Adrenal fatigue, bioidentical hormones, and health literacy

Northwestern University Feinberg School of Medicine

Adrenal Fatigue and Bioidentical Hormones

Endocrine Health and Society

Daniel Toft, MD

Learning Objectives

1. Review the importance of health literacy for providers,

patients, and systems

2. Review the popular definitions of adrenal fatigue

syndrome and bioidentical hormone replacement

3. Consider the scientific evidence

4. Consider some of the personal and societal factors that

make these topics popular

5. Discuss the role of health care providers in promoting

health literacy of their patients and society

Case – 52 year old woman

In May at her gym she had a panel of labs obtained. Found to have very

high E2 levels (412 in follicular phase), saw her gynecologist who

identified an ovarian cyst that was removed in Aug (unilateral

oophorectomy), benign reportedly.

Tired, cold all the time, weight up. Questions about TFTs, cortisol, E2.

No matter how much she sleeps very fatigued; always very cold for years

now. She can get 9 hours and is still not rested. 15# sudden weight gain

several years ago; again 7# up since the ovarian cyst. Was having

periods prior to surgery but irregular; none since. She does not think she

could be pregnant. Having some night sweats but still cold.

Case – 52 yo woman

ROS: Awakens to use the rest room. Frozen shoulder pain was also

awakening her. She does not snore. No napping. Boxes, Pilates, 2-

4days/wk working out; used to work out more and felt better when she

did so. No work travel. Carries a heavy bag for work - pharma rep, bag

full of literature. Cooks for herself, higher protein diet, did Atkins years

ago maintaining weight 135 for 10 years. A little depressed - a vicious

cycle, fed by weight gain.

She is worried that she has an endocrine problem contributing to her

fatigue mood and weight gain (“Is it my thyroid? Adrenal fatigue? Just

menopause?”) . She plans to have a colonoscopy. Concerned that her

lipids are not as well controlled now on Lipitor; was on Crestor before.

Case – 52 yo woman

No Known Allergies

MED: Lipitor, Advair, Singulair, meloxicam prn shoulder pain

PMH: HL, Allergy induced asthma, Frozen shoulder

PSH: unilateral oophorectomy, chin ganglion cyst removal

FH: F-MI age 57, M-lung cancer, bro-MI age 50, sis-well, no kids

SH: Lives with husband, pharmaceutical sales, no tob

Case –52 yo woman

BP 114/72, pulse 80, resp. rate 12, height 5' 5”, weight 161 lb, BMI 26.79

Gen: NAD, A&Ox3, well-nourished, well-developed, full range of affect, tearful

when discussing mood.

Eyes: EOMI, no pallor, anicteric, no lid lag, no proptosis, no xanthoma

ENT: MMM, OP clear

Neck: no LAD or bruit, no acanthosis nigricans

Thyroid: normal size, no nodules

CV: RRR, normal S1S2, no s3/s4/m

Lungs: CTA B no wheeze

Abd: NABS, soft, ND, NT

Ext: no LE edema. pulses 2+ symmetric. no tremor.

reflexes: 2+ without delay

May 2013 thyroid function tests normal, AM cortisol 11, E2 >400, LH/FSH normal,

total chol 210 LDL 120 HDL 88 Tg normal

Case – Summary

52 year old woman with

• 3 months of amenorrhea

• 7# weight gain

• Fatigue

• Down mood

• Night sweats

• BMI 26.8 otherwise unremarkable exam

• Endocrine testing normal

Case – Diagnosis?

There’s nothing wrong with her

Adrenal fatigue

Hypothyroidism

Perimenopause

Other suggestions?

Mood disorder

Primary sleep disorder

Dr. Oz Video on Dealing with

Menopause Symptoms

http://www.oprah.com/health/Learning-to-Deal-with-

Symptoms-of-Menopause-Dr-Oz-Video

http://www.oprah.com/health/Learning-to-Deal-with-Symptoms-of-Menopause-Dr-Oz-Video

What messages are you

hearing?

• Quality of life is important

• Women are searching for solutions

• Menopause is a disease

• Shot adrenals are part of menopause and this

can’t be measured

• The normal range is irrelevant

#2359 selling book

Fam Med 2012

Teaching Health Literacy

Health literacy is more than

communicating in plain language

• Plain language is one means to communicate

effectively, but plain language, health

communication, and health literacy are not

synonymous.

• Health literacy encompasses much more than

plain language, reading, writing, numeracy, and

effective communication between health

professionals and the public.

The Calgary Charter on Health Literacy: Rationale and Core Principles for the Development of Health Literacy Curricula. 2009

Health literacy defined:

Health literacy allows the public and personnel working in

all health-related contexts to find, understand, evaluate,

communicate, and use information.

Health literacy is the use of a wide range of skills that

improve the ability of people to act on information in order to

live healthier lives.

These skills include reading, writing, listening, speaking,

numeracy, and critical analysis, as well as communication

and interaction skills.


Health literacy applies to all

individuals and to health systems.

An individual can be health literate by using the skills

needed to find, understand, evaluate, communicate, and use

information.

Health care professionals can be health literate by

presenting information in ways that improve understanding

and ability of people to act on the information.

Systems can be health literate by providing equal, easy,

and shame-free access to and delivery of health care and

health information.


Situations in which health literacy is critically

important for individual users, health care

professionals, and health systems include:

• health system reform efforts

• understanding health issues

• preventing poor health

• communicating complexity

• culturally appropriate communication

• behavior change efforts

• health promotion

• navigation of health systems


Case – Diagnosis?


