In 2014, nurse practitioner Karl Lambert heard about the Academy of Preventive & Innovative Medicine by Worldlink Medical. A colleague told him about hormone optimization with bioidentical hormones and he was intrigued.
Karl was frustrated that his patients never really improved. He’d see them in his office, talk with them about their obesity, blood sugar, diabetes, blood pressure, cholesterol, and other risk factors. He’d prescribe medications and have the best intentions for them, but not hold out a lot of hope for their prognosis.
Karl would see the same patient, back in the office 6 months or a year later. Nothing had changed. Their weight was the same or higher, blood sugars still elevated, hemoglobin A1C creeping up - everything that goes along with “aging.”
Karl never felt a sense of getting ahead of any of his patients’ labs or symptoms. He especially felt inadequate when it came to understanding and treating the root problems underlying all these issues.
After attending Worldlink’s Part I Hormone Optimization course, Karl started implementing bioidentical hormone optimization with his patients right away. He saw immediate improvements in their health. He looked forward to seeing some of them again because they were heading in the right direction.
Karl was still handcuffed by the limited time he could spend with his patients and the sheer number of them. He was still working long hours and charting late into the night, which cost both him and his family.
When a colleague suggested they work together to start a direct primary care (DPC) practice, Karl wasn’t quite sure what that was. He did some research online and gradually started to see an exciting picture emerge.
Direct primary care (DPC) is primary care sold directly to individual patients, bypassing insurance (for the most part). Karl started Redi-Medi Integrative Clinic in 2014 to serve the primary care needs of Wenatchee, a small town of about 30,000 in central Washington state.
Redi-Medi’s website provides a transparent overview of Karl’s brand of DPC:
"We have shrugged the bureaucracy. We have shredded red tape. In refusing to recognize any interference with the sanctity of the patient/provider relationship, we have returned family practice medicine to its root values of clinical excellence for and compassionate knowledge of every patient. In every aspect of family health care, and custom health care, we promise accessibility, convenience, and affordability.”
Redi-Medi offers care for patients from age 0 to 100, with an affordable sliding fee scale: $20/month for young children to $55/month for adults 18-50 and $90/month for patients over 81.
That’s less than a monthly cell phone bill, something almost anyone can afford.
I talked with Karl about his DPC practice and the way it has evolved into an entirely cash-based model that’s focused on wellness and prevention, rather than chasing disease and waiting for reimbursements from insurance companies and Medicare.
In this unprecedented time of crisis, The Academy by Worldlink Medical is helping you stay safe and stay ahead with online CME mini-courses and live-streamed conferences. Earn CME credit and keep from getting cabin fever in the comfort of your own home or office.
Your newsfeed, email inbox, car radio, and television news have been chock full of information about Covid-19 and its far-reaching impact on our health and our economy. Worldlink Medical is committed to your safety and to the health and welfare of everyone in all our communities. We’ve been working tirelessly to provide you with alternatives to in-person conferences so all of us in the Worldlink community can stay safe but also stay up-to-date on evidence-based CME.
Consume something healthy for your body AND your mind
Green, leafy vegetables, small portions of high antioxidant berries and fruits, and healthy fats like avocado, olive, and fish oil all reduce inflammation and help you fight infection. Filling your mind with powerful, evidence-based continuing education helps reduce misinformation and keeps you sharp for your patients.
Without sporting events, theaters, meetings, and possibly even restaurants, many of us are going to have some extra time on our hands. Instead of numbing our minds with the latest #trendingonnetflix, let’s check out some of the brand new, accredited CME mini-courses at worldlinkmedical.com.
Topics range from clinical to medical practice business to lifestyle medicine. Here’s a sampling:
Testosterone Update Part 2 in 2020
Chronic Fatigue Syndrome & Hyperthyroidism
Estrogen Dominance in Men - A Misnomer
The Moral Imperative of the Integrative Practice of Medicine
Reversal of Cognitive Decline
CME mini-courses are a perfect way to get caught up between conferences or to catch those few extra credits you need at the end of the year. We’ve just launched online mini-courses and we plan to have many more in the coming months.
Keep your “social distance” but don’t lose touch with your community
If you have some extra time on your hands, this might be a good window to join the Worldlink community as a Free, Level I, or Level II Member. Membership allows you access to several benefits that can help you enhance your knowledge and your reputation as a hormone optimization specialist:
Free Level Membership Benefits
Provider directory - put your practice details on our website for possible patient referrals
Provider forums - get your questions answered by your colleagues with more experience
Level I Membership ($495/year) Benefits
All the benefits of Free Membership PLUS
Ebsco Host online research tool - helps you find and organize relevant evidence and studies for yourself
Journal Club - monthly discussions by a panel of Worldlink graduates, going over important studies in detail. Past Journal Club sessions are archived so you can watch them while you’re stuck at home.
Monthly CME Webinars - accredited webinars on a variety of topics. More high-quality education to take the place of mindless movie streaming when you can’t leave the house
Level II Membership ($795/year) Benefits
All the benefits of Level I PLUS
Simple Hormones - a revolutionary patient education program that helps you get your patients on the same page with you about hormones, while simultaneously saving you the time and frustration of having to answer the same questions over and over again
Avoid travel as much as possible
Don’t book any unnecessary travel plans for the next several weeks, maybe longer. This helps you steer clear of lines and crowds at airport security and hotels.
The Academy has announced live-streaming of our upcoming Part II and Part III courses. You will now be able to watch the entire Part II or Part III conference remotely, from the comfort of your own home or office.
While we firmly believe that live events and networking with your colleagues is the best way to learn, it’s not possible until this time of uncertainty has passed.
For now, we know you’ll miss out on the chance to rub elbows with the Worldlink community, but you’ll be able to do that at future courses, once the virus has run its course.
If you’ve already registered for Part II in Salt Lake City April 3-5 or Part III in Chicago May 1-3, simply let us know and we can change your reservation from the live attendance to online streaming.
In addition, we have moved The Business of Creating Health, to July 24-26. All other details (location, speakers, etc.) will remain the same.
Stay safe and spend some quality and quantity time with those you love!
Every occupation has its “occupational hazards.”
Nurses get stuck with needles. Police officers and military personnel get shot with real bullets in the line of duty. Firefighters get burned and suffer from smoke inhalation.
In 1860, Orange, New Jersey physician J. Addison Freeman published an article in The Transactions of the Medical Society of New Jersey entitled “Mercurial Disease Among Hatters.” Dr. Freeman gave a clinical account of symptoms common among people who worked in the hatmaking industry.1 This occupational hazard earned affected hatmakers the term “Mad Hatter” for the psychological and neurological symptoms of erethism or mercury poisoning.18
What if we discovered that members of a specific occupation group had high rates of depression, physical and emotional exhaustion, depersonalization, and lack of a sense of personal accomplishment?
What if 34% to 68% of those workers experienced at least 1 of these symptoms and the rates continued to climb, year after year?
Wouldn’t we want to figure out what’s behind this hazard?
Would there be a public outcry demanding a regulatory investigation, systemic change, and accountability for those responsible for placing people in danger? Maybe we’d even call for hazard pay or compensation?
This is exactly what’s happening to a group of workers you’re very familiar with.
Physicians, nurse practitioners, and physicians assistants are stressed, exhausted, overwhelmed, and even suicidal.
