therapy any many other beautifying treatments. Each of Dr. Birken’s procedures enhances the appearance and quality of life for women and men alike.

Dr. Randy Birken lends his 28 years of experience in practice to ensuring the highest quality patient care and results.

For more information or to set up an appointment with Dr. Birken 281.419.3231.

To print out the coupon, click the link under the Coupon section to the left and print.

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The Medical Management of Aging: One Physician’s Experience with Bio-Identical Hormones

APRIL 2008

Over the past several years, the buzz surrounding compounding, or bio-identical hormones (BHRT), grew louder in my ear, like a pesky mosquito that wouldn’t go away. While Suzanne Somers’ books, The Sexy Years and Ageless provide enlightening information to the public, her media blitz expounding the virtues of BHRT seemed self serving; but the ever present comments from patients such as “my friend takes natural hormones and is losing weight,” “I heard that they are safer,” “my sister sleeps better on her bio-identical hormones,” were hard to defer without understanding these substances. No, I thought. I’m a board certified specialist, read my journals, take the appropriate CME courses, and besides, the American College of Obstetricians and Gynecologists Committee Opinion from November of 2005 emphatically stated that “there is no scientific evidence to support claims of increased efficacy or safety for individualized estrogen or progesterone regimens.” (1) Malarkey? Well, maybe I should just find out for sure. But why? Could it be that patients actually feel better on bio-identical substances; do they have more endurance, sleep better, and even have improved libido? I need to find out, but without the hype and high price offered by some physician courses whose interest may be clouded by monetary factors.

While strolling through the plethora of “hits” from a Google search, past the glut of anti-aging sponsored websites, I find one unadorned and with a genuine feel to it: Dr. Neal Rouzier’s WorldLink Medical Seminars.(2) Good karma or just plain luck? Who knows, but off to Salt Lake City for a two day weekend course entitled, “the Effects of Hormonal Therapies on Quality of Life Issues: The Medical Management of Aging.” Intrigued? Yes. Skeptical? You bet.

The upscale hotel accommodations contrasted with the Spartan conference room: No breakfast? Oh well, a quick trip to the first floor, a Starbucks and a muffin now in hand, and let the show begin. Instead of sophisticated PowerPoint slides, Dr. Rouzier uses an overhead projector sans microphone, his voice loud and commanding. And so began a two day course unlike any other CME seminar I have ever attended; from eight AM sharp until almost six PM, Dr. Rouzier meticulously covers all the topics with an occasional five minutes respite for a bathroom break. Even lunch is a working session as the two intense days cover seminal medical publications coupled with practical clinical applications, moving rapidly with constant edifications, a course so enlightening that the two days seem like an hour lecture.

First, Dr. Rouzier presents material on the use of human growth hormone (HGH) a pituitary substance that affects nearly every organ in the body, necessary for proper growth and development. A landmark study by Rudman et al concluded that diminished secretion of HGH was responsible in part for decrease in lean body mass, the expansion of adipose tissue mass, and the thinning of skin during old age. (3) Various publications concluded that physiologic HGH replacement therapy might reverse or prevent some of the inevitable sequela of aging. Dr. Rouzier slowly and methodically walks up and down the conference room with his head slightly tilted downward, a gesture of contemplation, articulately referencing all the good things about HGH within the medical literature. The man, dedicated to the quest for knowledge, reviews a legion of medical publications per week; this is not a show, but a well organized and researched seminar from a doctor who has practiced using bio-identical hormones for ten years.

Just as interesting is the next section on testosterone, revealing that its physiologic replacement in men and women results in increased muscle mass, strength and endurance, decreased fat, increased exercise tolerance, as well as increase libido and sexual performance. Thoroughly, Dr. Rouzier covers a review article from the New England Journal of Medicine on the risks of testosterone replacement therapy and recommendations for monitoring. His survey is honest and fair while raising points about proper use and potential complications.(4)

What about DHEA, a substance that patients ask about often? Is it for real? Can a hormone secreted by nerve tissue and adrenal glands result in a shift from a catabolic to an anabolic or protein-building state reducing cardiovascular risks while improving mood, memory, and energy? Articles from the American Journal of Physiology, Journal of Endocrinology and Metabolism, and the New England Journal of Medicine support some of these claims, especially one from 1994 concluding that DHEA was associated with a remarkable increase in physical and psychological well being in men and women. (5) I lean back in my chair, a bit overwhelmed, but wanting to learn more.

Estrogen and progesterone, those much maligned hormones, suddenly seem amazingly safe and necessary from a bio-identical perspective. These are not just plant derived hormones, but structures that are chemically identical and therefore physiologically beneficial, protecting against heart disease, stroke, osteoporosis, Alzheimer’s and memory disorders as well as elimination of menopausal hot flashes and vaginal atrophy. Since progesterone is not progestin, a synthetic formulation, it ameliorates PMS and menopausal symptoms while lowering cholesterol, increasing bone density, and providing a natural mood calming affect. A study from Hargrove et al revealed that the combination of micronized estradiol and progesterone offered substantial clinical benefits for women with postmenopausal symptoms and an intact uterus. (6)

Dr. Rouzier is just warming up. His strongest opinions are saved for the controversial section on thyroid treatment, stating that it is the “most misunderstood hormone.” Expertly, he dissects nearly forty medical articles about thyroid treatment, emphasizing that bio-identical thyroid, not synthetic, reduces fatigue, thin hair, skin and nails, while promoting weight loss and reduction of body fat.(7) His wrath against the synthetics crescendos as he justifies bringing triodothryronine (T3) levels back to physiological levels, interspersing actual patient lab results on the overhead projector, teaching the correct interpretation of the most clinical useful blood tests.