Adrenal fatigue

Hypothyroidism

Perimenopause

Case – JC Diagnosis?


Adrenal fatigue

Hypothyroidism

Perimenopause

Why Does Your Energy

Level Fluctuate?

http://www.oprah.com/health/Dr-Oz-Reveals-

Common-Energy-Problems-Video

http://www.oprah.com/health/Dr-Oz-Reveals-Common-Energy-Problems-Video

Low energy is caused by

• Insulin resistance

• Viruses

• Sleep deficit

• Hormone imbalance – “slow functioning adrenal

and thyroid glands” manifested by high cortisol

levels caused by stress

#2124 selling book

#266,511 in books

Adrenal Fatigue

Causes: • Long-term mental, emotional, or physical stress

Symptoms:

• Tiredness

• Trouble falling asleep or waking up

• Salt and sugar craving

• Needing stimulants like caffeine to get through the day

Etiology:

• In the setting of long-term stress, the adrenal glands

cannot keep up with the body’s need for stress hormones

Adrenal Fatigue

Diagnosis:

• Symptoms

• Serum or salivary cortisol levels

Treatments:

• Sleep

• Exercise

• Avoidance of tobacco/alcohol

• Vitamins and supplements

• Adrenal/pituitary/hypothalamic “extracts”

• Corticosteroids

Adrenal Fatigue – Myth vs. Fact

• “Adrenal fatigue” is not a real medical condition. There are no

scientific facts to support the theory that long-term mental, emotional,

or physical stress drains the adrenal glands and causes many

common symptoms.

• Adrenal insufficiency is a real disease diagnosed through blood tests.

• There is no test that can detect adrenal fatigue.

• Supplements and vitamins made to “treat” adrenal fatigue may not be

safe. Taking these supplements when you don’t need them can cause

your adrenal glands to stop working and may put your life in danger.

• The symptoms attributed to AFS deserve thoughtful consideration and

may be manifestations of adrenal insufficiency, depression,

obstructive sleep apnea, or other health problems.

http://www.hormone.org/hormones-and-health/myth-vs-fact/adrenal-fatigue

Case – Diagnosis?

Adrenal fatigue

Hypothyroidism

Perimenopause

Hypothalamic-Pituitary-Ovarian Regulation

Hypothalamus

Ovary

+-

-+

-LH FSH

GnRH

Estrogen Progesterone

FolliculogenesisInhibin (Activin, Follistatin)

Activin ↑ Follistatin ↓

Pituitary

Inhibin

+

Estrogen Progesterone

Estrogen

Stress

-

Menses MensesFollicular phase Luteal phase

Menopause

• Permanent cessation of menstrual periods,

defined as no cycles for 12 months

• Average age is 51

• Low estrogen and high FSH biochemically

• Perimenopause refers to the time around

menopause – typically starts 4 years before

cessation of menses

Perimenopausal symptoms

• Irregular menstrual cycles

• Marked hormonal fluctuations

• Hot flashes

• Sleep disturbances

• Mood symptoms

• Vaginal dryness – can cause dyspareunia

• Joint pain

How to treat menopausal

symptoms

http://www.oprah.com/health/Dr-Oz-Talks-with-Dr-

Prudence-Hall-About-Bioidenticals

http://www.oprah.com/health/Dr-Oz-Talks-with-Dr-Prudence-Hall-About-Bioidenticals

What what?

• Menopause is a disease

• Progesterone prevents cancer

• Estrogen and testosterone are necessary for libido

• 35 yo hormone levels are the goal

• Bioidentical hormones decrease death; synthetic

hormones cause death

What are bioidentical hormones?

Identical in molecular structure to endogenous hormones:

• 17-beta Estradiol (E2), estrone (E1), Estriol (E3)

• Progesterone

• Testosterone

However, all are synthesized chemically.

• Molecularly identical hormones typically start with

chemicals extracted from soy and yams

• “Synthetic” hormones typically come from animals

Bioidentical hormone therapy: clarifying the misconceptions. Cleve Clin J Med. 2011

Compounding


Bioidenticals – key points

• Hormone therapy is indicated for relief of menopausal symptoms;

claims of reversal of the aging process are unsubstantiated.

• Products that are custom-compounded are not regulated by the US

Food and Drug Administration and therefore carry no assurance of

purity, safety, or efficacy.

• Transdermal progesterone creams may not achieve high enough

serum levels to protect the endometrium.

• Hormone therapy is titrated on the basis of symptom response.

Measuring hormone levels in saliva is not called for and is probably

not reliable.


Case – JC

Adrenal fatigue

Hypothyroidism

Perimenopause!

Case – JC

Plan:

• Open discussion of her lab results

• Discussed perimenopausal symptoms and changes

• Discussed the potential risks and benefits of combined

estrogen and progesterone replacement

• Encouraged continued regular exercise

Final thoughts

Health literacy includes an awareness of and ability to

navigate differences between the cultures of the health

system and the public. It also includes an awareness of and

ability to minimize the power imbalances between the health

system and the public.

Health literate health professionals and systems are those

that allow and encourage patients to feel welcome and

empowered to ask questions, that deliver information in

ways that people can use, and that proactively take the

steps to prevent ill health and provide treatment to all people

in need.

Adrenal fatigue, bioidentical hormones, and health literacy

Health & Medicine

Transcript of Adrenal fatigue, bioidentical hormones, and health literacy