34% - In 2016, 34% of physicians self-reported burnout to a survey by Stanford Medicine's WellMD Center2
54.4% - The Mayo Clinic reported 54.4% of physicians it surveyed in 2014 as experiencing at least 1 symptom of burnout, up from 45.5% in 20113
68% - In 2019, Medical Economics asked physicians, “Do you feel burned out right now?” More than 2/3rds of physicians surveyed (68%) said, “Yes!”4
45.6% - The Journal of the American Medical Association reported an increase in burnout responses in their surveys from 40.6% in 2014 to 45.6% in 20175
42% - Medscape runs a burnout and depression survey for physicians every year and has reported a slight decline in physician burnout from 46% in 2015 to 42% in 2020.6
Whether the rate of burnout is 34%, 68%, or somewhere in between, medicine has a huge problem. The word epidemic has been used in dozens of articles and blog posts over the past few years to characterize medical burnout.
"There is a severe and worsening epidemic of physician burnout in the United States, which threatens the health of doctors and patients alike.”8
"There is an epidemic of physician burnout in the United States, and it has a pervasive negative effect on all aspects of medical care, including your career satisfaction.”9
"Physician burnout, defined as a work-related syndrome involving emotional exhaustion, depersonalisation, and a sense of reduced personal accomplishment, is not only a serious concern in China but also has reached global epidemic levels. Evidence shows that burnout affects more than half of practising physicians in the USA and is rising.”10
"There is a burnout epidemic that affects both physicians and patients. With a majority of American physicians experiencing some sign of burnout, it is a condition that affects all specialties and all practice settings.”11
"There’s a dangerous epidemic among medical professionals: Forty-four percent of all doctors surveyed in a 2019 Medscape report said that they feel long-term, unresolvable job stress, detachment and burnout from their work.”12
"When over half of all physicians are burned out and the trend is continuing to rise, there is a silent healthcare epidemic in this country that needs to be addressed. How long can we continue to ignore what is becoming a 'critical condition’?”13
"When over half of all physicians are burned out and the trend is continuing to rise, there is a silent healthcare epidemic in this country that needs to be addressed. How long can we continue to ignore what is becoming a 'critical condition’?”
"Physicians between the ages of 40 and 54 experience a higher rate of burnout than older or younger doctors, according to a recent survey of more than 15,000 physicians who cited administrative tasks and work hours as key drivers of their stress.”14
Electronic medical records, charting/paperwork, and work-life balance concerns show up repeatedly in these surveys as contributing to feelings of burnout.
Physicians Simon Talbot and Wendy Dean see a deeper root cause underneath concerns reported in surveys. The real issue, they say, has to do with healthcare providers who have lost any sense of control or autonomy. Their relationship to patients (and their lives) are controlled by insurance companies, physician groups, guidelines, electronic medical record systems, administrators, and bureaucratic busywork. They’ve lost the ability to do what they feel morally obligated, by their calling in medicine, to do, which is to care for patients.
“The real issue . . . has to do with healthcare providers who have lost any sense of control or autonomy.”
Talbot and Dean draw a chilling parallel between PTSD suffered by combat veterans and burnout suffered by physicians.
"The term 'moral injury' was first used to describe soldiers’ responses to their actions in war. It represents 'perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.' Journalist Diane Silver describes it as 'a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.’
The moral injury of health care is not the offense of killing another human in the context of war. It is being unable to provide high-quality care and healing in the context of health care.”15
Burnout plays a role in the suicides of roughly 300 to 400 healthcare providers every year. Physicians take their own lives at the rate of one per day. The suicide rate among doctors is 28 to 40 per 100,000, twice that of the general population and the highest of any profession.7
By comparison, the suicide rate among combat veterans is 30 per 100,000 . . . about the same as the rate among physicians, a statistic makes the case for the "moral injury” of healthcare practitioners even more chilling.16,17
“The suicide rate among doctors is 28 to 40 per 100,000, twice that of the general population and the highest of any profession . . . By comparison, the suicide rate among combat veterans is 30 per 100,000 . . .”
Healthcare provider burnout is a huge problem, an epidemic that’s leading people to take their own lives at alarming rates. But what can we do about moral injury and the lack of control providers experience in the healthcare system?
Many voices in the healthcare community advocate changing the system, allowing doctors more autonomy and giving them more time face-to-face with patients and less time pecking away at a computer screen. The problem with that solution is that the healthcare system is less about health or care and more about money. Insurance companies, pharma, hospital chains, medical investment groups, physician groups like AMA, ACOG, and NAMS . . . all of them take a piece of the pie. All of them have vested interests in keeping the system as it is. The physician has nothing to say about dwindling reimbursements, forced EMRs, and endless administrative tasks.
A second response is providers choosing to cut back their hours, retire early, or quit medicine altogether. This option has appealed to a growing number of physicians and the bleeding may contribute to a medical crisis of another kind.19,20 There’s a shortage of physicians in the U.S., especially in family practice and primary care.
Some healthcare providers still hear the call on their lives. For them, many are finding it is possible to stay in medicine and build a different type of healthcare practice that allows them to truly care for patients.
They’re making a difference in health and wellness . . . one patient at a time.
There’s no one-size-fits-all medical practice. Each provider is unique, with an individualized approach to caring for patients and building a sustainable, fulfilling, even profitable practice.
Types of medical practices include
Cash-based "Direct Primary Care” (DPC) model - patients pay a low monthly membership fee ($55 to $90/month) for the basic preventive healthcare
Cash-based “Concierge” model - patients pay a higher fee and get comprehensive wellness care and personalized attention from a physician, PA, or nurse practitioner
"Hybrid” model - takes insurance and also has a cash-based program for patients who want more extensive services like hormone optimization
Worldlink Medical has developed an accredited CME conference that helps you as a provider discover ways to blaze your own trail. It’s called The Business of Creating Health.
Whether you choose to take insurance, build a cash-based practice, or make a hybrid of both, our team of expert speakers can help you move toward the fulfilling practice of medicine you dreamed of when you went to medical school.
The Business of Creating Health is a 2 & 1/2 day immersive experience where you’ll get expert advice and input from attorneys, physicians, and qualified consultants who’ve helped hundreds of providers transform their practices into what they really can be.
You’ll hear from colleagues who have been where you are. They’ve made the leap into a practice where they’re spending more time caring for patients and their families and less time doing meaningless administrative tasks. You’ll hear their success stories and the pitfalls they faced along the way. You’ll understand how to build a legally compliant, financially sustainable, fulfilling medical practice that fits the way you want to treat patients.
If you’re ready to get take control of your medical destiny and create the practice you’ve always dreamed of . . . Join us in Dallas, Texas April 17th through 19th.
Freeman, JA (1860). "Mercurial Disease Among Hatters". Transactions of the Medical Society of New Jersey: 61–64.
2016 Physician Wellness Survey - Full Report, Stanford Medicine WellMD Center
Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014 [published correction appears in Mayo Clin Proc. 2016 Feb;91(2):276].Mayo Clin Proc. 2015;90(12):1600–1613. doi:10.1016/j.mayocp.2015.08.023
2019 Physician Burnout Survey: Results show growing crisis in medicine Medical Economics August 12,2019
del Carmen MG, Herman J, Rao S, et al. Trends and Factors Associated With Physician Burnout at a Multispecialty Academic Faculty Practice Organization.JAMA Netw Open. 2019;2(3):e190554. doi:10.1001/jamanetworkopen.2019.0554
Medscape National Physician Burnout & Suicide Report 2020 Medscape, January 15, 2020
Physicians Experience Highest Suicide Rate of Any Profession Medscape Medical News May 7, 2018
Peter Grinspoon, MD, Harvard Medical School June 22, 2018
Dike Drummond, MD Family Practice Management, September, 2015
Editorial, The Lancet, July 13, 2019
American Medical Association website
Lauren Steussy, New York Post, February 19,2019
Agnees Chagpar, MD, The Health Care Blog, February 5, 2016
Brianna Abbott, The Wall Street Journal, January 15, 2020
Physicians aren’t ‘burning out.’ They’re suffering from moral injury. Simon G. Talbot MD, Wendy Dean MD, Stat July 26, 2018
Why suicide rate among veterans may be more than 22 a day, Moni Basu, CNN, November 14, 2013. Retrieved: 25 December 2014
Veteran Suicides Twice as High as Civilian Rates, Jeff Hargarten, Forrest Burnson, Bonnie Campo and Chase Cook, News21, Aug. 24, 2013. Retrieved: 25 December 2014.
