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  • FAQ | Dr. Jonathan Lee

    ASK, ANSWER & LEARN FAQs: Hormones What are bioidentical hormones? What are the "experts" saying? Ever since Oprah Winfrey aired two shows on bioidentical hormones there have been questions and concerns about comments voiced by the “experts” that appeared on the program. Unfortunately, the interviews created some confusion, even amongst our enlightened clients. The following is an attempt to clarify some of the issues raised. It remains amazing to me that these “experts” do not understand and/or are unaware of the medical literature supporting bioidentical hormones, as well as hormones in general. Are hormones harmful? Should they be taken less often to control perimenopausal symptoms? If the hormones are synthetic, like Premarin® and Provera®, then they can be harmful. The combination Premarin® and Provera® have demonstrated an increased risk of breast cancer, strokes and heart attacks. This was published in the WHI trial. However, do not extrapolate the harm of synthetic hormones to bioidentical HRT. Natural progesterone has never been demonstrated, in any study, to increase these risks, whereas Provera® has definitely been shown to increase these risks. Natural progesterone has been shown to decrease the risk of breast cancer, whereas Provera® increases breast cancer in every study to date. Natural estradiol has been proven to not have the clotting or inflammatory properties as does Premarin®. Are all hormones the same, whether bioidentical or synthetic? Do they all share the same risks? Dr. Wolfe Utian from the North American Menopausal Society (NAMS) stated that, "hormones are all the same, whether bioidentical or synthetic. Therefore, they all share the same risks and harm." This is absolutely false! Nothing could be further from the truth. The chemical structures are different and that makes a difference in how the cells in the body respond to the hormone. A synthetic hormone (non-human, chemically-altered) does not fit perfectly into the hormone receptor site and thereby can cause harm and side effects. The human-identical hormones have demonstrated much less side effect and harm in comparison with the non-human, chemically-altered hormones. In my book, “How To Achieve Healthy Aging,” over 200 references are cited to medical articles that support the healthy benefits of bioidentical hormones without the harm of synthetic hormones. Evidently these "experts" aren't reading the same research that I am. Should all women use a transdermal application (skin cream or patch) of estrogen? No. Although the current trend is to prescribe transdermal creams in place of oral estrogen, the medical studies give us some compelling data. Oral estrogen is far better at cardiovascular protection (fewer heart attacks, strokes and plaque formation in blood vessels) than transdermal cream. Transdermal estrogen has minimal effect on improving serum lipids (good or bad cholesterol), whereas oral estrogen certainly does. Studies have demonstrated that oral estrogens marked beneficial effect on cholesterol, LDL and HDL, provides the most protection, whereas transdermal provides much less cholesterol effect and therefore much less cardiovascular protection in the long run. In a few women with a particular health history, oral estrogen is contraindicated and transdermal is therefore recommended. However this is not the case for most women. Oral estrogen has many more health protective benefits than does transdermal estrogen and thus is the preferred form of estrogen unless there is the rare contraindication. Can oral estrogen cause blood clots in legs and lungs? Yes and no. It is primarily Premarin® and Provera® that cause this, particularly Provera®. However, the Journal of the American Medical Association (JAMA) published an article demonstrating increased blood clots with Premarin® but not with other oral estrogens. Another study proved that oral estradiol did not increase blood clots. If you have experienced a blood clot in the legs or lungs, or have a genetic clotting disorder, transdermal estrogen is safe and preferred. If you do not have a high risk for a blood clot, oral estrogen is more effective and protective. Should all women on oral estrogen take aspirin? Yes, but only if you have had a heart attack or stroke. If you have not had a heart attack or stroke, then absolutely not. Recent studies demonstrate that aspirin benefits women only if you have had a prior incident. But aspirin is of no benefit in prevention if you have never had a heart attack or stroke. In fact, several studies show that aspirin might actually be harmful. In fact, more than 20,000 people die every year from bleeding or hemorrhaging while taking aspirin. If you have had a prior heart attack or stroke, then you should be taking aspirin. If you have not, you should not take aspirin and you should be on oral estrogen for maximal cardiovascular protection. Should progesterone be prescribed only as a cream? Absolutely not. In our experience, creams are inconsistently absorbed and often should be applied 2-3 times per day in order to maintain adequate levels. Most women can’t be compliant with this regimen. Optimal levels of progesterone are particularly important because of the breast and uterine protection. Two recent studies demonstrated that progesterone cream was not strong enough to protect against uterine cancer. Optimal levels are best obtained with sublingual or oral progesterone which then protects against breast cancer and uterine cancer. Studies demonstrate that the higher the level, the better the protection. Where would you like your levels to be? Are saliva tests better at assessing hormone levels? We're constantly studying the information about saliva testing. There's no scientific evidence or basis for using saliva levels over blood levels. There is some correlation between saliva levels and blood levels for evaluating baseline levels of hormones while not taking any hormones. This is not true when monitoring hormone levels while a person is taking hormones. Saliva levels can be high when blood levels are low. This can give a false confidence that your hormone doses are giving you levels that are protective when they usually are not. Therefore, we should abide by the medical studies that give us the guidelines for hormone levels that are the most protective. These studies utilize blood levels and not saliva levels. We want to achieve these protective blood levels that are well documented in all our medical studies for maximum breast and uterine protection. If you don't achieve and maintain these protective levels, your hormone program will not provide optimal protection and may put you at risk. Should I use estriol as my estrogen replacement (not estradiol)? Does estriol prevent breast cancer? There is no scientific evidence that estriol prevents breast cancer, nor protects against heart disease, bone loss or Alzheimer’s disease. In fact, estriol is an end-stage metabolite of estradiol and provides only very weak symptom improvement and no protective benefits. Therefore, estriol has minimal beneficial effect in comparison to estradiol which is the primary estrogen. Estriol’s primary beneficial effect is on the skin. Estradiol has been shown to provide the most protection and therefore is the estrogen of choice. (Multiple studies have demonstrated a decrease in breast cancer incidence when progesterone—not progestin—is added, but not estriol). Are compounded, bioidentical better than conventional, pre-manufactured products? The experts from the menopausal and gynecological academies claim that there are no studies to support the use or benefit of compounded, bioidentical hormones as opposed to conventional, pre-manufactured products. The FDA approval process for synthetic drugs is meant to prove that a drug is effective for the purpose intended, is absorbed properly, and maintains adequate serum levels to guarantee efficacy. These conventional, manufactured drugs are standardized and guaranteed to have a certain consistency and effectiveness. So how do we know that the prescriptions compounded by hand in compounding pharmacies are consistent and effective? We test levels in our patients and assure that the hormones prescribed consistently provide protective levels. The medical studies demonstrate exactly where the hormone levels should be for maximum protection. Every doctor prescribing compounded bioidentical hormones should abide by these scientific standards in order to assure the optimal protection for the patient. If we are seeing a pattern of poor levels, we question the pharmacy on the source of their pure ingredients and their compounding process. Compounding pharmacies can dispense different grades of hormones from different suppliers, but we must assure through serum testing that what is being dispensed provides exact amounts of hormones and efficacy. Does testosterone increase the risk of stroke or heart attack? Recent research and evidence doesn't support an increased risk of cardiovascular events with testosterone therapy. (ie: Source #1) Does testosterone therapy increase the risk of prostate cancer? No, the evidence doesn't support the increased risk of prostate cancer with testosterone therapy. (ie: Source #1)

  • Dr. Jonathan Lee, M.D., Medical Aesthetics & Hormone Therapy

