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"Sexy" - part 3 of the CWI Lecture Series - June 2012f sss lectures series for slide share - june july 2012.pt
1. SEXY! Part 3 of 3, plus…
21 Century Medicine
st
Louis B. Cady, MD – CEO & Founder – Cady Wellness Institute
Adjunct Professor – University of Southern Indiana
Adjunct Professor – Indiana University School of Medicine
With Whitney W. Gabhart, ND - Cady Wellness Institute
Newburgh Public Library July 11, 2012
3. CURRENT PRACTICE OF MEDICINE:
What a patient had to say about her “specialists”:
“They just monitor my
degeneration.”
4.
5. Cady Wellness Institute – July 2005
The Reasons:
• Conventional medical practice had failed me twice.
• A lot of “psychiatric cases” WEREN’T “psychiatric.”
• Nobody was integrated.
• Nobody was looking at ALL of the peer-reviewed
literature.
6. Orientation to this talk
• Review the fundamental differences
between “wnl” and OPTIMAL
• Quick review of hormones having to do with
with “slim and sane” sections of this series
– Thyroid
– DHEA
– estradiol/progesterone
– IGF-1 (“food soldier” of growth hormone)
– Integration of testosterone
• Exposure to current “state of the art”
7. American Journal of Health Promotion;
November/December, 2002
66% 19% of those
18.8%
“Incompletely healthy” surveyed were
completely
completely
unhealthy,
healthy with
defined as
high levels of
having low
both physical
levels of health
and mental
with high Two-thirds of the adults health and a
levels of reported some low level of
illness. degree of mental
illness.
or physical
illness that kept them
from being completely
healthy.
OPTIMAL
“Incompletely healthy.”
DEAD
HEALTH continuum
8. Critical area of concern for men &
women. Things that will make them:
• Tired &/or depressed
• Unable to cope
• “Mean”
• Stressed
• Demented
• Deficient in libido or in the bedroom
10. “Age management” “Conventional practice”
There are fuel additives No fuel additives should
we can use to keep our be used. They are
cars burning cleaner and unnatural. Gas is all that
preserve engines. is required.
We should use optimal The quality of the gas is
quality of gas. Cheap gas irrelevant. Anything that
causes “pinging” which is the motor will burn is
hard on the engine. adequate.
We should take our car in Preventive maintenance? This
for preventive is silly! Wait until something
breaks, then have the car
maintenance before
towed in so the mechanic can
anything breaks.
really tell what is wrong.
11. And if you’re just a tired
ol weenie (or weenette),
you will definitely note
be feeling SEXY.
12. Toward an INTEGRATED approach:
Traditional INTEGRATED
Optimal Health
No Disease = Health
Medicine Medicine
Forestall and
Diagnose and PREVENT Disease –
Treat Disease Optimize Mood &
Death
Function
New Drugs Functional
New Surgical & Informed
Techniques Lab Testing
Vitamins, HRT, Nutrition, Exercise
19. • Early 20’s college student
• Weight gain, fatigue, brain fog
• Saw “numerous” MD’s asking for help
• Told “nothing is wrong with your thyroid;
your labs are fine.”
20. Selenium, the Thyroid, and You
• “T3” is the ACTIVE
form of thyroid
• Conversion of T4
to T3 is selenium
dependent
• LP Nano has
200% of RDA of
Se+
selenium
21.
22.
23. “Thyrotropin (Thyroid-Stimulating
Hormone or TSH). Measuring TSH is the
most sensitive indicator of
hypothyroidism.” (hunh?!)
http://www.umm.edu/patiented/articles/how_serious_hypothyroidism
Accessed: 9/5/2011
24. Rev T3
Se
CORTISOL
“the foot soldier” “the evil twin”
25.
26. Case report:
• 55 year old male entrepreneur
• Runs company with 200 employees – multi
hundred million dollar budget
• Stressed with economy
• Very tired in the a.m.
• “Crashes” at night.
• Still golfing, exercising.
• Looks marvelous.
28. Why isn’t adrenal fatigue diagnosed?
• Not a medical emergency.
• Patient is blamed”
– “just neurotic”
– “avoidant”
• “Functional medicine” testing not
typically done (& rarely is DHEA-S
checked)
• Modern medicine focuses on
NORMAL, rather than OPTIMAL.
function.