- By Steve Goldring, RPh
If you’ve taken any of Worldlink Medical’s CME courses with Dr. Neal Rouzier, you’ve learned about the hornet’s nest of controversy over prescribing hormones to women in menopause that’s been stirred up over the past two decades. If you haven’t attended a Worldlink course, you’re probably familiar with the landmark 2002 study, The Women’s Health Initiative.
That study had a major impact on the prescribing of hormones and, even more dramatically, on women’s willingness to take hormone replacement therapy. The WHI was stopped early, in 2002. Preliminary results were initially announced through press release and press conferences, rather than through articles in peer-reviewed scientific journals.
The most alarming statistic to come from the WHI was the contention that women taking HRT had a 26% increased risk of breast cancer over women who weren’t on hormones. Headlines in the lay media took hold of that terrifying number and ran with it, creating mistrust and fear in women (and healthcare providers) that has reverberated since.1
There it was . . . the last word on HRT.
“Hormones cause breast cancer!”
(according to the Women's Health Initiative)
Careful evaluation of the WHI leads thoughtful practitioners to question this statement, which has become conventional wisdom in the past couple of decades. The reality is much less frightening, if equally dramatic.
The data in the WHI does not show HRT to increase risks for invasive breast cancer.
We need to understand several key points regarding the WHI in order to untangle the truth from what the primary investigators have reported.
Let’s take a look at the patient population in the WHI.
The women recruited to complete the study were, on average, 63 years old. That’s about 12 years past the average age of menopause, 51. That means that very few of these patients were experiencing the symptoms that HRT would be prescribed for in the first place. The researchers specifically excluded patients who had moderate to severe hot flashes, on the grounds that these patients would easily see through double blinding and guess whether they were on the hormone treatment or placebo.
Because these patients were significantly older than women entering menopause, they also had multiple health issues that are associated with advancing age. About 35% of them were overweight. 34% were obese. 36% were hypertensive. Nearly 50% reported a history of smoking.2 The health status and age of the patients may have contributed to any untoward effects of the treatment provided in the study.
The poor health of a significant portion of WHI participants is ironic, considering the title of the final report, which refers to "Healthy Postmenopausal Women."
The specific hormones used in the Women’s Health Initiative were widely accepted as the standard of care at the time of the study.
The estrogen used in the WHI was conjugated equine estrogens. This estrogen combination was used in menopausal women since it was developed in the early 1940s by Wyeth-Ayerst. The specific estrogens in conjugated equine estrogens are somewhat of a mystery. Wyeth (now Pfizer) has been able to keep the exact composition a ‘trade secret” for decades. The pharma giant successfully blocked a “citizen’s petition” to the FDA to clarify its ingredients in 1996.3,4. There are at least 10 distinct conjugated estrogens in the horse urine preparation.5. Several of these estrogens are not found in human females and their safety and efficacy as individual drugs has never been studied. It’s obvious that a mixture of hormones derived from horse urine would likely be contaminated with an untold number of by-products, hormones and kidney-metabolized waste.
Wyeth also supplied the progestin given to these patients, medroxyprogesterone, a synthetic version of progesterone chosen for its potency. Medroxyprogesterone is chemically similar to progesterone except that it has an alpha-hydroxy group at position 17 and a methyl group at position 6.6 These slight chemical changes make medroxyprogesterone 10 to 20 times more potent than progesterone and have the potential to completely change its safety profile. Medroxyprogesterone has been used since the 1960s to counteract the endometrial hyperplasia caused by uterine exposure to estrogens.
In the past all estrogens were widely considered to have the same risks and benefits. All progestins were similarly considered equivalent. The evidence accumulated after nearly 2 decades since the study points to major differences between specific hormones, both in safety and effectiveness.7,8,9,10,11,12
A single sentence, or more precisely, a single word, from the Women’s Health Initiative findings telegraphs what’s wrong with the study.
“The 26% increase (38 vs 30 per 10 000 person-years) observed in the estrogen plus progestin group almost reached nominal statistical significance and, as noted herein, the weighted test statistic used for monitoring was highly significant.”13(emphasis added)
This sentence clearly states that the “26% increase” in breast cancer incidence seen in the WHI did not reach statistical significance. It almost did.
"The 26% increase (38 vs 30 per 10 000 person-years)
observed in the estrogen plus progestin group
almost reached nominal statistical significance . . ." WHI Writing Group
Study investigators chose to emphasize relative risk in their conclusions, highlighting a “26% increase” in risk that appears to be dramatic and frightening. The reality is that relative risk is just that, relative. The absolute risk is also found in the same sentence. “(38 vs. 30 per 10,000 person-years) . . .” The absolute risk of breast cancer was increased in the estrogen+progestin group by 8 breast cancer cases out of 10,000 women. That’s an absolute increase of 0.08%, much less dramatic sounding than the 26% emphasized in the study conclusions.
Again, this 26% increase in relative risk was not statistically significant, according to the researchers who wrote the study results.
That means there is no valid statistical argument from this study that conjugated equine estrogen plus medroxyprogesterone increases the risk for breast cancer and any increase would have to be considered coincidental. The investigators also concluded that there was an absolute decrease in breast cancer incidence in women taking only conjugated equine estrogens. Multiple evaluations of the WHI data since the original publication have confirmed the weakness of the association between HRT and breast cancer risk.
" . . . this 26% increase in relative risk [for breast cancer]
was not statistically significant"
A Fearful Message With Devastating Results
This post is not intended as a comprehensive review of every aspect of the Women’s Health Initiative study. Many qualified scientists have rightly criticized the study and the outrageous conclusions drawn by investigators.14 Others have taken these conclusions at face value, disseminating a message that hormone replacement is something to fear. That message has had devastating results on millions of women denied safe, effective treatment for life-changing menopause symptoms over the past two decades.15,16
If you’d like to understand more about the nuanced interpretation of The Women’s Health Initiative, you have two great options:
First, register for Worldlink Medical’s Part I Hormone Optimization course. In that AMA accredited CME course, Dr. Neal Rouzier goes into much greater detail about the WHI and the conclusions reached by researchers. You’ll discover the controversies and the political intrigue that has cast a shadow over hormone replacement for the past two decades. You’ll also discover the benefits of hormone optimization in reducing long-term health risks, including breast cancer, as proven by hundreds of valid studies showing actual statistical significance.
If you’ve already taken Worldlink’s Part I course, you’re eligible to become a member of the Worldlink community. Membership offers several benefits for providers who are making a difference by optimizing their patients’ hormones. A key benefit of Worldlink Level 1 and Level 2 Membership is Journal Club, where a panel of Worldlink trained practitioners evaluate relevant studies in detail, including a riveting session reviewing the Women’s Health Initiative.