    DR. JONATHAN LEE, M.D. Medical Aesthetics & Hormone Therapy Professional Quality. Personal Attention. Proven Results. Call Now BOTOX, JUVEDERM & MORE Injectables & Fillers Say goodbye to frown lines, crows feet, forehead wrinkles and facial creases. Restore what nature has taken away with simple, safe and effective injections. Schedule Now Botox® $18/Unit* Botox® shots (also known as botulinum toxin) block certain chemical signals from nerves that cause muscles to contract. The most common use of these injections is to relax the facial muscles that cause frown lines and other facial wrinkles. Botox® injections also are used to ease symptoms of some health conditions. Learn More *Prices subject to change. Contact us for more details. Dysport® $18/Unit* Dysport® is primarily used for correcting glabellar lines, the frown lines between your eyebrows. Dysport® is a great option for those who have moderate to severe frown lines. Botox, on the other hand, can be used to treat many different types of wrinkles, including crow's feet, forehead wrinkles and laugh lines. Learn More *Prices subject to change. Contact us for more details. Juvederm® $24/Unit* Juvederm® is a hyaluronic acid (HA) based filler, which is meant to restore and refill naturally occurring HA to areas on the face where it has been depleted. The type of Juvederm® chosen (several options available) will depend on the location and severity of the patient's wrinkles, creases and volume loss. Learn More *Prices subject to change. Contact us for more details. Voluma®/Vollure® $24/Unit* Juvederm® Voluma XC® dermal filler gel is injected deep into the cheek area. It adds fullness underneath the surface of the skin, offering a lift and developing a more youthful definition. Juvederm® Vollure XC® plumps the skin and addresses moderate to severe wrinkles and folds on the face and forehead. Learn More *Prices subject to change. Contact us for more details. Restylane® $32/Treatment* Restylane® is the trade name for a range of injectable fillers with a specific formulation of non-animal sourced hyaluronic acid (HA). In the United States, Restylane® was the first HA filler to be approved by the U.S. Food and Drug Administration for cosmetic injection into subdermal facial tissues. Learn More *Prices subject to change. Contact us for more details. Restylane® Lyft® $32/Treatment* Similar to Restylane®, Restylane Lyft® is a safe, effective, and dissolvable hyaluronic acid (HA) filler specifically designed to create structure in the face, usually used in the cheek areas, or add fullness in the backs of the hands by replenishing lost volume under the skin for a more healthy and youthful-looking appearance. Learn More *Prices subject to change. Contact us for more details. Refyne®/Defyne® $32/Unit* Restylane® Refyne® and Defyne® are both hyaluronic acid (HA) fillers manufactured by Galderma®. They differ in their indicated uses and degree of correction. While Refyne® is intended to soften moderate lines and provide moderate lifting, Defyne® is designed to address deep lines, folds and volume loss. Learn More *Prices subject to change. Contact us for more details. Hyperhidrosis Therapy® $54/Unit* Hyperhidrosis is the occurrence of abnormal or excessive sweating in the extremities, underarms and face, usually unrelated to body temperature or exercise. Hyperhidrosis therapy uses anticholinergic or antimuscarinic which work by blocking the effects of the acetylcholine, which activate the sweat glands. Learn More *Prices subject to change. Contact us for more details. CALL TODAY FOR YOUR Free Consultation People will truly admire your flawless skin once the wrinkles are gone. Schedule your Botox® or Dysport® appointment today. Contact Us AGE SPOTS, ACNE & MORE Professional Skin Care Dr. Jonathan Lee utilizes one of the largest collection of medical procedures, skin care products and specialty lasers in Colorado to treat a variety of skin problems. Schedule Now Age & Sun Spots Treatment Age spots are small, flat dark areas on the skin. They vary in size and usually appear on areas exposed to the sun, such as the face, hands and arms. Age spots are also called sunspots, liver spots and solar lentigines. Older adults, people with fair skin, and those who've spent lots of time in the sun are the most at risk. Learn More *Prices subject to change. Contact us for more details. Microdermabrasion Microdermabrasion is a minimally invasive procedure used to renew overall skin tone and texture. It can help improve the appearance of skin affected by sun exposure, wrinkles, acne, and other conditions. The procedure uses a special applicator with an abrasive surface to gently sand away the outer layer of the skin. Learn More *Prices subject to change. Contact us for more details. Acne Treatment & Care Acne is not just a problem at the surface of the skin. Dr. Lee offers a proven, prescription acne care system that is scientifically formulated to treat acne at the source for long-lasting results. We utilize prescription medications, Obagi Clenziderm® systems, along with other treatments designed just for you. Learn More *Prices subject to change. Contact us for more details. Obagi® Blue Peel® If you’ve been considering a chemical peel procedure, you should know that Obagi® Blue Peel® may help to restore a tighter, smoother, more radiant look to your skin. Use of the Obagi® Nu-Derm® system is recommended before and after your Blue Peel® treatment, which we perform safely in our office. Learn More *Prices subject to change. Contact us for more details. Obagi® Nu-Derm® The Obagi® Nu-Derm® treatment system is the latest in anti-aging transformation and skin rejuvenation. Skin aging is a natural process, but daily sun exposure can contribute to premature aging, slowing down the turnover of new skin cells from old, damaged cells. Obagi® Nu-Derm® can help turn back the clock. Learn More *Prices subject to change. Contact us for more details. Sebaceous Glands Treatment Hypertrophic sebaceous glands are the result of over-grown oil glands on the surface of the skin. Unlike millia, which are round inclusion that can be easily extracted, hypertrophic sebaceous glands are not extractable. Dr. Lee uses a radio-frequency probe to safely remove these small, raised, unsightly skin bumps. Learn More *Prices subject to change. Contact us for more details. Wart Removal Along with many other professional skin care products and services, we specialize in persistent wart removal. If you struggle with unsightly warts on your face, hands or feet, Dr. Lee can safely and effectively "zap" them with one of the most efficient and effective wart-removal laser treatment systems available. Learn More *Prices subject to change. Contact us for more details. Mole & Skin Tag Removal Moles, also known as nevi, are quite common. These dark colored or pigmented spots occur in individuals of all ages. Benign moles(non-cancerous) and skin tags are common on the face, neck, or torsos of some individuals. Dr. Lee can safely remove those unsightly moles or skin tags with little or no scarring. Learn More *Prices subject to change. Contact us for more details. YOUR ONLY DERMATOLOGIST & Skin Care Center Don’t put up with age spots, sun damage, warts, moles, aging or unhealthy skin. Let us professionally treat your skin today. Contact Us TESTOSTERONE, ESTROGEN & MORE Hormone Therapy At the DJL Clinic, we specialize in a variety of total hormone replacement regimens to achieve maximum benefits and help deter the aging process. Get The Facts Testosterone for Men Testosterone has always been known as the male sex hormone. However, testosterone has recently been shown to be linked to longer, healthier lives in both men and women. As testosterone levels decline with age, many specific health problems and concerns that accompany this loss of hormone may arise. Take The Quiz! *Prices subject to change. Contact us for more details. Testosterone for Women Testosterone is also a female sex hormone. Total hormone replacement means restoring the natural balance of all hormones to the levels of our physical and mental peaks. For women, this also includes testosterone. Many women take estrogen and progesterone, but they still don't feel like their youthful selves. Take The Quiz! *Prices subject to change. Contact us for more details. Thyroid (Unisex) The thyroid gland is an endocrine gland in your neck. It makes two hormones that are secreted into the blood: triiodothyronine (T3) and thyroxine (T4) and are necessary for all the cells in your body to work normally. About one in 20 people has some kind of thyroid disorder, which may be temporary or permanent. Learn More *Prices subject to change. Contact us for more details. Estrogen (Women) Estrogen is a category of hormone responsible for the development and regulation of the female reproductive system. In addition to regulating the menstrual cycle, estrogen affects the reproductive tract, urinary tract, heart and blood vessels, bones, breasts, skin, hair, mucous membranes, pelvic muscles, and brain. Learn More *Prices subject to change. Contact us for more details. Progesterone (Women) Progesterone is an endogenous steroid and progestogen sex hormone involved in the menstrual cycle, pregnancy and embryogenesis of humans (females), as well as other species. Progesterone belongs to a group of steroid hormones called the progestogens and is the major progestogen in the body. Learn More *Prices subject to change. Contact us for more details. HGH (Human Growth Hormone) HGH is a hormone secreted by the pituitary gland in the brain. Secretion occurs during Stage IV (deep) sleep. HGH is responsible for growth and healing. It's also responsible for increased muscle and strength, decreased body fat, decreased cholesterol, energy levels and enhanced sexual performance. Learn More *Prices subject to change. Contact us for more details. DHEA (Unisex) DHEA (Dehydroepiandrosterone), also known as androstenolone, is an endogenous steroid hormone precursor. It's a hormone that the body naturally produces in the adrenal gland and is one of the most abundant circulating steroids in the human body. DHEA is produced in the adrenal glands, the gonads and the brain. Learn More *Prices subject to change. Contact us for more details. Melatonin (Unisex) Melatonin is a hormone that your brain produces in response to darkness. It helps with the timing of your circadian rhythms (24-hour internal clock) and with sleep. Being exposed to light at night can block melatonin production. Research suggests that melatonin plays other important roles in the body beyond sleep. Learn More *Prices subject to change. Contact us for more details. NO MATTER YOUR AGE, Look & Feel Great We offer total hormone replacement regimens, along with diet and exercise, to achieve maximum benefits and love life. FAQs REAL PATIENTS, REAL RESULTS Before & After Photos At the DJL Clinic, we offer the very best in real-time results. Although outcomes aren't typical for everyone, we strive to get as close to perfection as possible. Photo Gallery DR. JONATHAN LEE, M.D. Medical Aesthetics & Hormone Therapy Denver, Colorado's premier clinic and treatment center for medical aesthetics, anti-aging, skin care and unisex hormone replacement and management. Email Dr. Jonathan Lee, M.D. is a medical doctor educated and trained at The Johns Hopkins University and Stanford University. He has been practicing medicine in Denver, Colorado for more than 25 years. Dr. Lee specializes in anti-aging, skin care and aesthetics medicines, as well as hormone replacement and management. He meets with all of his patients personally for consultation, evaluation, diagnosis and treatments. He doesn't delegate clinical diagnosis or treatments to physician extenders, such as Nurse Practitioners (NPs) or Physician Assistants (PAs). Dr. Lee takes pride in his work and the wellness of the people he treats. He thrives to provide the best care possible to all of his patients personally and throughly. Pamela A., CO “Dr. Lee’s assessment was less about symptoms and more about results. Once we discussed where I wanted to be, the solutions he presented