• “Bell Curve” paradigm
30. One destigmatizing notion:
Estrogen as MAOI
• Estrogen & Testosterone (!) decrease
MAO
– Luin, VN. Brain Res. 1975;86:273-306
• Platelet MAO levels inversely
correlated to estradiol levels
– Klaiber EL et al. Psychoneuroendo-
crinology. 1997 Oct;22(7):549-58.
• Estrogen decreases MAO-A & MAO-B
– Holschneider DP et al. Life Sci. 1998;63(3):155-60
31. Psychoactive Progesterone*
Increases energy and libido
Has a calming effect, acting like a
benzodiazepine to the brain (HS dosing)
Enhances mood
Balances blood sugar (appetite)
Regulates fluid balance, sodium mineral balance
Necessary for fertility
Helps relieve menopausal symptoms
Decreases risk of endometrial cancer and may help protect
against breast cancer, fibrocystic breasts, and
osteoporosis * Adapted from Whitney Gabhart, N.D.
32. Testosterone: The “sexist” bias
against women
• Fall in the circulating testosterone and the
adrenal preandrogens most closely parallel
increasing age.
• Accelerated decrease occurs in the years
preceding menopause (like estrogen).
• Their loss affects: libido, vasomotor symptoms
(hot flashes), mood, well-being, bone structure,
and muscle mass.
– Burd, Bachmann. Androgen replacement in menopause.
Curr Womens Health Rep. 2001 Dec; 1(3):202-5.
33. Brief Description of Hormone
Function (Men AND Women)
Testosterone
– Enhances sex drive
– Builds muscle & decreases
fat
– Elevates mood
– Prevents osteoporosis
– Improves memory
– Lowers cholesterol
– Protects against heart
disease
34. We use Bio-identical “HRT” at CWI:
• Synthetic means that the molecule is not
natural to the human body.
• Bio-identical hormone is one whose
molecule is identical to that made by a
human organ.
SV2003- 34
35. 50’ish year old female, post-
menopausal, on no hormones
• On aggressive supplement regimen with
daily MVI and others
• Not ill
• Top rated medical care with previous labs
done
• Nothing identified as seriously abnormal
• “Just interested in having my hormones
checked.”
36.
37.
38.
39.
40. Treatment for this “normal” patient
1. Armour thyroid – ¼ grain for 1 week, then ½ grain.
(Aiming for T3 in “high 3’s.”
2. DHEA – 25 mg SR micronized, compounded – in
a.m.
3. Progesterone – 50 mg SR compounded – at night.
4. Testosterone – 3mg topical per day x 1 wk, then 6
mg. “Decrease dosing as needed for side effects.”
5. Vitamin D – 5,000 IU twice daily x 3 weeks, then
decrease to one dose per day.
6. Fish oil – 4.6 grams (c. 1660 mg EPA and 1,250 mg
DHA by compound weight, plus misc. Omega 3)
41.
42. What’s life like now?
• “it’s like the colors of the rainbow have gotten more into the
pink.”
• “My computer will survive – I use to ‘lose it’ over
my computer. I would swear obscenities.”
• “I’ve gotten into a zen like mode. Handling
everything that life can throw at me.”
• “It’s almost as if I’ve taken a pill or drug that jus
makes me handle everything that life is throwing at
me. I can roll with it.”
• “I’m not irritable any more. Time pressure has just
one away.”
43. The Case of the Crying Cleaner
• 1/11/12 - Symptoms:
– Crying/depressed = on
Citalopram
– Hot flashes
– Night sweats
• RX:
– Estradiol – 2 mg @HS
– Prometrium – 100 mg
@HS
– (continue citalopram)
• 1/15/12 – RESOLVED
• IN 2 WEEKS!!!.
Photo & data used with permission
44.
45.
46. Observational study of randomly selected men –
Boston
3 cohorts of men: 1987-1989; 1995-1997; 2002
-2004.
1374, 906, and 489 men, respectively.
“Age independent decline in T that does not appear to
be attributable to observed changes in explanatory
factors, including lifestyle characteristics such as
smoking and obesity.”
“Recent years have seen a SUBSTANTIAL, and as
yet UNRECOGNIZED age-independent population-
November 2009
level decrease in T in American men.”
“Alpha Male” issue
Travison, Araujo, et al. Jrnl of Clin. Endocrinol & Metabol 92:1; 196-202.