Haas JS, Geller B, Miglioretti DL, et al. Changes in newspaper coverage about hormone therapy with the release of new medical evidence. J Gen Intern Med. 2006;21(4):304–309. doi:10.1111/j.1525-1497.2006.00342.x
Langer RD, White E, Lewis CE, Kotchen JM, Hendrix SL, Trevisan M. The Women’s Health Initiative Observational Study: Baseline Characteristics of Participants and Reliability of Baseline Measures. Ann Epidemiol 2003;13:S107–S121.
Department of Health and Human Services Office of Inspector General -- AUDIT "Review of the Food and Drug Administration's Handling of Issues Related to Conjugated Estrogens," (A-15-96-50002) May 16, 1997
Federal Register / Vol. 61, No. 217 / Thursday, November 7, 1996 / Notices
Bhavnani BR. Pharmacokinetics and pharmacodynamics of conjugated equine estrogens: chemistry and metabolism. Proc Soc Exp Biol Med. 1998;217(1):6–16. doi:10.3181/00379727-217-44199
Compound summary: Medroxyprogesterone | C22H32O3 PubChem
Fournier A, Berrino F, Clavel-Chapelon F. Unequal risks for breast cancer associated with different hormone replacement therapies: results from the E3N cohort study [published correction appears in Breast Cancer Res Treat. 2008 Jan;107(2):307-8]. Breast Cancer Res Treat. 2008;107(1):103–111. doi:10.1007/s10549-007-9523-x
Regidor PA. Progesterone in Peri- and Postmenopause: A Review. Geburtshilfe Frauenheilkd. 2014;74(11):995–1002. doi:10.1055/s-0034-1383297
Asi N, Mohammed K, Haydour Q, et al. Progesterone vs. synthetic progestins and the risk of breast cancer: a systematic review and meta-analysis. Syst Rev. 2016;5(1):121. Published 2016 Jul 26. doi:10.1186/s13643-016-0294-5
Mirkin S, Amadioa JM, Bernicka BA, Pickarb JH, Archer DF 17-Estradiol and natural progesterone for menopausal hormonetherapy: REPLENISH phase 3 study design of a combination capsuleand evidence review Maturitas S0378-5122(15) 00314-X/dx.doi.org/10.1016 j.maturitas.2015.02.266
Miller VM, Naftolin F, Asthana S, et al. The Kronos Early Estrogen Prevention Study (KEEPS): what have we learned?. Menopause. 2019;26(9):1071–1084. doi:10.1097/GME.0000000000001326
Palacios S, Mejía A. Progestogen safety and tolerance in hormonal replacement therapy. Expert Opin Drug Saf. 2016;15(11):1515–1525. doi:10.1080/14740338.2016.1223041
Writing Group for the Women's Health Initiative Investigators. Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women: Principal Results From the Women's Health Initiative Randomized Controlled Trial. JAMA. 2002;288(3):321–333. doi:10.1001/jama.288.3.321
Critiques of The Women’s Health Initiative PubMed Bibliography
Millions of women are missing out on hormone replacement therapy The Economist December 12,2019
Have you experienced the frustration of a patient who never seems to get better? You’ve diagnosed her with insulin resistance or even full-blown Type II Diabetes. You’ve counseled her on changing her diet. You’ve prescribed metformin to reduce glucose production in the liver. But on her next visit, her fasting blood glucose hasn’t changed or is even a bit higher. Her hemoglobin A1C isn’t budging. She lost a couple of pounds early on, but gained it back after a few weeks.
You’ve asked her how she’s doing with changing the way she eats and she says, “I’m trying."
Worst of all, your patient is clearly feeling discouraged. She’s ready to give up. "What’s the use?”
If you’ve ever experienced this scenario, you’re not alone. This frustration comes up all the time in our discussions with providers at Worldlink Medical CME events.
Nurse practitioner Beth York, from Nashville, TN, expressed her ongoing disappointment about her patients that never made any progress. She began to feel as though she was putting a Band-Aid on serious health issues, rather than truly moving patients toward health. She knew how to diagnose things like Type II Diabetes, but prescribing a medication and talking with the patient about lifestyle changes didn’t seem to be quite enough.
Not Making A Difference
Nurse practitioner Karl Lambert, from Wenatchee, WA, had been seeing 20 to 30 patients a day. He wrestled with the feeling that he wasn’t making any difference in their lives. This suspicion was confirmed when he’d see them again, 6 months to a year after, and nothing had changed. Same symptoms, same lab results.
Here’s the Good News!
You can make a difference.
It’s possible to start seeing patients improve their health, even patients with chronic diseases like diabetes and obesity that don’t seem to respond well to traditional treatments.
Providers who have trained with Dr. Neal Rouzier of Worldlink Medical have discovered a new paradigm in medical practice.
They’ve gone beyond the diagnosis of disease they’d been taught in medical school. They’ve started recognizing the impact that sub-optimal hormone levels can have on long-term health. These providers are looking at estradiol, progesterone, testosterone, thyroid hormones (T3 and T4, as well as TSH), DHEA, pregnenolone, melatonin, cortisol, and others.
They’ve discovered that getting these hormones back to “optimum” levels has a profound impact on whether patients make progress toward their health goals.
They’re also helping patients understand the benefits of diet and lifestyle changes that are much more effective when hormones have been optimized.
These practitioners are helping patients see the big picture of wellness and helping them feel better, lose weight, regain energy, and experience a fulfilling life.
Patient’s Body Fat Drops From 46% to 15% in 9 Months
New Jersey physician, Johanan Rand, MD describes his experience with a morbidly obese male patient. Presenting with chronic pain issues, the patient was objectively measured at 323 pounds and 46% body fat on Dr. Rand’s body composition machine. After optimizing the patient’s hormones, based on protocols taught at Worldlink Medical courses, and providing patient education, lifestyle management, and nutritional supplements, Dr. Rand saw the patient’s body composition dramatically improve, down to 15% after only 9 months.
Reducing Or Eliminating Medications
Nurse Practitioner Teresa Mealy, from Springfield, MO, has experienced the power of looking at the big picture in patients struggling with diabetes, rather than simply looking at the disease process alone. In her practice, she optimizes all the patient’s hormones, deals with lifestyle issues, diet, exercise, nutritional support, and stress. She has several examples of patients who had been diagnosed with Type II Diabetes. Some of them have been able to eliminate or at least reduce the number of medications they were on after being on her holistic program for a time.
You’ll Never Want To Go Back
Karl Lambert would never want to go back to the “Sickness Model” of treating patients. The results he’s seeing have revitalized his passion for medicine. He’s even looking to approach companies with a proposal to help them with diabetic patients by getting them healthier.
Helping diabetics reverse their diabetes is something no one dreams of . . . until they find out it’s really possible.
If you’d like to learn more about the tools of hormone optimization these providers have used to make a difference for their patients, Worldlink Medical’s Part I Hormone Optimization course is the best place to start. Click here to register for the next session of this life-changing, accredited CME course.