were clear. And within weeks, so was my skin!" MEET OUR SKILLED TEAM The DJL Clinic Family Owner & Founder Dr. Jonathan Lee, M.D. Dr. Jonathan Lee attended The Johns Hopkins University and completed his residency training at Stanford University. He's been practicing medicine in Colorado for more than 25 years. Dr. Lee's focus is on injections and fillers, laser cosmetics, skin care medicine, and hormone replacement therapy. He's dedicated to treating his patients with the utmost care and is recognized as one of the top physicians for Botox® and Juvederm® in the state. Contact Me Director of Administration Jalene S. Lastname Insert a small bio about this employee here. It's please ass additional text and information about this person and their experience after all. Insert a small bio about this employee here. It's please an additional text and information about person. More information to come. Insert a small bio about this employee here. It's please insert additional text and information about this person and their experience after all. Insert a small bio about this employee here. Contact Me Chief Marketing Officer Insert A. Namehere Insert a small bio about this employee here. It's please ass additional text and information about this person and their experience after all. Insert a small bio about this employee here. It's please an additional text and information about person. More information to come. Insert a small bio about this employee here. It's please insert additional text and information about this person and their experience after all. Insert a small bio about this employee here. Contact Me Sr. Aesthetician & Nurse Practitioner Molly A. 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  • Descriptions | Dr. Jonathan Lee

    Descriptions: Aesthetics Botox Should You Give Botox® a Shot? ​ Botox® injection is one of the most frequently administered cosmetic treatment in the United States—it is a non-surgical procedure that is relatively quick, affordable treatment option. Dr. Lee at the Doctor Jonathan Lee (DJL) Clinic is among the top 5% of Botox® cosmetic injectors in the nation, and has been for multiple years. Dr. Lee has performed thousands of Botox® injections to patients over the last 20 years. ​ Botox® cosmetic (Botulinum toxin Type A) has been an FDA approved treatment for “frown lines” and other cosmetic procedures since 2002. Other areas such as crows feet, forehead lines, upper lip wrinkles or jaw lines can be treated with Botox® at the doctor’s discretion. ​ Botox® works by blocking nerve impulses to the injected muscles. This reduces muscle activity that cause those lines after repeated muscle contractions. The Botox® cosmetic injection reduces the lines by relaxing the muscles, all in an outpatient procedure. Visible results occur within days, and Botox® can continue working for up to four months. You can achieve a natural, refreshed younger look with Botox® treatments without making you look as if you “had the work done.” ​ Discover the proven results that 11 million women and men have experienced. Documented results of Botox® can be seen in our “Patients Wall of Fame” photo galle ry. All patients who wish to discuss their situation with Dr. Lee personally are encouraged to schedule a free consultation. What You Should Know About Dysport®: Over time, repeated movement of the facial skin by the forehead muscles forms lines between the eyebrows. Frown lines are “dynamic”—they happen because of the way a person’s face moves. Because frown lines are created by facial movements, such as frowning or squinting, they may develop even in younger adults. ​ Prescription Dysport® temporarily improves the look of your frown lines without changing the look of your whole face. Untreated facial muscles still work normally. In some cases, the effects of Dysport® and all botulinum toxin products may affect areas of the body away from the injection site. These effects can cause symptoms of a serious condition called botulism. Symptoms of botulism can happen hours to weeks after injection and may include swallowing and breathing problems, loss of strength and muscle weakness all over the body, double vision, blurred vision and drooping eyelids, hoarseness or change or loss of voice, trouble saying words clearly, or loss of bladder control. ​ The dose of Dysport® is not the same as the dose of any other botulinum toxin product. The dose of Dysport® cannot be compared to the dose of any other botulinum toxin product you may have used. Do not have Dysport® treatment if you: ​ Are allergic to Dysport® or any of its ingredients. (Please contact us for a medication guide and a list of ingredients.) Are allergic to cow’s milk protein. Had an allergic reaction to any other botulinum toxin product (such as Myobloc® or Botox®). Have a skin infection at the planned injection site. ​ The Facts About Juvederm® XC: ​ Juvederm® is a filler that helps reduce fine lines and wrinkles around the nose and mouth. One will be able to get amazing results that can last up to one year with just a single treatment. It contains a substance naturally-produced in the body called hyaluronic acid (HA). Even though your body naturally produces hyaluronic acid, the natural aging process, sunlight and lifestyle factors reduce the production of it. ​ A loss of hyaloronic acid causes your skin to lose volume and structure. This leads to the development of fine lines and wrinkles. Juvederm® is a safe and effective filler that helps restore the lost volume. ​ Juvederm® involves the use of a fine needle. In many cases, Juvederm® can be completed within 15 minutes. There is no downtime needed, so you can immediately return to work and your other daily activities. Juvederm® has lidocaine, which is a type of anesthetic. The lidocaine helps minimize pain. ​ Most people immediately notice an improvement after getting Juvederm®. However, it is important to note that the amount of time it takes to see results can vary from person to person. Side effects of Juvederm® are typically mild. Some of the most commonly reported side effects include swelling, bruising and redness at the injection site. These side effects typically go away within seven days. ​ There are several benefits that come along with getting Juvederm®. This treatment allows people to get phenomenal results without going under the knife. Because there is no cutting involved, it is a lot safer than many other cosmetic procedures. Furthermore, Juvederm® gives people very natural-looking results. ​ Juvederm® XC is the smooth gel filler that your doctor uses to instantly smooth away wrinkles around your mouth and nose. With just one treatment, you’ll get smooth and natural-looking results that last up to a year. It is manufactured using Hylacross™ technology, creating a smooth-consistency gel, and is infused with lidocaine to improve comfort during treatment. With Juvederm® XC, you get the smooth results you expect, with the improved comfort you want. Everyone will notice, but no one will know. Young, healthy-looking skin contains an abundance of a naturally hydrating substance (hyaluronic acid). But as you age, sunlight and other factors can reduce the amount of HA in your skin. The lack of HA causes your skin to lose structure and volume, creating unwanted facial wrinkles and folds—like those parentheses lines around your nose and mouth. ​ Everyone’s skin ages differently and Juvederm ® XC may be used to rejuvenate multiple problem areas. From smile lines to vertical lip lines, you can smooth away unwanted wrinkles and restore natural contours. ​ Using a dermal filler like Juvederm® XC is a safe and effective way to replace the HA your skin has lost, bringing back its volume and smoothing away facial wrinkles and folds. Look at our "Patients Wall of Fame" photo gallery to see the difference Juvederm® XC can make. The Differences Between Juvederm® Voluma®, Vollure® & Volbella®: The Juvederm® collection of products contains several dermal fillers that are each based on a hyaluronic acid formula that gradually and naturally helps the sub-dermal layers of your skin restore collagen production. The Volbella® and Vollure® variants are particularly popular for those who have mild to moderate volume loss and other visible signs of aging. But while these variants are similar, each of them serves different purposes and produce different results. ​ Voluma® is a unique new filler from the makers of Juvederm® and Botox®. It was approved by the FDA in December of 2013 and is the first filler to claim it can “temporarily correct age-related volume loss in the cheek area of adults over the age of 21." ​ This is possible because it contains hyaluronic acid which, as stated above, is proven to restore age-related volume loss in the cheeks and cheekbones. As we age, a combination of fat and bone absorption causes skin to sag and a hollowing of the cheeks to develop. Voluma® works to temporarily restore the effects of aging and provide a younger, tighter appearance where applied. Voluma® treats the root problem of mid-face aging changes, and improves the appearance, convexity and contour of the area. ​ As you age, certain undesirable features will develop on your skin and face. This is usually sagging skin, fine lines, wrinkles and a loss of facial volume. While these things may develop on other parts of your body, the face is the one part of your body that you are unable to hide. Today, various techniques will make you look younger. Two of the most commonly used treatments are Juvéderm® Vollure® and Juvéderm® Voluma®. The main difference between Juvederm® Vollure® and Juvederm® Voluma® is what it is used to treat. Vollure® is designed for treatment around the corners of the mouth and nose. This will allow you to get rid of marionette lines, nasolabial folds and mild to moderate facial wrinkles and lines. Voluma®, on the other hand, is used to plump up the cheeks. By adding volume to the cheek region of the face, it will provide an overall lift to the rest of the face. While the treatments themselves are very similar, this main difference will determine which product needs to be used. When it comes to the actual treatment method, these two procedures are quite similar. Both feature an injection into the face but sticking a tiny needle just below the surface of the skin. The filler that’s used contains lidocaine in both situations. This helps to reduce the amount of mild pain or discomfort during the procedure. The doctor might also massage the area to make you feel more comfortable. The primary difference here is what is injected into the face. Vollure® injects a dermal filler. Voluma® features the injection of hyaluronic acid, the natural substance that contributes to your skin’s firmness. With both