Does the man ever get tired or his is Olympian stamina related to his use of bio-identical hormones? Perhaps it’s the melatonin he takes, that great sleep promoter and immune enhancer that provide him with superman endurance; or could his encyclopedic knowledge be enhanced by the use of pregnenolone, a hormone that may protect against memory loss? His one man show is more than impressive, it’s inspirational as well. Dr. Rouzier’s enthusiasm is contagious especially when he relates clinical stories of patients who not only respond to BHRT, but who can stop other medications, such as statins, anti-depressants, and bisphosphonates. I leave Salt Lake City anxious to begin bio-identical hormones assessment and treatment and to register for his Part II and Part III courses, further probing the mostly untapped benefits of hormone therapy.

I reread the 550 pages of Dr. Rouzier’s handout, searching for a way to begin BHRT counseling. How do I start? Will patients be interested in BHRT or satisfied with their current regimen? Don’t know, but the first patient I treat is my wife, who has been on synthetic estrogen and progesterone for several years. Not thrilled about being a guinea pig, she agrees to have blood levels tested, remaining skeptical to the concept. Eagerly, I wait for the results: an estrogen level pitifully low; the expected almost non-existent progesterone level; and testosterone and DHEA values well below optimal range. “Are you game?” I ask. After some coaxing, she reluctantly agrees. Now, instead of one pill per day, she has three as well as a cream, finding it inconvenient. Wait, I reassure her. Let’s see what happens. It may take time.

Surprising, most of my patients who take HRT are interesting in either changing to BHRT or learning more about them. Even patients who have been off hormones are intrigued by the possibility of improved stamina, sleeping better, and aid with weight loss. Lab tests are ordered, the results reviewed, and patient consultations made with recommendations for estrogen, progesterone, and testosterone replacement along with thyroid and DHEA supplementation if indicated by suboptimal values and clinical symptoms. It will be a month before I see these initial patients again, so cautiously, I watch my wife and wait to hear her take, a barometer for my patients.

Just three days after starting her BHRT, she unexpected, without provocation, tells me that she thinks something is working. I raise my eyebrows. “How so?” A tilt of her head suggests deep thought. “Not sure”, she says, “but I feel different, better, not sure exactly why or how.” I smile.

And so it goes with my patients as well. Most feel better, and many claim to sleep longer, have more energy, less hot flashes and/or night sweats, seem happier, and have less vaginal dryness; most comment that their libido has improved. During one patient’s return visit, her response to my question about how she feels was answered with a stare and a finger pointed directly at me. My initial concern she was upset was quickly overturned by her grin. “You’re never, ever going to take me off this stuff. I haven’t felt this well for years. Look,” she says. “I’m smiling! I haven’t been this happy in a long time.”

Wow. Okay, but not all will be this elated, and sure enough, I’m right. Those with no or little clinical response have lab values consistent with minimal changes. Customizing the dosages as well as the combination of estradiol to estriol and T4 to T3 makes me feel like an internist instead of a gynecologist. Yet, it all makes sense, and even these poor responders return with improvement and positive feedback. The hardest patient, my wife, also requires some tweaking to her hormones dosages and combinations until the desired values and clinical responses are met.

Anecdotally, I make an interesting observation. Every patient who is taking testosterone seems to have better looking skin. Is this for real or just my imagination?

“You’re right,” my wife says. “I now have some oil to my skin when before it was dry.” She nods. “My skin feels soft and silky like when I was young.”

Okay. Settle down. Don’t get over excited. This seems like the real deal and maybe I should convert everyone to BHRT, but there are some drawbacks. First, because they are bio-identical substances, they cannot be patented by pharmaceutical companies and therefore are not regulated by the FDA. While as physicians we have the knowledge and expertise to use bio-identical hormones, some clinicians feel uncomfortable using non-FDA medication. Secondly, most insurance companies won’t cover these compounded hormones and usually patients pay significantly more for them compared to hormones on insurance formularies. But for many, the improvements in energy, clearer thinking, enhanced libido, and better sleep is worth any price. And it takes time to find the right combination for each individual with several follow-up visits and repeat blood tests to reach optimal levels and realistic clinical improvement.

Now, having crawled through the initiation of BHRT within my practice, I run, strong and rhythmic, while watching patients change from fatigued, overweight, stressed, and frustrated adults to those with drive, stamina, and improved metabolism. Perhaps, after taking Dr. Rousier’s next two courses, I may consider prescribing HGH. While BHRT may or may not slow the aging process, it works well clinically resulting in improved quality of life as well as enhanced sense of well-being, and maybe and most importantly, better and safer overall health for my patients.

References

1. Committee on Gynecologic Practice. Compounded Bioidentical Hormones, Number 322, November, 2005, http://www.acog.org/publications/committee_opinions/co322.cfm. Accessed January 9, 2007
2. Rousier, N. World Link Medical. www.worldlinkmedical.com. Accessed January 9, 2007
3. Rudman, D, et al. “Effects of Human Growth Hormone in Men Over 60 Years Old” New England Journal of Medicine 1990; 323:1-6.
4. Rhoden, L and Morgentaler, A. “Risks of Testosterone Therapy and Recommendations for Monitoring” New England Journal of Medicine 2004; 350:482-92.
5. Morales, A, et al. “Effects of Replacement Dose of Dehydroepiandrosterone in Men and Women of Advancing Age” J Clin Endocrinol Metab 1994; 78(6):1360-67.
6. Hargrove, J. “Menopausal Hormone Replacement Therapy with Continuous Daily Oral Micronized Estradiol and Progesterone” Obstetrics and Gynecology 1989;73:606.
7. Bunevicius, R. “Effects of Thyroxine as Compared with Thyroxine Plus Triiodothyronine in Patient with Hypothyroidism: The New England Journal of Medicine 199; 340:424-9.