Evidence Supporting Improved Outcomes With Optimal Hormones
Heufelder AE, Saad F, Bunck MC, Gooren L. Fifty-two-week treatment with diet and exercise plus transdermal testosterone reverses the metabolic syndrome and improves glycemic control in men with newly diagnosed type 2 diabetes and subnormal plasma testosterone. J Androl. 2009;30(6):726–733. doi:10.2164/jandrol.108.007005
English KM, Steeds RP, Jones TH, Diver MJ, Channer KS. Low-dose transdermal testosterone therapy improves angina threshold in men with chronic stable angina: A randomized, double-blind, placebo-controlled study. Circulation. 2000;102(16):1906–1911. doi:10.1161/01.cir.102.16.1906
Shifren JL, Braunstein GD, Simon JA, et al. Transdermal testosterone treatment in women with impaired sexual function after oophorectomy. N Engl J Med. 2000;343(10):682–688. doi:10.1056/NEJM200009073431002
Achilli C, Pundir J, Ramanathan P, Sabatini L, Hamoda H, Panay N. Efficacy and safety of transdermal testosterone in postmenopausal women with hypoactive sexual desire disorder: a systematic review and meta-analysis. Fertil Steril. 2017;107(2):475–482.e15. doi:10.1016/j.fertnstert.2016.10.028
Salpeter SR, Cheng J, Thabane L, Buckley NS, Salpeter EE. Bayesian meta-analysis of hormone therapy and mortality in younger postmenopausal women. Am J Med. 2009;122(11):1016–1022.e1. doi:10.1016/j.amjmed.2009.05.021
Sánchez-Rodríguez MA, Zacarías-Flores M, Castrejón-Delgado L, Ruiz-Rodríguez AK, Mendoza-Núñez VM. Effects of Hormone Therapy on Oxidative Stress in Postmenopausal Women with Metabolic Syndrome. Int J Mol Sci. 2016;17(9):1388. Published 2016 Aug 24. doi:10.3390/ijms17091388
Rossi R, Origliani G, Modena MG. Transdermal 17-beta-estradiol and risk of developing type 2 diabetes in a population of healthy, nonobese postmenopausal women. Diabetes Care. 2004;27(3):645–649. doi:10.2337/diacare.27.3.645
Smith NL, Blondon M, Wiggins KL, et al. Lower risk of cardiovascular events in postmenopausal women taking oral estradiol compared with oral conjugated equine estrogens [published correction appears in JAMA Intern Med. 2014 Sep;174(9):1523]. JAMA Intern Med. 2014;174(1):25–31. doi:10.1001/jamainternmed.2013.11074
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Janjgava S, Zerekidze T, Uchava L, Giorgadze E, Asatiani K. Influence of testosterone replacement therapy on metabolic disorders in male patients with type 2 diabetes mellitus and androgen deficiency. Eur J Med Res. 2014;19(1):56. Published 2014 Oct 23. doi:10.1186/s40001-014-0056-6
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Yassin DJ, Doros G, Hammerer PG, Yassin AA. Long-term testosterone treatment in elderly men with hypogonadism and erectile dysfunction reduces obesity parameters and improves metabolic syndrome and health-related quality of life. J Sex Med. 2014;11(6):1567–1576. doi:10.1111/jsm.12523
A recent paper claimed that nonalcoholic fatty liver disease is an unrecognized epidemic. There is no FDA approved drug for treating and reversing NAFLD, however, sustained weight loss can reduce the risk of cardiovascular events and diabetes. Unfortunately, the article did not address how to be successful with weight loss. Weight loss attempts have obviously been unsuccessful if NAFLD is now epidemic. “Both NAFLD and CAD represent end-organ manifestations of the same systemic metabolic insult, all related to insulin resistance.” What the authors did not address is that the cause of the insulin resistance is hyperinsulinemia, and not the other way around. (Thank you, Jason Fung, for introducing this concept). In my last newsletter I described the lack of success and the increase in harm we have recently encountered with commonly prescribed diabetic medicines. Not only are we not making a dent in CVD prevention, but we now see an epidemic of NAFLD as over 70% of diabetics have NAFLD, which apparently is not being controlled by standard diabetes treatments. And I wouldn’t expect it to as I now have an understanding that diabetic meds don’t get rid of serum glucose, rather they drive the glucose into another compartment: the cell. I believe that this increase in NAFLD is due to our inability to understand the mechanism of current medicines which increase production of, or function of, insulin that drives glucose into the cells. Overloading the cell with glucose is not the solution. Rather, preventing intake of glucose by diet, maintaining a fasting state to provide ketosis to reduce visceral and intra-organ fat, preventing storage of glucose into glycogen and fat, increasing metabolism of fat, and increasing excretion of glucose, as opposed to sweeping it under the carpet or into the cell, is the solution. And the basic underlying problem is hyperalimentation of glucose and sugars that result in hyperinsulinemia when the cell cannot handle the increased glucose load caused by the hyperalimentation.
Professor Samuel Klein states that 2 million people have cirrhosis caused by NAFLD. However, the main cause of death is not liver failure but is CVD and the incidence of CVD continues to increase despite multiple drugs used to prevent DM and CVD. It’s the hyperinsulinemia that increases fat deposition in the liver and adipose tissue. Weight loss reduces visceral and liver fat, but this is difficult to implement. Well, not if you know how to do it. Jason Fung and his staff will take us through the educational process to understand how to be successful in treating ourselves and our patients. Nevertheless, not everyone can be successful as our hypothalamic set point fights us by slowing down our metabolism to maintain a set weight and body mass index, which can be difficult to overcome. I too will demonstrate my success with patients in helping them maintain optimal metabolism, which maintains weight loss. I will also provide all the literature support and studies demonstrating safety and efficacy of optimizing hormones, but probably different to what others are accustomed to doing. I will also provide all the studies that practitioners should be familiar with when optimizing HRT. Our focus should be on prevention, treatment, and reversal of disease which has not occurred in the majority of trials for CVD prevention using conventional medications.
The following are excerpts from recent papers from JAMA and NEJM:
“However, a resurgence of diabetes complications has appeared in national statistics and in the epidemiology literature. An increase in diabetes-related amputations has occurred nationally. Updated national statistics indicate that the recent increase in complication rates is occurring in middle-aged adults, among whom the risk of hyperglycemic crisis, AMI, CVA, and amputations each increased by more than 25%.” We obviously are not doing something right. “Most counties in the U.S. have seen an increase in cardiovascular disease mortality among adults.” Hmmm, just what is it that we are doing wrong that’s not working? Rather, what should we be adding that we are not? Perhaps not giving drugs that drive glucose into the cell should be a start. Other than type I diabetes, I know of no other disease entity in which there is a deficiency of glucose entering the cell. If the cell is storing glucose as fat, triglycerides, and glycogen, then the cell is already overloaded and getting plenty of glucose on its own. If the liver, kidney, pancreas, and visceral organs are all storing excess glucose as fat, then there is plenty of glucose getting into the cells. Enter diet, exercise and life-style change. Secondly, we should be disposing of the glucose by every other means possible and keep it out of the cell. Next we should be preventing the glucose from getting into the cell by metabolizing it in muscle and liver. Enter hormones. Next we should be providing less glucose into the body in the first place. Enter Jason Fung. (I’m currently fasting as I write this, and it really is easy.). Lastly, we should be disposing of and excreting the glucose that enters the body. Enter the new diabetic drugs. Perhaps we should be preventing this metabolic insult instead of just treating the disease by pushing serum glucose into the cells. That has been Dana’s goal for 20 years-establishing a medical academy that focuses on health and wellness, and promotion of that concept to physicians. This next Hormones and Beyond Cardio-Metabolic Symposium brings all this to fruition. Other medical academies attempt to reach this goal but have failed. And that’s why I am so excited about the upcoming Hormones and Beyond Symposium.