treatments, the primary benefits are that they solve the aging skin condition they’re designed to and last longer than other options. Vollure® is softer than other treatment options of the mouth and nose, which allow for longer-lasting results. The results of this treatment generally last up to 18 months following the injection. Voluma® allows patients to receive the benefits of a facelift without experiencing invasive surgery. The results of this treatment may last up to two years. In both cases, the results will be seen immediately. ​ Patients who dislike returning for frequent refills would be happy to know that Voluma® can last for up to two years. Like other fillers, Voluma® is made of hyaluronic acid, a natural substance found in the skin. While most fillers are injected into the nasolabial folds, like laugh lines, Voluma® goes deeper and is applied to the top of cheek bones. This allows physicians to reverse signs of aging by lifting the face. ​ Similar to other fillers, Voluma® has a few side effects, which include tenderness, bruising and swelling—all of which clear up within a week of treatment. Before Voluma®, surgery was the only option to tighten the overlying skin and lift the deeper soft tissues. In general, Vollure® is a filler treatment that is designed to treat fine lines and wrinkles around the nose and the mouth. This filler softens the appearance of nasolabial folds, parenthesis lines, and marionette lines. Sometimes, this filler is used to correct fine lines on the corner of the mouth and can be used to augment the shape of the lips or even skin laxity in the cheeks. ​ Volbella®, on the other hand, is a treatment designated for filling in lost volume in the lips to correct lipstick lines and contour the shape or fullness of the lips. Volbella® is frequently used on fine lines and wrinkles around the mouth, particularly on the corner lips. This filler is often used to embolden the vermillion border and emphasize the Cupid’s bow. One of the most distinct differences between these two fillers is the structure of the formula. Volbella® has a comparatively thinner and silkier formula that allows it to move more fluidly beneath the skin to produce natural-looking fullness. Vollure®, however, is a more substantial filler that has a more durable distribution that translates to more stable volume restoration. Another stark difference between these two fillers is how long the results of each last. You can expect Volbella® results to last for 12 months in the lips or around the mouth, while Vollure® results typically last about 18 months on nasolabial folds and up to 12 months on the lips. Naturally, the length of time your results last will also depend on how well you maintain your results, such s the skincare products you use and your suncare habits. The treatment you end up using for your aesthetic rejuvenation will depend mainly on the purpose of your treatment. For example, if you intend to restore lip volume, then you should use the filler that is intended for lip rejuvenation. If you want to soften fine lines and wrinkles, then you should use the filler that has the distribution that matches your needs. Lip augmentation is any filler treatment that alters the shape or fullness of the lips for the specific purpose of achieving an aesthetic goal. While some lip augmentation is done solely to restore lip volume, most of the time this treatment is meant to enhance the appearance of the lips. For that reason, the amount of enhancement you wish to accomplish is important. If you intend to restore lip volume, smooth the lips, and shape the lips, then Volbella® is your best choice. Age-related concerns are usually most prominent on the mid to lower face, which are the areas where fine lines and wrinkles tend to form in dynamic locations on the face. Dynamic wrinkles are caused by a combination of volume loss and repeated facial movements, and for that reason, these wrinkles tend to be more challenging to treat. For fine lines and wrinkles around the nose or mouth, Vollure® is the most appropriate treatment. Volume replacement is usually necessary for the cheeks and the lips, as well as tear troughs beneath the eyes. Volume loss in the mid-face creates a hollowed-out appearance that can prematurely age you. Ideally, a dermal filler used for treating volume loss will have a thicker consistency that will distribute evenly beneath the skin. For that reason, the best treatment for volume replacement is Vollure®. Since each of these fillers serves a different purpose, it’s common to use a combination of Juvederm® fillers to accomplish your aesthetic goals. For example, one reason to use different fillers is the fact that volume loss may be at different levels of progression on various areas of your face. We will help you match one of these fillers to the most appropriate areas of treatment. We may even recommend other Juvederm® fillers to rejuvenate and augment your appearance for optimal results. ​ Using Restylane® For Anti-Aging: ​ It’s a part of life—our skin changes as we age. It becomes thinner, loses fat, and no longer looks as plump and smooth as it once did. How your skin ages will depend on a variety of factors including your lifestyle, diet, heredity, and personal habits. So what actually happens as we age? Hyaluronic acid (HA) is a naturally occurring substance in your skin that helps provide fullness and elasticity. As we age, our skin loses that naturally-occurring Hyaluronic Acid. As HA diminishes, skin loses volume, increasing chances for wrinkles and folds to appear. The good news is that you can do something about it. You can use products in the Restylane® family to reveal a younger-looking you. Products in the Restylane® family are used to add volume and fullness to the skin to correct moderate to severe facial wrinkles and folds such as the lines from your nose to the corners of your mouth (nasolabial folds). Restylane® is also the first and only FDA-approved dermal filler for lip enhancement in patients over 21 years of age. ​ Treatment with a product from the Restylane® family typically takes less than one hour (individual treatment times may vary). Generally, there is little to no downtime associated with treatment using the Restylane® family of products. ​ Feel free to discuss all your options with Dr. Lee., including Restylane-L®, Perlane-L®, and pain medication. We're here to make you as comfortable as possible during the procedure. The doctor will cleanse and prepare the area(s) to be treated. Next, the clear gel in the Restylane® family of products is injected into the treatment area(s) using an ultra-fine needle to create the desired aesthetic effect. After treatment, you might have some swelling, redness, pain, bruising and/or tenderness. These symptoms are typically mild in severity and normally last less than seven days in the nasolabial folds and less than 14 days in the lips after treatment. Swelling may be more likely in patients under 36 years of age, and bruising may be more likely in patients over 35 years of age. ​ The Differences Between Restylane® Refyne®, Defyne® & Lyft®? ​ When it comes to dermal fillers, the newest line is Restylane®. Restylane® is a different type of filler with a different goal in mind. As you age, wrinkles and folds occur. Tightening the skin can help eliminate fine lines and wrinkles, but often the cause of them is volume loss in the cheeks and jawline. Restylane® products are FDA approved to restore volume to reduce these wrinkles and folds. ​ There are several different products available from Restylane®. Which filler you use will be based on the target area and the depth of the lines and wrinkles you wish to reduce or eliminate. Understanding the differences between the three different Restylane® products will help you make an informed decision when you come in for a consultation. Restylane® Refyne® is a filler that flexes the skin to eliminate fine lines and wrinkles both when you are at rest and when you show facial expressions. The filler moves with you to allow you to fully express yourself while diminishing lines and wrinkles you don’t want to show. It is most effective for moderate lines and wrinkles, and lasts for up to 12 months. Restylane® Defyne® is the latest product in the Restylane® line. It is designed to restore volume where age has created volume loss around the lower cheeks. Such volume loss can cause marionette lines and laugh lines. This filler is FDA approved to restore volume to diminish these heavy lines and wrinkles so that you can show expression while enjoying the benefits of the filler. Restylane® Lyft® is similar to Defyne® in that it restores volume loss in the face to eliminate fine lines and wrinkles. The biggest difference between Restylane® Lyft® and Defyne® is that Defyne® is used to treat severe smile lines while Lyft® is used to treat mild to moderate lines and wrinkles. ​ Restylane® Lyft® is a dermal filler used to treat wrinkles in adults. Formerly known as Perlane®, Restylane® Lyft® has technically been on the market since 2015. Both contain a plumping substance called hyaluronic acid (HA), but in different amounts. Restylane® Lyft® is primarily used for adding lift to cheeks, smoothing smile lines, and adding volume to the backs of hands. Restylane® Lyft® consists of individual injections that contain hyaluronic acid, lidocaine, and water. The combination of HA and water creates a plumping effect, which adds volume beneath your skin upon injection. This helps to temporarily smooth out wrinkles in the target area. Future follow-up treatments are necessary to help maintain these effects. The addition of lidocaine in Restylane® Lyft® helps to minimize any pain during the procedure. This can also help save time, as you won’t need to wait for a separate pain reliever to take effect before each treatment. Each Restylane® Lyft® injection is performed with a fine-needle syringe in the target area. Due to the addition of lidocaine, these injections shouldn’t be painful. The injections take only a few minutes at a time. Depending how many injections you’re getting, you may only be in the office for 15 minutes at a time. More injections can take up to one hour. ​ What is Hyperhidrosis & How to Treat it: ​ Excessive sweating, or hyperhidrosis, affects about one in 25 people. Excessive sweating can cause embarrassment, low self-esteem, and general discomfort in social situations. Hyperhidrosis occurs when sympathetic nerves cause sweat glands to produce too much sweat. The underlying cause is not known, but anxiety and other heightened emotional states can trigger the condition. The most common types of hyperhidrosis are palmar hyperhidrosis (sweaty palms) and axillary hyperhidrosis (excessive underarm sweating). Dr. Lee