47. Fast food (low Zn) is bad for you.
• Fast food = high energy density = low essential
micronutrient density, ESPECIALLY ZINC
• Antioxidant processes are dependent on Zinc
• Fast food = severe decrease in antioxidant
vitamins and zinc, correlating with
inflammation in testicular tissue – with
underdevelopment of testicular tissue and
decreased testosterone levels
48. Special needs - Zinc
• Low Zinc- associated with low testosterone
– Per USDA, 60% of US men between 20 – 49
years of age do not get enough.
– N.B.: Do not supplement with > 50 mg daily
(can interfere with Cu+ metabolism)
• Tsai, E.C., Boyko, E.J., Leonetti, D.L., & Fujimoto,
W.Y. (2000). Low serum testosterone level as a
predictor of increased visceral fat in Japanese-
American men.
International Journal of Obesity and Related Metabolic Dis
24, 485-491
50. Physiology of testosterone
• T regulates
– Nitric oxide (NO)
– Phosphodiesterase type 5 (PDE-5)
– Both critical for initiation & maintenance of
erectile function
• T maintains
– Penile structural integrity
– Functional integrity
Wang C, J Clin Endocrinol Metab. 89(2004):2085-98
51. “Hence, among older men reporting excellent
asymptomatic health, age has no effect on
serum T or E2 with a minor increase in DHT
while obesity decreases serum androgens…”
52. “…both estrogencs and androgens can play a
protective role against AD related
neurodegeneration.”
“Hypogonadal in later life” = “problems with memory”
53. Testosterone (Men)
• Decline in male sex steroids not as
abrupt as menopause, but equally
debilitating
–Between 40 – 70, average male
loses:
• Nearly 2" of height
• 15% of bone density
• 10 – 20 pounds of muscle
• At 70 yoa, 15% completely
impotent
54. Andropause: Characteristics of
Change
• Insidious & unpredictable onset
• Slow progression
• Subtle & variable manifestations
• Cannot be linked directly to a decrease in
the hormone testosterone
• Very different from menopause in women!
• (Hubby reference: www.isitlowt.com)
Charlton R. JMHG. 1(2004): 55-9
Kaufman JM. Endocrine Reviews. 26(2005):833-76
55. T vs Cognitive Function
• 400 independently living men, 40-80yo
– 100 in each age decade
– MMSE 21-30, average 28
– TT: 208-1141ng/dL; Bio-avail T 78-470ng/dL
• HIGHER T = better cognitive performance in
OLDEST AGE category
• Men with lowest 1/5 T = worse than men with
highest 1/5 T
• Highest Bio-available T more significant
than TT, age, intelligence level, mood,
smoking, and alcohol.
Muller M. Neurology. 64(2005):866-71
56. T vs Mood in men
• Study: 278 men, >45yo, followed 2 years
• Compared to eugonadal patients,
hypogonadal men w/TT <200ng/dL had
– 4-fold increase risk of depression
– Significantly shorter time to depression
diagnosis
• Depression risk inversely related to TT
w/statistical significance <280ng/dL
Shores MM, Arch Gen Psychiatry. 61(2004):162-7
57. The Case of the Mismanaged
Executive - summary
• 42 year old male ADHD CEO. Background in
psychology. Now EXTREMELY stressed.
• “So tired I feel like I’m dying.” “Depressed.”
• Lab findings – low testosterone, despite multiple
pumps of Androgel per day managed by
endocrinologist (!). Low thyroid. Low DHEA.
• RX: Testosterone cypionate IM – 60 mg twice
weekly. DHEA – 50 mg SR. Armour thyroid – ½
grain.
• Clinical status: total resolution of symptoms in 3- 4
weeks. No antidepressant used.
59. Testosterone and “Prostate Cancer risk”
• Prostate CA found 2.15 & 2.26 times more
likely in lowest compared to highest tertile
of total and free testosterone
• “. . . there are several papers showing a
relationship between LOW testosterone
and prostate cancer. Specifically, low
testosterone has been associated with
high-grade tumors, advanced stage of
presentation, and worse prognosis.”
Morgentaler A. Eur Urol. 50(2006):935-9
Morgentaler A. Urology. 68(2006):1263-7
60. Treatment options – the needle
HCG – human chorionic gonadotropin -1250 – 2500 x/wk
(tiny needle; “off-label”, doesn’t work in much older men)
Testosterone cypionate – 200mg/cc – dosing determined by
size – administered IM – one to two X per week– (bigger
needle; on-label per FDA, works in everyone, shrinks
testicles).