“This means that the future direction of diabetes complications has enormous collective implications for health and costs.” (JAMA 2019;321(19):1867-68). Yes, but why do studies show that CVD and outcomes are getting worse? And why is it that spending billions of dollars on health care and medications do not result in less CVD? Here’s why as explained in JAMA.
“Optimal diabetes care is predicated on balancing the immediate and long-term sequelae of the disease and its therapies and improving patient health and well-being. Professional societies have focused on HgBA1C levels to gauge the quality of diabetes care. The preferential use of HgBA1C levels in research, policy, and practice stems from the demonstrated association between lower HgBA1C levels and disease endpoints. (Observation does not prove causation and a correlate does not a surrogate make). However, these studies did not demonstrate improvements in outcomes that are most meaningful to patients such as CVD, stroke, and mortality. Thus, HgBA1C level is a surrogate marker for a proxy of uncontrolled disease. (Remember, just because high levels portend harm does not mean that lowering HgBA1C fixes the problem. And that depends on how one lowers the HgBA1C by either driving glucose into the cell ((bad)) or metabolizing it ((good))).”
“Similarly, for clinicians, HgBA1C level is an effective monitoring tool that is responsive to real-time changes in blood sugar control. Nevertheless, even though HgBA1C level is a valuable forewarning of future events in patients with diabetes and has an important role in reflecting the patient’s average level of glycemia, it (HgBA1C) should not be the outcome that matters most or that is prioritized at the expense of meaningful outcomes that are important to patients (and us).”
“Fallacy of the Surrogate: The rationale for using HgBA1C level as a surrogate marker for diabetes outcomes is predicated on the assumption of its direct correlation with improved outcomes that patients and doctors value like MI, CVA, and quality of life. Yet, the strength of this relationship has been called into question as the outcomes can be worse (even though the HgBA1C is lower). Meta-analyses revealed a null association between intensive glycemic control and these cardiovascular outcomes.”
“However, the importance of glycemic control for patients with type II diabetes cannot be extrapolated from data developed among patients with type 1 diabetes. The glucose-centric model of type 1 diabetes cannot be transferrable to the management of type II diabetes.” (In type I DM there is a deficiency of insulin and intracellular glucose whereas in type II there is excess insulin and intracellular glucose). Moreover, HgBA1C level may be misleading and its singular prioritization could lead to patient harm.” Yikes!
“The new GLP-1 RA and SGLT-2 inhibitors were demonstrated to reduce major macrovascular events and death independent of glycemic control.” (In other words, these new meds can lower CVD disease by other mechanisms other than lowering serum glucose). Then, what parameters and outcomes should we measure and follow? “Consideration should be given to reverse the routine use of surrogate markers like HgBA1C and instead refocus on the following outcomes that are important: CVD. Encouraging clinicians to embrace patient centered care unencumbered by the constraints of the HgBA1C level could allow them to instead focus on the outcomes like CVD. To improve the quality of value of diabetes care, it will be necessary for patients and all those involved in their care to focus on what truly matters-that which improves their lives and outcomes, and not their laboratory numbers.” (JAMA 2019;321(9):1865-67). Bingo!
I hope that the foregoing was as enlightening for you as it was for us. I’ve stopped chasing HgBA1C levels and the fruitless administration of expensive diabetic meds that lower HgBA1C but not disease outcomes. I now focus on lowering HgBA1C levels by other means. Instead I chase waist circumference, visceral fat, body weight and BMI, vascular responses, lipid levels, plaque scores, quality of life, and patient satisfaction. That’s what Hormones and Beyond is all about. Hope to see you in Austin.
Click Here To Access Articles Referenced
The timing was perfect as it could not have happened at a more opportune time. Two articles in JAMA made claim to the fact that our treatment of diabetic patients with typical diabetic medicines increases the risk of MI and CVD. What? I thought that we needed tighter BS control to lower the risk of CVD and diabetic vascular disease? Later, the NEJM published a study that tight BS control did not improve CVD outcomes and even showed an increase in CVD events. What, how can that be? Is everything that I/we have been teaching, preaching and doing for the last 30 years incorrect? Now, after reading Jason Fung’s book I understand why that is. It is true that the higher the HgBA1C level, the worse the prognosis and the sooner one dies from the foregoing diseases. However, just because high levels of HgBA1C are associated with increased morbidity and mortality, that does not mean that lowering the HgBA1C results in less disease, or that lowering the blood sugar is of benefit. It makes sense to lower BS and gain tighter control and lower HgBA1C levels if high levels increase the risk of disease, but the outcomes prove otherwise. Why? Maybe because what we have been doing, and falsely misled to believe, is wrong. Lowering blood glucose is correct and appropriate, however, how we lower it is the key to understanding why using one method improves but the other worsens outcomes.
A recent TV ad for a GLP-1 analog claimed that there was no increase in MI or CVD events with this medication; their selling point was that there was no increased risk of MI? Yay, yippee, finally a drug that does not increase heart attacks! Wait. What? Why are we giving drugs to lower BS that in turn increase heart attacks, cause significant weight gain, and increase morbidity and mortality? I thought that lowering BS was good. For years I kept increasing diabetes meds, trying to maintain tighter BS control. But the patients all gained weight and their disease got worse. So, I added more meds and started long-acting insulin and they gained even more weight. I once bet a patient that if he lost 20 pounds I would give him $10,000. He failed. Then I went double or nothing. Not only did he fail but he gained weight. I blamed him but little did I know and realize that it was my fault and not his. This was before I read Jason Fung’s book The Diabetes Code and learned how and why DM meds made CV disease worse. My heart sank.
A recent video on Medscape made reference to the fact that “Cardio-Metabolic Disease” should be made a new specialty. Based on all the GLP-1 analogs and sodium-glucose cotransporter 2 inhibitors reducing weight, disease, and MI risks, the specialty is definitely changing and gaining momentum. So why are these new drugs any different? Although these meds work by various mechanisms to lower BS, lower HgBA1C levels, and improve CVD outcomes, the main importance is that they lower BS by different mechanisms other than increasing beta cell function, insulin levels, and driving glucose into the cell. These new wonder drugs decrease appetite, slow down glucose absorption, decrease gluconeogenesis, and increase glycosuria through the kidneys. The most important take away is the ability to decrease BS by different mechanisms other than driving glucose into the cell which all past drugs did, particularly insulin. By cramming all the excess glucose into the cell, the cell becomes overloaded with glucose which the cell must dispose of by storing it as fat and glycogen or converting it into triglycerides. Hence, the onset of fatty liver, fatty pancreas, fatty kidneys, dyslipidemia, NAFLD and NASH. I blamed all my patients for their weight gain and disease progression. And I blamed myself for not being more vigilant in maintaining tighter BS control. I had no clue. Mea culpa, mea culpa, mea maxima culpa.
In June, Reaven published in the NEJM that intensive glucose control in type 2 DM patients proved just as likely to cause a MI as standard therapy. Patients also gained weight and had worse disease outcomes. Perfect. There was no better outcome in MI, CVA, CHF, CVD, death, DM complications, or QOL scores. Even after 15 years of tight control, no benefit. So, what was their suggestion to improving outcomes? The researchers recommend treating DM even sooner and much more aggressively, as though 15 years of tight BS control was not enough? (Einstein said insanity is doing the same thing over and over again but expecting different results!) Professor Simmons stated that the data from the VADT study was consistent with findings from other studies. She finally admits that perhaps we should decrease medications if the risks outweigh the benefits. The authors do note that these results are before the GLP-1 receptor agonists and SGLT2 inhibitors were available. However, their treatment suggestion was to use more and more drugs that consistently do not work. Hmmm. Those thousands of researchers need to read and grasp Jason’s book in order to see why they, and their patients, fail.