prefers to use the least invasive procedure that will meet your needs and highly recommends Botox® as a safe and very effective remedy for excessive sweating. Botox® is one of the most popular treatment for excessive sweating of the palms and underarms. Botox® weakens the nerves that supply the sweat glands, preventing the release of acetylcholine, and therefore greatly reducing or eliminating sweating in the treated area. The amounts of Botox® used are not enough to significantly affect the muscle motion of the hand, although some very slight weakness is possible. Botox® treatment of hyperhidrosis lasts about eight months to up to one year. Other areas treated for excessive sweating include the face and the soles of the feet. Dr. Lee believes that Botox® treatment of hyperhidrosis is simply the safest, most effective therapy we currently have for this disorder. ​ Age & Sun Spots: Aging has three main factors: genetics, time and environment. While you can’t change what kind of skin you inherit or the number of years on your calendar, Versa Pulse-C Laser® uses the state of the art Q Switched Alexandrite® light to effectively remove unwanted hyper-pigmentation. We can r emove and treat a ge s pots, sun damage, melasma, freckles and other hyper-pigmentation of the skin. ​ Unlike Intense Pulsed Light™ (IPL) which one can expect up to five or six treatments, Versa Pulse-C Laser® is a true laser, unlike IPL or “photofacial”, Versa Pulse-C Laser® requires only one to two treatments. Dark spots darken temporarily after treatment, then slough off in a matter of days, revealing smoother, more even skin tone and a more youthful appearance. After the treatment, you can maintain that clear skin complexion by using a medicated skin cream regiment that Dr. Lee prescribes. ​ Microdermabrasion: ​ The DiamondTome™ Skin Resurfacing System is t he original medical grade crystal free treatment that can reduce the effects of aging on your skin. Using the patented DiamondTome™ wand, the treatment is a safe, clinically proven therapeutic approach to superior skin care results. Non-invasive skin conditioning is an exfoliation technique for removing the topmost layer of skin, leaving it more supple and vibrant. The DiamondTome™ Skin Resurfacing System removes this layer by gently exfoliating the skin with natural diamond chips bonded to the tip of the wand, while vacuuming the exfoliated skin cells away in a controlled manner. Removing this outer layer leaves a smoother texture and promotes the growth of healthy new skin. Unlike other exfoliation treatments, the DiamondTome™ Skin Resurfacing System uses no loose abrasives to contaminate you or the environment. ​ Non-invasive skin conditioning also stimulates the vascular circulation to the surface of the skin resulting in a healthier and firmer appearance. Treatment can be performed on the face, neck, chest, hands, back, legs, elbows and feet. It can be used alone or in combination with other treatments. ​ The DiamondTome™ Skin Resurfacing treatment is non-invasive, pain-free and requires no down time. To achieve maximum results, several treatments are recommended for healthier, younger looking skin. ​ Prescription Acne Care Treatment: ​ Acne is not just a problem at the surface of the skin. Dr. Lee offers a proven, prescription acne care system that is scientifically formulated to treat acne at the source for reliable, long-lasting results. Dr. Lee utilizes compounded acne prescription medications, Obagi® Clenziderm® systems, along with other treatments that are specific for your acne problems. ​ Obagi® Blue Peel: ​ If you’ve been considering a chemical peel procedure, you should know that the Blue Peel® may help to restore a tighter, smoother more radiant look to your skin. The use of the Obagi® Nu-Derm® system is recommended before and after your Blue Peel®, which takes place right in our physician’s office. Once your skin has completely recovered and is finished peeling, you will notice a visible improvement in your complexion. Your skin’s appearance should continue to improve for the next four to six weeks, becoming firmer, clearer, smoother, healthier, and more youthful looking. The Blue Peel® uses trichloroacetic acid (TCA) as the active ingredient mixed with the patented Blue Base® from Obagi®. Dr. Lee can customize the depths of your peel based on the strength of the TCA and the number of layers of acid application on your skin. To find out if you’re a candidate for Blue Peel®, contact us today. ​ Obagi® Nu-Derm® ​ Obagi® Nu-Derm® is the newest in anti-aging technology and transformation. Skin aging is a natural process, but daily sun exposure can contribute to premature aging, slowing down the turnover of skin cells between healthy new cells and old damaged cells. Signs of aging and photodamage include: Age spots. Fine lines and wrinkles. Rough skin. Skin laxity (loss of elasticity). Erythema (redness). Sallowness (complexion). Hyperpigmentation (discoloration). The Nu-Derm® System is an anti-aging therapy that penetrates below the skin’s surface to transform skin cell functions at the cellular level and correct the damage within… revealing healthy, younger-looking skin. As you begin using the Nu-Derm® System, your skin will undergo four phases of transformation: Phase 1: Out With the Old (Weeks 1-6): Promotes cellular turnover and maximizes the results of your procedure by penetrating the layers of your skin: Old, dead skin cells are pushed to the surface and replaced with fresh cells. Itching, dryness, and redness are normal reactions as your skin adapts to the active ingredients in the system. Pigmented skin cells begin to become regulated, creating a more even-toned appearance. Phase 2: In With the New (Weeks 7-12): Smoother, softer, clearer skin is created: Your skin begins producing normal, healthy cells. Pigment cells are distributing melanin more evenly. Collagen production is stimulated. Your skin begins to acclimate to the active ingredients of the system. Phase 3: Healthy Glow (Weeks 13-18): Your skin cells are in the process of transformation: Collagen production continues. Your skin is smooth, naturally hydrated, evenly colored and more resilient. Your skin is becoming clearer, firmer and tighter with improved clarity and a healthy glow. Phase 4: The New You (typically lasts indefinitely, with maintenance): You can enjoy a complexion that’s smoother, clearer and firmer. But remember that maintenance is crucial to long-term success! ​ Sebaceous Glands: ​ Skin millia and hypertrophic sebaceous glands are small, raised, bumpy lesions on the face. Hypertrophic sebaceous glands are the result of over-grown oil glands on the surface of people with oily skin. Unlike millia, which are round inclusion that can be easily extracted, hypertrophic sebaceous glands are not extractable. Dr. Lee uses a radio-frequency probe to safely remove these unsightly skin bumps. ​ Wart Removal: ​ Nobody wants warts. Other people might not see the warts on the bottom of your feet, but you certainly do. Warts are ugly, and they are very often painful. If you are looking to remove any unwanted warts on your face, hands or feet, then you are in luck. The most effective wart-removal laser in all of Denver, CO is available at Dr. Lee’s office. Warts not only diminish self-esteem, but they can also cause pain and discomfort. Warts at the bottom of your feet are particularly troublesome, as they create difficulties and pain in walking and other active pursuits. Warts are caused by a virus that feeds off your blood supply and progressively grows and multiplies. Many methods of wart removal—such as medication, acid and freezing—have been attempted, but none have been proven effective. Dr. Lee’s use of innovative technology has remedied this problem. In order to completely remove a wart, the virus that produces the wart must be destroyed, and this is achieved by cutting off its blood supply. Lasers have long been used for removing warts, but never this kind of laser. The lasers used in the past have all been used to cut or burn warts and required multiple appointments, which often left people bleeding and in pain. The laser used by Dr. Lee promises no cutting, bleeding or pain both during and after the procedure. This is all made possible by the innovative technology behind the YAG laser. We shouldn’t say "zero" bleeding as there is a small amount of blood on deeper warts, and there can certainly be some discomfort if the warts are deeply embedded. Wart treatments are different for each person, but our lasers provide the most comfortable and effective treatment possible. Warts can be stubborn and persistent, as anyone who has suffered with warts knows all too well. ​ Since warts are actually caused by a virus, once that virus is active, it feeds off your blood supply and progressively grows and multiplies. Large warts on your toes or feet, or clusters of warts on the bottom of the foot (often referred to as plantar warts), can become a serious problem very quickly. They can become extremely painful and they can make walking or playing sports painful. ​ Unfortunately, getting rid of warts is extremely challenging. (That is, it has been until now!) Plantar warts are persistent, tenacious and can be extremely difficult to rid yourself of. Warts on the feet are resistant to just about every treatment you can subject them to, even medication. Acid or freezing, even combined with regular scraping, cutting, digging... and still, after all of that, all too often the warts just keep coming back. The warts continue to spread... they continue to grow. ​ Some patients, suffering with especially bad cases of plantar warts, eventually come to believe there is no solution. And it's hard to blame them when nothing they try ever really works, even after months (or years) of treatments. ​ We have an exciting new piece of technology—technology in a very specific form—A laser. This is not your ordinary laser wart-removal treatment. Unlike other lasers in several very important ways, this one has actually made destroying warts surprisingly simple. ​ This is not just any laser. In order to effectively destroy warts and eliminate them for good, it requires a very specific kind of laser, and it has to pack a really hefty punch. In order to destroy warts in a serious way, the laser needs to be able to knock out the virus while at the same time cutting off its blood supply so that it can't survive. One particular laser does this job of wiping out warts quite well. It's called an Nd:YAG® long-pulse laser. And the long pulse frequency doubled YAG® laser in Denver, CO in the office of Dr. Jonathan Lee takes the long-pulse fd:YAG® a step further with several very specific traits enabling it to completely destroy warts in only