65. What is Raman Spectroscopy?
Monochromatic photons interact with molecules that have
vibrational energy (e.g., carotenoids), and gets scattered at
a higher wavelength. Sir C. V. Raman, Nobel Prize in
Physics, 1930
Carotenoid molecules shift blue laser light color to green:
473 nm to 510 nm
68. “Pending strong evidence …from randomized trials, it
appears prudent for all adults to take vitamin
supplements.” Fletcher & Fairfield, JAMA 2002
69. “The Complete Idiot’s Guide to the
“Cady White Paper”
• Pp 1-3 Patent claim synthesis: assessing
the overall antioxidant status in human
tissue via Raman spectroscopy via
measuring carotenoids
– Carotenoids are antioxidants
• Identified in 1992
• Potent antioxidants
• Lycopenes and carotenoids appear to diminish risk of
prostate CA.
• P 4 Further discussion of prostate CA
70. Lipid peroxidation, antioxidant status
& survival in institutionalized elderly
• Plasma MDA
predicted mortality
independently of all
other variables.
• B-carotene and
alpha tocopherol
were independently
association with
survival. Huerta JM et al. Free Radical Research
2006, vol 40, no 6. pp 571-578.
71. Epidemiology of Vascular Aging (EVA)
• Study population:
– N=1,389; age range {59-71 yoa}
– 9 year study
• Relative risks:
– all cause mortality at 2.94X in men in lowest
quintile (95% CI, P=0.03)
– cancer 1.72X in men (95% CI, P=0.01
• “Total plasma carotenoids levels
were independently associated
with mortality risk in men.”
72. Antioxidants and brain tumors?
• “free radicals are another etiological factor
of brain tumor and are removed by cellular
antioxidants in the human body.”
• Inverse correlation between:
– antioxidant levels and oxidative DNA damage
– Grades of malignancy
• Decrease in antioxidants are associated
with severity of malignancy
73. A quick look back in history
The Interpretation of Ugo Cerletti 1935
Prozac - 1987
Dreams – 1885 - 1890
74. The Therapeutic Trifecta of Psychiatry:
Shrinking
Shocking
or Drugging
[Supposedly] the only three
things you could do to a patient’s
brain…]
75. Faraday’s Law of Induction
TMS Induced neuronal
Magnetic current
field
76.
77. From electricity to
magnetism
• Bartholow, R (1874)
– Stimulation of human brain
(exposed cortex) of patient with
cranial defect.
• d’Arsonval – “Phosphenes
and vertigo” induced inside
powerful magnetic coil
• Silvanus P. Thomson, Ph.D.
– new type of magnetic Thompson, SP. “A Physiological
Effect of an Alternating Magnetic
stimulation (1910) Field.” Proceedings of the Royal
Society of London B82:396-399, 1910
78. NeuroStar Directly Depolarizes Cortical
Neurons
Neuron Pulsed magnetic fields
from NeuroStar:
•induce a local electric
current in the cortex which
depolarizes neurons
Neurons are •eliciting action potentials
“electrochemical •causing the release of
cells” and respond to chemical
either electrical or neurotransmitters
chemical stimulation
79.
80.
81. Does it work?
• Original registration trial
– 307 major depressed patients
• 67% women
• 93% recurrent depressives
• 43% had been hospitalized already
– 42 sites
– Treatment per label
• Results: ½ patients responded; 1/3 of
patients remitted.
• 80% patients completed the treatment.
82. Who Was Studied?
• Primary diagnosis: DSM-IV Major Depressive
Disorder
– Unipolar type, non-psychotic
– Moderate to severe symptoms at baseline
– Approximately one-third of patients had a co-morbid anxiety
disorder (OCD excluded)
• Antidepressant Treatment History:
– Average number of antidepressant medication trials in current
episode = 4 (range: 1 to 23 attempts)
• Majority of treatment attempts were unable to achieve adequate
dose and duration of treatment due to intolerance
– In the indicated patient population, all patients failed to
achieve satisfactory benefit from one antidepressant
medication at an adequate dose and duration in current
episode
82
Demitrack and Thase (2009) Psychopharm
Bulletin
87. “But my patients don’t know about
this and aren’t asking for it….”