In the REWIND study, dulaglutide reduced MI risk by 12%. That’s relative risk and not absolute risk which was much smaller. (The RR was 12% but the absolute risk (AR) was only 1.4%, with 3.4% MI in control group and 2.0% in treatment group=1.4% AR). It was the first major study that proved superiority over standard care, which has been consistently harmful. (An absolute risk reduction of 1.4% is quite underwhelming, but the researchers jumped for joy). So, there is less harm with the new drugs than in comparison to standard therapy (which increased risk), but what about with control groups? “In assessing the individual components of the composite outcome, Gerstein noted that there was no discernable effect observed for nonfatal MI with dulaglutide and a neutral effect observed for CV death.” You mean, no benefit? That is correct, no benefit. No benefit after spending millions of dollars on drugs and they do not work to reduce CVD? Hmmm. Their conclusion was that dulaglutide “could be considered for the management of glycemic control.” Could be? Why didn’t they state, “should be or must be?” Because the results were underwhelming and the cost $900/month!
There are better, safer, tried and true solutions to the above. That is what Part V Hormones and Beyond is all about. Jason Fung will review his secrets and insight for success. I will review all the medical literature demonstrating what we should be doing as well as what we should not be doing. Hope to see you in October.
You will find a new level of confidence as you move from the basics of Part I to the advanced protocols in Part II. The Part II course provides the experienced practitioner with training that is essential for mastering more complex cases. The course will serve as a short refresher, but will highlight new important therapies, clinical pearls, tricks of the trade, controversies and everything that I could not cram into Part I that you still need to know. The field of age management medicine continues to grow at a rapid rate, and we only seem to get busier, making it difficult to stay abreast of all the changes. This is why we’ve condensed an inordinate amount of material into 2 ½ days—in fact, there are over 1,300 slides of information (Yikes! I’ll talk fast).
My favorite part of this course are the informal discussions and Q&A sessions at the end of the day where we discuss anything that you want to discuss. This is one of the most interactive ways that new attendees expand their clinical knowledge by learning and sharing experiences, audience discussions, difficult cases, controversies, legal issues, suggestions, medical board issues, trials and tribulations from other seasoned attendees. I’ve yet to find anywhere else where can one go to participate in such a gathering and meeting of HRT practitioners that share their successes and challenges. This discussion is a wonderful prelude to the topics covered throughout the remainder of the weekend:
Antiaging, definitions of, and why we call it that. This is a review of the medical literature articles that shows us why we refer to BHRT as antiaging and provides credence for why we do what we do.
Longevity medicine and which hormones have a proven record of extending health, wellness, and longevity. Yes, optimization of HRT does extend life.
*NOTE: THE SECTIONS ABOVE ARE RECORDED AND WILL BE SENT OUT AHEAD OF TIME AS A REVIEW. THE ACTUAL COURSE INSTRUCTION WILL FOCUS ON ALL NEW MATERIAL.
Section 1 – Review and Critique of the WHI and HERS Study
Making sense out of the many HRT studies, the critiques, and the rebuttals. Putting the pieces together will make you an expert on all the ifs, ands, and buts. It is the knowledge and command of this scientific literature (that your colleagues will never know) that makes you the expert.
Section 2 – Bioidentical HRT: A Critical Literature Review
The positive and negative articles on BHRT. Laying to rest estriol as the worthless metabolite it is. What the literature shows we should use and shouldn’t use, and disproving what many others are teaching without any basis.
Section 3 - Hormones and Cancer Protective or Causative
“There are no studies that prove BHRT is different than synthetic HRT.” Baloney! Many studies contrast the BHRT with SHRT. Know when it’s safe to prescribe and when
Section 4 – Important Articles on HRT, Don’t Ignore the Literature
A literature review proving that HGH, testosterone, estrogen, progesterone, DHEA, and melatonin protect against cancer.
Section 5 – Progesterone Optimization
This section is “R” rated for language and me acting out: Optimization of progesterone and case examples, multiple studies that prove transdermal cream is worthless and harmful, and saliva testing for monitoring therapy is fraught with error. Scientific studies prove where your levels should be for maximum protection, and where they should not be if one wants to protect against cancer. Case studies with labs show the good and bad.
Section 6 – Testosterone, New and Different Administration
New and different methods for raising testosterone in men and women besides creams: Oral, SQ, IM, HCG, Clomid, which are the cheapest and which are the best.
Section 7 – Oral vs Transdermal Estrogen
Oral vs. transdermal estrogen, relative risks for both, safest vs. most beneficial. Which, when, why and how the ESTHER study guides us.
Section 8 – Thyroid and CVD vs Osteoporosis
A literature update of thyroid for cardiovascular protection and osteoporosis protection. So you think you know thyroid? More literature backing for why we do what we do.
Section 9 – Cardiovascular Disease Prevention
Cardiovascular disease protection, cardiac markers, eicosinoids, diet, EFA’s, insulin, inflammation.
Sections 10 – Cardiology Case Management
Cardiovascular disease protection, cardiac markers, eicosinoids, diet, EFA’s, insulin, inflammation.
Section 11 – Complex cases with Lab Review
Cardiovascular case studies with management beyond statins.
Section 12 – More Literature Review for HRT
Diagnosis and treatment of the most common premenopausal endocrinopathy that everyone fails (misses) to diagnosis, and it’s relation to CAD, breast CA, and uterine CA.
Section 13 – Question with Answers
Section 14 – PCOS
Polycystic Ovary Syndrome is the most common endocrine disorder in premenopausal women. It’s more common than you think, learn to recognize and treat this condition
Section 15 – Osteoporosis and Estrogen Metabolites
Treatment of osteoporosis beyond biphosphonates: E2, D3, Vit K, strontium, & ipraflavone. Measuring and monitoring NTX & CTX. Estrogen metabolites- do they or do they not predict breast cancer and should we waste money on testing? 2OH-E1 vs. 16αOH-E1?
Section 16 – Estrogen and Progesterone in Men
Importance of optimization of estrogen in men too and the harm of suppression. The harm of giving progesterone to men that increases inflammatory cytokines and ED (what are they thinking)?
Section 17 – Chronic Fatigue Syndrome and Cortisol
Cortisol for fatigue and CFS, how and when to use it, how to monitor it, and test it with ACTH.
Section 18 - References
Complex cases, labs, adjustments, fun and interesting cases, and lots of WWND (What Would Neal Do?)
Thanks everyone hope to see many of you in Indianapolis!
It is now time to start to prepare the lectures for Part V, which I start organizing a year in advance. It is also time for everyone to block out October 5-7 on their calendar, so you can attend this year’s WLM symposium. My interest/focus this year will be the brain, breasts, prostate, and mitochondria. And I’m pleased to announce this conference as our 20-year anniversary event. Dana has worked long and hard to make this reunion special. And so have I by organizing a review of the most recent profound literature that we should all be aware of. It is my annual update of literature that I can’t cram into the courses but that we should have command of to better treat our patients.