one or two short treatments. The combination of these traits in the laser makes the procedure not only extremely effective, but quick and easy. ​ Lasers have long been used in getting rid of warts on the feet, but these lasers were cutting lasers, burning lasers, requiring many treatments, all of them leaving your feet bleeding and in pain. But that's not what we are talking about here with the laser at the DJL Clinic. We are talking about something completely different. ​ If you live in the Denver, CO area, you can now enjoy the results of a far superior approach to treating the warts on your toes or feet: No cutting. No bleeding. No walking around with sore, painful feet afterward. ​ Why is that? It all comes down to the laser at work and the technology behind it. And with this particular long-pulse fd:YAG® laser, it comes down to two specific bits of science (just in case you happen to be curious). The two interesting bits of science that set apart the laser at the DJL Clinic in Denver, CO (and make it so effective at destroying warts) are the following: ​ First, the fd:YAG® laser at the DJL Clinic used for wart treatments makes use of the 1064nm wavelength. This particular wavelength is indifferent to skin pigment, making the laser safe on all skin types and allowing it to penetrate the skin and pass on to where you want the energy to build when treating warts... at the blood supply feeding the virus. The 1064nm wavelength specifically targets hemoglobin and uses the blood supply feeding the virus to cook the virus dead, while at the same time cutting off the blood to the warts. Most lasers on the market make use of ineffective wavelengths, or entirely inappropriate beam types, which either build up heat on the surface (or burning it) without penetrating the actual blood supply feeding the wart, or simply fail to create enough heat to get the job done. And this takes us to the next point. ​ Second, the proper fd:YAG® laser for wart treatments needs to be a true long-pulse laser. The pulses being delivered should not zap too quickly, but rather need to pour in slowly enough to heat the full volume of the blood supply surrounding the wart virus. This longer pulse duration allows for the substantial, full- volume heating of the blood right at the base of the wart. Too many of the lasers out there have very short pulses (typically less than 1 millisecond). A full-on long-pulse laser truly effective at this treatment will make use of a much longer pulse duration, typically between 25 to 45 times longer than everything else out there. And that is how you pack the kind of punch you need in order to knock out warts on the feet and put them down for the count. ​ The laser at the DJL Clinic can deliver the correct kind of energy, across the ideal wavelength, at the exactly correct penetration. And when you combine this with the appropriate pulse duration needed to consistently destroy warts, you have yourself an extraordinary new wart treatment now available in Denver, CO. ​ Warts might once have been a terribly frustrating problem (and often an embarrassing problem to doctors who could not seem to get them to go away in spite of all their best efforts). But now, equipped with the ideal laser for the job, we can ensure that your warts are destroyed in only one or two quick treatments, all without medications, and normally (except in the most severe cases) even without any local anesthetics. ​ Call us today to set up a quick consultation visit, or send us a message from our "Contact" page. Schedule a quick visit with Dr. Lee in our Denver, CO office and take care of those warts on your toes or feet once and for all! ​ Mole & Skin Tag Removal: ​ Moles, also known as nevi, are quite common. These dark colored or brown-pigmented spots occur in individuals of all ages. Moles can appear anywhere on the body but are generally more common on the face, extremities and the back. The majority of moles develop in childhood or teenage years. The color of moles can vary from light brown to black. ​ Benign moles (non-cancerous) and skin tags are common on the face, neck or torsos of some individuals. Dr. Lee can safely remove those unsightly moles or skin tags with little or no scarring. Dysport Juvederm Voluma/Vollure Restylane Restylane Refyne/Defyne Hyperhidrosis Age And Sun Spots Microdermabrasion Acne Treatment Blue Peel Obagi Nu-Derm Sebaceous Glands Wart Removal Mole And Skin Tag Removal Descriptions: Hormones Hormones What Are Hormones? Hormones are molecules that are synthesized and secreted by specialized cells often localized in endocrine glands in the body. Hormones are released into the blood stream and exert biochemical effects on target cells. Hormone action is determined by the presence of specific hormone receptors located either on the cell surface or intracellularly in the target cells. Hormones turn on the cellular machinery and therefore cause increased metabolism, increase in protein synthesis, increase in cellular repair, and increase in cell replication. Some of the hormones such as insulin, thyroid, testosterone, estrogen, and progesterone are well known to most people. But how well do people understand what they do? All aspects of aging are influenced by hormones. As we age cellular receptor sites become less sensitive to stimulation by hormones, thus requiring an increased amount of hormone to affect a cellular change. This is precisely why people need optimal levels of hormones. And even though their levels might be normal, they still need more hormones in the body to improve and feel better. (This is particularly true with thyroid.) These changes in hormones result in decreased healing and repair of tissues. Research has now proven that hormone therapies are valid means to improve and prolong quality of life, thus showing that deficiencies in hormones and endocrine dysfunction can contribute to the signs and symptoms of getting old. Nothing reverses aging. However, hormones can slow down the process and help us maintain our good health. Unfortunately, the technology to accomplish this age reversal by genetic engineering is not currently available. In the meantime, we must take advantage of the current state of the art, preventive medicine techniques which include avoidance of risk factors of disease, optimum nutrition, adequate exercise, caloric restriction, antioxidant therapy, and optimal hormone replacement. We can certainly slowdown that aging process to achieve less deterioration, less illness, a better quality of life and to feel and function better. This is true Preventive Medicine. ​ Benefits of Hormone Replacement Therapy (HRT): ​ In 1990, there was a landmark article published by Dr. Daniel Rudman in the New England Journal of Medicine. He and others showed that hormone deficiency was in part responsible for increased body fat, decreased muscle, decreased strength, decreased bone and skin thickness. Replacement of hormones resulted in overwhelming improvement in signs and symptoms of getting old. The findings of this famous study were consistent with the hypothesis that it was the deficiency of a hormone that contributed to the age-related changes. Many studies have since shown the same clinical utility of hormone replacement to effect clinical improvement in many of the signs and symptoms we encounter with aging. ​ Investigators are now combining various hormones and are seeing even more improvement. Dr. Mark Blackman, an endocrinologist from John Hopkins, recently published his findings in the Journal of Clinical Endocrinology and Metabolism. In this five-year study, he combines testosterone, estrogen and progesterone. Although there were different arms within the study, all men and women benefited from hormones, while those not on hormones did not. This investigator discovered again that the deficiency of hormones leads to symptoms and illness that were improved and prevented by hormones. Improvements seen were: ​ Increased breakdown of fat, weight loss and reduced body fat. Decreased incidence of heart disease and atherosclerotic plaque. Increased energy and exercise capacity. Improved vitality and quality of life. Increased strength, endurance and muscle tone. Improvement in hair, skin and nails. Improved sleep and well-being. Reduced levels of cholesterol and triglycerides. Less incidence of heart disease and diabetes. No increase in cancer was seen with any hormone. Progesterone decreases the incidence of breast cancer. ​ All hormones showed beneficial health effects, improvement in body composition, lipid profiles, cardiovascular risk factors, and increase in muscle strength and fitness. What is difficult to understand is why this article did not make national headlines? It can be concluded from this and other studies that hormone supplementation can reduce the incidence of major illness and thereby prolong life. It is not only the longevity that is important, but more so the quality of life, free of illness and disability. It should be every physician’s goal to extend the health and vigor of our middle-aged years into the latter years. The research and science is there. Physicians just need to learn to apply it. HRT is the ultimate of preventive medicine. ​ Hormone deficiency is responsible for many of the symptoms that occur as we get older. Hormone deficiency is a relatively simple malady to treat. Severe deficiency over prolonged periods might result in illness, physical impairment, disability and increased morbidity and mortality. Despite this evidence, patients are being seriously undertreated or ignored. Barriers to treatment can be addressed by educational programs aimed at increasing awareness and knowledge about natural hormone replacement therapy and its effectiveness. In spite of effective treatments being available, most individuals go without treatment. It is disturbing that the medical research papers and advances in diagnosing and treating hormone deficiencies has not revolutionized treatment practice. I frequently lecture to medical specialty academies to introduce the concept and the medical basis for such therapy. Optimal hormone therapy can help improve the outcome of treatments for many medical specialties. It might take years for medical school curriculum to teach this information and even longer for it to become the standard of care. ​ The benefits of HRT are dramatically enhanced with exercise. Hormone replacement along with a strength training program greatly enhances exercise tolerance, muscle strength, endurance and prevents fatigue. Exercise enhances our sense of well-being, decreases weight and helps lower cholesterol. Many people complain that they see no weight loss, strength improvement, fat reduction or better endurance in spite of consistent