“It’s not the
consumers’
job to know
what they
want.”
- Steve Jobs
88. Perhaps the ability not only to acquire
the confidence of the patient, but to
deserve it, to see what the patient
desires and needs, comes through the
sixth sense we call intuition, which in
turn comes from wide experience and
deep sympathy for and devotion to
the patient, giving to the possessor
remarkable ability to achieve results.
...William J. Mayo, 1935
Notas do Editor
These symptoms correlate to decrease in bioavailable testosterone
RIA (in-house after diethylether extraction) Total testosterone - T (RIA) 208-1141ng/dL, average 536+/-153ng/dL Bioavailable testosterone - BT (calculated) 78-470ng/dL, average 236+/-63ng/dL
Hypogonadal if TT < 200ng/dL or FT < 0.9ng/dL
He discovered that if you shine a particular wave length of light on a substance it may give off another wave length of light. It will absorb one and give off another wave length of light. Today this is called the Raman Effect, or the substance that does this is “Raman Active.” And he discovered that based on the intensity of that light that is fed back into the spectrometer, we can quantify the exact amount of molecules in that substance. So what does that do for us, but to allow the measurement of the exact number of carotenoid molecules in someone’s tissue. The specific wavelength of light that we are looking for is a green wavelength of light. You’ve all see the blue light that comes out of the scanner. But did you know we are looking for a green light that is fed back into the scanner off of your palm. And based on the brightness of that light we can tell how many carotenoid molecules are in your tissue.
In the following section of my talk, I ’d like to discuss TMS in more detail. I will review its mechanism of action, and then discuss some of the most recent randomized clinical trial evidence supporting its efficacy and safety. I will also discuss recent outcomes in real-world practice settings obtained from an ongoing large, prospective outcomes study.
Capacitors of the day did not permit high intensity or rapid frequency use. The “ phosphenes ” were either generate from effects on the occipital cortex or directly on the retina of the eye. 1959 – Kolin et al – first to demonstrate magnetic field could stimulation a peripheral frog muscle preparation.
The underlying rationale for the use of TMS exploits the fact that neurons are electrochemical cells. This means that neuronal activity can be affected either chemically, via the use of drugs, or electrically, via interventions like TMS. Unlike drug action, whose effects tend to be anatomically diffuse, the effects of TMS are anatomically focused, and by design are non-invasive and non-systemic in action. Under normal conditions of use, TMS therefore incurs far fewer adverse events, and is devoid of undesired systemic adverse events commonly observed with antidepressant medications. The TMS device is a powerful electromagnet, which is turned on and off in a rapid fashion, producing a pattern of “pulsed” magnetic fields. When pulsed magnetic fields are positioned close to an electrical conductor, like neurons, a local electrical current is produced in that conductor. This electric current is powerful enough right under the magnetic coil to elicit action potentials, which then travel down the neuron, ultimately causing the release of neurotransmitters at the synapse (Post 2001, p. 193A) . References : Post A, Keck ME. Transcranial magnetic stimulation as a therapeutic tool in psychiatry: what do we know about the neurobiological mechanisms? J Psychiatric Research. 2001;35: 193-215.
This slide describes some of the major demographic and clinical characteristics of the patients studied in the registration clinical trials that led to FDA clearance for the NeuroStar TMS Therapy system. All patients had a diagnosis of unipolar, non-psychotic major depression, with moderate to severe symptoms at entry to the study. About a third of all patients had a concurrent secondary diagnosis of an anxiety disorder. All patients received a rigorous characterization of their antidepressant medication treatment history in the current illness episode. Most patients had received numerous medication treatment attempts, with one of these treatment attempts being administered at an adequate daily dose and for at least four weeks without clinical benefit. The average number of overall treatment attempts (which includes all antidepressant medications administered in the current episode, regardless of whether they reached an adequate dose and duration) was 4, with a range across the study population from 1 to as many as 23 treatment attempts. Consistent with the data that I reviewed earlier in this presentation, about 75% of the time, these antidepressant treatment attempts were unable to achieve this minimum level of exposure adequacy (usually because of treatment intolerance, or failure to adhere to the recommended treatment regimen). References : Demitrack, MA , Thase, ME,. (2009) Clinical significance of transcranial magnetic stimulation (TMS) in the treatment of pharmacoresistant depression: synthesis of recent data. Psychopharm Bulletin 42(2) :5-38