During my toxicology fellowship we were taught that the best treatment for a poisoning was to prevent the poisoning in the first place. The same concept applies to dementia and Alzheimer’s disease. After 30 years of failure by the pharmaceutical industry to develop a cure for Alzheimer’s disease, we still have no treatment after billions of dollars in research. However, the best treatment still is to prevent the disease in the first place. There is an amazing plethora of data proving loss of hormones is culpable and replacement is protective. Our ignorance is embarrassing when it comes the research showing benefit. “Yea but…the WHI showed…” I hope that I can cram all the articles that I want to show you into 3 hours of lecture demonstrating many different hormones affect the brain. UCLA is one of the outstanding universities that has a special section devoted to treating dementia, with Dr. Bredesen heading that endeavor. Unfortunately, he will not be presenting but Dr. Sharlin will review UCLA’s protocols as well as functional medicine treatments that have been shown to provide reversal of cognitive decline and improvement in symptoms. SPECT scans demonstrate plaque reversal with BHRT but not so with SHRT. It’s impressive. Patients can now go to you for treatment/prevention without having to travel to UCLA.
As you know I used to run at the front of the pack. In the last 10 years I have moved to the back of the pack, choosing not to fight the fight I used to fight, allowing the naïve specialists to have the upper hand. The pendulum has now swung back in the opposite direction. Patients should not have to suffer the inadequacies of their specialists nor should we have to play second fiddle. I’m tired of dealing with physicians that don’t understand why we do what we do or ignore the literature that supports it. It’s time to show and prove to the specialists that which they should know but don’t. Yes, I do pity them because there is no venue for them to learn this information other than WLM. Unfortunately, it is the patient that suffers the consequences of the physician’s lack of knowledge. Thus, I’ve taken on the role of being the patient’s advocate, empowering them to understand an alternative treatment or prevention that is all evidenced based, but that which is going to be rejected by their PMD’s. I now provide articles to patients supporting the important benefits of testosterone in prostate cancer patients, progesterone and testosterone in breast cancer patients, and the safety and efficacy in prevention and treatment of these diseases. I will provide and review all the studies that you should have in your quiver to present to patients and their physicians that reject what we do because the physicians have not a clue. I’m tired of letting the patients endure the consequences of physician ignorance. All new and recent evidence will be presented. Please utilize these studies to provide direction and support to your colleagues and patients.
The diagnosis and treatment of prostate cancer continues to evolve yet remains controversial. Dr. Bernadette Greenberg from Desert Medical Imaging will present the update in diagnosis and treatment as well as the use of genomics to predict outcomes. This will be the most captivating lecture you will ever hear as I have never experienced any lecturer as dynamic as this lady. Be prepared to be blown away by her knowledge and presentation.
We at WLM are pleased to now have a 2-hour presentation before Part I to help attendees “figure me out.” This is presented by Dr. David Kern who has the same sarcasm and insight as I do. He will be presenting all the data on how glucose affects the brain, dysglycemia, and protein glycation.
A new addition to WLM is a separate course on PRP, injection techniques, and the latest literature by Dr. Nacouzi. Unfortunately, the PRP course sells out due to the popularity of this new and easy treatment. We’ll learn why it is so popular and how to incorporate this procedure into your practice.
We have tried to introduce new and promising concepts that we can incorporate into our practices. I know nothing about genetic testing, epigenetics, when to test, and what to do with the results. What I have read in JAMA is confusing and perhaps political. Dr. Stickler will enlighten us as to what, when, and why to test and then what to do with the results.
I also know little about cannabis, cannabinoids, CBD, etc. Are they a safe and effective alternative to opiates now that we suffer from opiate paranoia? I have had many patients request it with excellent results. Now that it is legal in California and other states, pot shop owners know more about cannabis than physicians. So, we have chosen Dr. Felice to enlighten us about what we should know about this alternative for pain and sleep management.
Our resident attorney and business consultant that teaches the WLM business course will provide an update on practice management, compliance, and how to avoid hassles with insurance and regulatory agencies. As far as hormones are concerned I have focused in this course primarily on breast cancer, prostate cancer, and mitochondrial dysfunction.
I would like to focus on the recent literature as it pertains to my personal situation and how HRT has helped me in this regard as well as the medical literature as it pertains to pain. After 30 joint surgeries, joint sepsis, 5 back surgeries, and over 20 IV antibiotics that have played havoc with my gut that resulted in significant inflammation, I’m an expert in pain management and gut dysbiosis. Pain can affect our psyche and sleep cycles. I’ll review the recent literature as it pertains to opiates effects on hormones. Concurrently, hormones have been shown to have a significant impact on multiple nociceptive pathways that result in significant pain improvement. Unfortunately, do to my snips, opiates and cannabis don’t work for me but I’ll present literature and as to what does work and why.
Lastly, and most disturbingly, is a topic that I must address but with grave reservation and frustration, and that is our legal environment. It is a complete system failure, from the process of medical board complaints, to medical board handling of complaints, to reliance on completely inappropriate endocrine guidelines as if they were case law. I will review all the cases (with fake names, case scenarios, and circumstances of course) that I have had to deal with so that history doesn’t repeat itself. More importantly, I will discuss my solution to the issues and how everyone can help. This will be an audience participation time, Q & A, discussion by Dr. Kadambi (esteemed endocrinologist that totally gets it), and how we can all help each other through this process. Number one on my current bucket list is to educate the medical boards to the literature as well as stop using worthless and outdated guidelines to sanction physicians that only make their patients better. WLM attendees should be the experts that review these cases, not a specialty that has no understanding of the literature and current studies. I will enlist everyone’s assistance in doing so. We will spend an entire evening addressing these issues and concerns.
Last year’s Beyond Hormones conference at the Lied Lodge will be hard to beat. However, we are going to try to make this anniversary celebration better than last year with great food and entertainment at a fabulous resort in Tucson. I’m looking forward to a great reunion this October and hope to see everyone there.
Kindest regards, Neal
Neal Rouzier, M.D.
When planning a weekend-long course to learn and incorporate a significant clinical advancement such as PRP, it should be thought of carefully. The presented material and exercises need to be clinically relevant, succinct, and applicable.
After attending many PRP-specific conferences, I recognized that the same contents and formats were endlessly being recycled. The hands-on exercises often left me wanting and in the worst cases, left me questioning the clinical experience of the instructors. As presented, to try and apply these experiences the next day in my own practice would be unreasonable, if not unsafe.
There needed to be a format that would allow attendees to easily apply the information they were presented. Thus, after performing over 2500 procedures in our office, I decided to put together a course summarizing the up-to-date thinking on PRP along with a way to establish confidence in those performing some of the most common procedures encountered.
As a result, my colleagues and I have summarized the majority of our experience thus far with PRP. We have read and abridged hundreds of articles regarding preparation, dosage, activation, and implementation of PRP into an easily applicable format. We then developed a system of reference for each step of implementation, including: functional diagrams, planning methods, safe zones, dosing, adjunct product use, pearls of injection, caution zones, follow-up, and discussion of relevant challenges encountered.
In addition, we will share the intricacies and important modifications needed for PRP preparation. The latest recommendations and reasoning proposed by leading European and international researchers.
In order to make the most of our time together, we will substitute more long-winded pathway lectures with hands on need to know material, and the complete reference material will be distributed to attendees in advance for their conference.
Every slide in our program will be relevant material aimed to benefit attendees in their own practice. As such, we will have two one-hour open discussion periods based on the questions asked at registration. The hands-on-lab will offer over ten live cases to participate in and will include the application of neuromodulators (Botulinum A toxins), Hyaluronic filler injections, facial volumetric remodeling, and other relevant procedures. In addition to our hands-on-lab, 5 conference attendees will be able to volunteer for 5 independent procedures guided by myself and my colleague.
We welcome you to our conference.
Dr. Nacouzi, MD
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