exercise. This is frustrating for them. However, when hormones are added to the formula improvements are seen. Hormone replacement also assists one in gaining the energy and desire to exercise. ​ The basics for optimal health and longevity are proper diet, exercise, nutritional supplementation and natural hormone replacement. HRT slows cellular degeneration and allows improved function and healing. This results in less disease and illness, a slowing of the aging process and a better quality of life. The scientific research has been impressive, the results dramatic, the public demand incredible. Don’t be without it! ​ Why is Hormone Replacement Therapy (HRT) Important As We Age? ​ Hormones decline in all people as they age. Many physicians assume this is the natural way it should be. If a younger person were to be diagnosed as having a hormonal deficiency, it would be quickly corrected. However, the same low level in an older individual is considered normal for their age and not something we treat. Normal is a relative term. No one wants the hormone levels of an 80-year-old, but labs report this low level as “normal” even though it might be only 20% of the level of a 30 year old. Researchers from around the world have now shown that the hormonal deficiency associated with age should be corrected to that of a younger person. When patients see and feel the improvement, they embrace it whole heartedly. It is not until one tries this new therapy and experiences the tremendous increased vigor that one realizes the harm that is being caused to the body by the lack of these hormones. The added benefit is that it is healthy too. ​ Thyroid, estrogen and progesterone have been prescribed for many years, but optimal hormone replacement is new. It has become logical therapy to replace and balance all of the hormones at the same time to a more optimal physiologic level instead of maintaining lower or mid normal levels. This is the difference between optimal hormone replacement in comparison with the standard medical therapy. Don’t wait for levels to be technically below a normal range. Accept a low normal level as not optimal and replace the hormone to high normal or optimal levels. Fortunately, many physicians as well as patients are able to key into the concept of optimal hormone replacement. ​ It has been shown that many changes seen in normal aging, including osteoporosis, muscle atrophy, sleep disorders and decreased sociability are in part caused by a decrease in hormones. Aging in man is associated with reduced protein synthesis, decreased lean body mass, decreased bone mass and increased body fat. The body composition changes are consistent with the progressive decline in the secretion of hormones. Much of what goes wrong in old age is the effect of our hormones no longer maintaining the balance that they once did. In fact, the diseases that have become associated with normal aging, such as diabetes, heart disease, and hypertension are largely a result of what happens when the correct balance of hormone levels is upset. By restoring the proper hormone balance, immunity is restored, and this can prevent many of the diseases associated with the aging process. ​ Many patients are typical, middle-aged, healthy people who experienced gradual increased symptoms such as decreased energy levels, decreased sense of well-being, laziness and lack of desire for common daily activities. Patients tend to lose muscle tone, gain fat around the midsection, and experience thin hair and thin skin. In addition to the symptomatic, degenerative problems, they will also experience increased cholesterol as well as signs of heart disease and arthritic change. Within six to twelve months of hormone replacement therapy, patients have noticed reshaped bodies, fat disappearing, increased muscle tone, and the energy of a younger person. Patients report an improved sense of well-being and an improved outlook on life. There are tremendous health benefits; there are great feel good benefits. ​ Unfortunately, nearly 90% of the patients we see who are taking “natural hormones” from other doctors are on an inadequate regimen. How do we know? When we measure the blood levels, they are near zero. In order for the hormones to be beneficial, the serum hormone levels must be kept within the optimal, upper limit of normal levels for a younger person. Most physicians are not trained to target optimal levels. ​ Many physicians do not understand how to prescribe the correct doses. They are not aware of the target optimal levels based on blood tests (not saliva tests). They might not be aware of the many options in the compounding of a natural hormone in order to provide a type that is absorbed and metabolized by the individual patient. ​ First and foremost, the patient must insist that the physician explain, monitor and optimize the hormone levels in order to guarantee that the therapy provides the maximum benefit. ​ Women who go through menopause will notice dramatic changes in skin thickness, texture, hydration and tightness. Women who stop hormone therapy notice the same disturbing changes. Literature in dermatology journals demonstrate that loss of thyroid, estrogen and testosterone hormones are responsible for this detrimental effect on skin. The only way to treat and prevent the changes in skin collagen, elastin, and prevent wrinkles is through hormone replacement. More importantly, however, are the changes within. The outside skin clearly displays signs of aging, but the inside also incurs significant deterioration that is not visible. This might be the reason that so many mid-life women and men say they just don’t feel as well as they would like. So much of this can be helped if treated early. When you go to that high school reunion, you’d rather hear, “Wow, you look great!” instead offering how much you’ve aged. ​ The Importance of Replacing Deficient Hormones: ​ Thyroid, testosterone, estrogen, progesterone, DHEA and growth hormone — to levels we had in our youth is beneficial to both our health and quality of life. This booklet is an overview of biologically identical hormone replacement for men and women. This specialty of medicine is growing at an impressive rate due to the increasing awareness of the health benefits of natural hormones and the detrimental effects of synthetic hormones. The first printing of this booklet was in 1998. A lot of media attention and medical studies have focused on hormone replacement in the last few years. This is our 4th revision and is reflective and explanatory of the recent mystery and misinformation about hormones. An additional excellent reference source on natural hormones for patients and physicians is a book I authored in 2002 entitled Natural Hormone Replacement for Men and Women: How to Achieve Healthy Aging. ​ Conventional medicine has always held the belief that aging is inevitable and that the progressive deterioration that occurs in our adult years cannot be altered. This is simply not true. We have also been lead to believe that the diseases of aging, such as heart disease, stroke, cancer, and senility, are all a part of the normal aging process. Fortunately, there is an exciting revolution in science and medicine that identifies hormone replacement as preventive medicine. The downward spiral of physical and mental decline that we have come to accept as a natural part of growing older is becoming recognized as somewhat controllable and preventable. The most effective solution to any disease process is the prevention of that disease. We are entering an era where mainstream medicine will focus on slowing down the aging process and thereby achieve prevention of both the illnesses of aging as well as the aging. One of the most important and successful treatments is optimal hormone supplementation. The amazing health-protective benefits of hormones are growing in understanding, acceptance, and application. Research has shown that maintaining our hormone levels in a youthful state can prevent the debility and illness that accompany the aging process. Obviously this will lead to increased longevity by preventing the illnesses that usually lead to our demise. However, most importantly is the fact that our quality of life in our later years will be significantly enhanced. ​ Over the last 50 years of research in the fields of endocrinology and immunology have improved our knowledge as to how and why we age. The rate and incidence of disease formation, as well as the rate of aging, are partially controlled by our endocrine and immune systems. These two systems are responsible for the adaptation and change of our bodies in relation to the aging process. The endocrine system regulates our body’s temperature, reproduction, growth, aging and immune system. Communication between the nervous system, the endocrine system, and the immune system makes it possible for us to adapt and survive in our environment. It is through hormones that these systems interact to accomplish this mission. Hormones are molecules that are released into the bloodstream and exert biochemical effects on distant organs and cells. Hormones can affect every cell in the body by activating a receptor site on the cell and thereby causing an internal activation of protein synthesis and activity. The hormones affect is determined by a specific receptor site on the target cell. Hormones might have different actions on different cell types in different tissues. Hormones serve as messengers from the central nervous system telling our internal organs how to function. A decrease in the production of hormones begins in middle age and continues to diminish in a linear fashion until old age. ​ Hormones are either proteins or derivatives of cholesterol. These molecules are manufactured in endocrine glands, which include the adrenal glands, the testes, ovaries, pancreas, thyroid, pituitary gland, and pineal gland. When there are degeneration and aging of the organs, the levels of hormones diminish. In addition, as we age, the specific receptor sites in the cells tend to change and become not as receptive to the hormones as they once were in our younger years. Whether the problem is low hormone levels or hormone resistance, the solution is optimal hormone replacement. ​ Whatever the cause may be, any decrease in the stimulation of the receptor site will result in a decrease in the stimulation of the cell, decrease in cellular repair, decrease in protein synthesis, the inability of the cell to regenerate and the gradual destruction of the cell. This is what occurs with age. A deficiency of hormones will, therefore, result in an imbalance in this very precise, self-regulating system. For many years, medicine has recognized the health benefits of replacing these waning hormones. For most physicians, synthetic hormones were the only option. Now it is possible to produce natural hormones that in every way match those produced by the body. Most hormones can be derived from plants, such as soy and yams. We have come to understand that synthetic hormones, which are chemically different than those naturally found in the body, can cause a whole host of side effects and even cancer. It does not make sense whatsoever to replenish with chemically different hormones when bio-identical hormones, to which our bodies are accustomed, are available. ​ There is a growing change in how we practice medicine. People are beginning to realize that they no longer have to accept the fact that their health, appearance, and function must deteriorate. They no longer want to accept growing frail and feeble. This new evolution is a culmination of research efforts over the years from some of the most distinguished medical and scientific research centers in the country. Physicians have finally realized that science has now given them the tools to enhance the quality of life by preventing deterioration through hormone replacement. Science is creating a new paradigm of preventive medicine by allowing our bodies to remain strong, healthy and vigorous. For centuries man has been searching for the Fountain of Youth, that potion that would stop the aging process. Research has now shown that part of the answer exists within our endocrine system. Medical journals have well-documented studies on the health benefits and feel-good benefits of HRT. Several medical references are listed in the book by Neal Rouzier, M.D., Natural Hormone Replacement for Men and Women: How to Achieve Healthy Aging. ​ Hormones control virtually all of the functions of the body including our reproductive, immune and metabolic systems. Hormones can actually control our overall physical and mental health. As the levels of hormones decline so do we decline both physically and mentally. We lose our energy, vitality, and health, as well as our longevity. By restoring these hormones to their youthful levels it is now possible to restore our youthful zeal and energy and to strengthen and bolster our bodies as well as our minds. We can improve many of the symptoms that we have come to associate with old age. We can also regain the youthful resilience that enables us to cope gracefully with the stressors that challenge us every day. ​ Hormone replacement therapy, however, is not a panacea. It will not reverse aging. It will not keep us permanently at one age. We will still continue to age and lose cells secondary to a process that is regulated genetically. With hormones, we can slow the precipitous decline that occurs after midlife. There will be no sudden falling off in our physical and mental health. We will stay resilient. There will only be a gradual transition that will be much less noticeable than it would be without the hormone replenishment. The purpose is to simply replenish the hormones that already occur naturally in our body and boost them back up to the appropriate medically sound levels necessary to maintain youthful health and vigor. Again, the key is to replenish all of the deficient hormones back to a more youthful balance, thereby producing a synergistic effect between the hormones. Which hormones to replenish, how much to replenish and how to adjust the hormones so that they have a synergistic effect is the art and science of the new specialty of natural hormone replacement medicine. I prefer the term preventive medicine. Vitamins, diet, and exercise are important, but hormone replacement is the only therapy that I have seen that can restore energy, make patients feel and function better and provide long term therapeutic protection. The next few chapters of the booklet will review each of the hormones, their health benefits as well as the detrimental effects of being without the hormone. ​ The Testosterone Quiz (For Men): ​ Men, are you currently experiencing the following symptoms? Declining sexual function, such as lower libido Lower energy level Loss of muscle mass Erectile dysfunction Weight gain, especially fat mass around the waist Depressed mood Declining strength and exercise endurance Poor self-esteem and worsening procrastination Generalized aches and pain Poor sleeping at night Increased irritability and decreased ability to deal with stress ​ Testosterone For Men: ​ Testosterone replacement in men has been shown to be effective in providing many health benefits. Testosterone replenishment results in increased muscle strength and lean body mass, improved sexual response, reversal of impotence, and improved body composition. Testosterone has also been shown to prevent osteoporosis, arthritis and degenerative joint change. It improves the sense of well-being and depressed mood that are frequently seen in andropause (male menopause). It has also been shown to improve memory, as does estrogen in women. Most of all it has been shown to protect against cardiovascular disease in both men and women. ​ Men who receive testosterone replacement consequently report that they feel sexier, stronger and healthier. They state that it makes them feel as they did when they were in their prime. After all, this is what replenishment of hormones is all about. It is about restoring hormones to youthful levels so you can feel as you did when you were at the peak of your physical and mental ability. Testosterone can slow down the physical decline that robs men of their energy, strength and libido. Testosterone can restore muscle tone and improve stamina. Testosterone can restore healthy sexual excitement and desire, which in turn results in an improvement in mood and overall well-being. ​ Testosterone is responsible for the sex drive of both men and women. As testosterone diminishes with age, so does the sexual functioning in both men and women. Restoring testosterone to youthful levels can reverse this situation. All too often, men and women automatically assume that as they age, their sexual capacity will diminish. There is no need to accept this loss of sexuality. Testosterone can play a critical role in helping to preserve and even restore sexual desire and function so that we can live our extended life span with the same excitement and enthusiasm we enjoyed in our youth. ​ Physicians are witnessing an explosion of interest in testosterone as a result of our growing realization that testosterone levels decline with age and that many men suffer serious consequences to their physical and mental health as a result. In women, it is expressed as menopause, whereas in men, it is expressed as andropause. Many of these symptoms and disease processes that we have come to accept as the result of normal aging are processes that are actually secondary to low testosterone levels and are easily correctable. Testosterone supplementation results in increased muscle strength, muscle size, increased energy level, decreased fat, and increased desire and endurance for exercise. As a result of this, the FDA recently approved the testosterone patch and topical gel. Now both men and women may be treated for their sex hormone deficiencies. ​ How many of the supplements that we take are not only beneficial to our health but also result in increased energy, increased stamina, and an elevated mood? What other supplement can build a strong body, strong muscles, strong bones, strong ligaments, and trim fat at the same time? An added benefit is an improved desire to exercise due to less exhaustion and lethargy. Clearly, testosterone is shown to have a positive impact on men’s health and well-being, our mood and our ability to learn and retain information. ​ There is good evidence that testosterone deficiency plays a role in heart disease. Despite many well-designed clinical research studies documenting a broad range of cardiovascular benefits from testosterone, it is virtually ignored by U.S. cardiologists. Patients with the greatest arterial blockage have the lowest testosterone levels from one recent study of 2500 men. This study from UC San Diego not only showed that men with higher baseline levels of testosterone had less cardiovascular disease, but supplementing to youthful levels prevented worsening of cardiovascular disease. In spite of this data available in the medical literature, physicians remain somewhat oblivious or resistant to the benefits of testosterone. ​ Testosterone supplementation helps reduce obesity, raise lean body mass, normalize blood clotting and raise the good HDL cholesterol, all of which decrease the incidence of diabetes and cardiovascular disease. It also prevents cognitive decline and Alzheimer’s Disease even better than estrogen in women. A recent medical study showed testosterone reduced C-Reactive Protein levels (CRP) a measurement of inflammation in blood vessels. Testosterone protected against heart attacks and progression of heart disease. Yes, testosterone has been demonstrated to increase lifespan. A recent study from the Annals of Internal Medicine demonstrated that men with the higher levels of testosterone lived the longest. Men with lower levels of testosterone did not live as long. This makes one wonder why most physicians fail to recommend testosterone for all men. ​ Testosterone should not be used if one has active prostate cancer. Multiple medical studies have proven that testosterone has not been shown to cause prostate cancer. In fact, low levels of testosterone are associated with more aggressive tumors. However, if one does develop prostate cancer, testosterone supplementation might accelerate the growth levels of the tumor. Therefore, there is a need to monitor the PSA on a regular basis to assure that one does not develop prostate cancer. Prostate cancer is the most common cancer in men. It can often be detected by an annual PSA test. ​ A recent summary article appeared in the New England Journal of Medicine, January 2004. The authors concluded, “We reviewed decades of research and found no evidence that testosterone therapy causes prostate cancer.” In fact, prostate cancer became more prevalent later in life when testosterone levels decline. The authors found no connection between higher testosterone levels and prostate cancer or any evidence that testosterone treatment provokes cancers. Researchers found no evidence that testosterone therapy causes prostate enlargement (BPH). More importantly, testosterone was found to significantly protect against heart disease. Testosterone was found to be a beneficial and safe hormone. ​ The Testosterone Quiz (For Women): ​ Women, are you currently experiencing the following symptoms? Feeling tired and fatigue easily Feeling "cold all the time” or your hands and/or feet are cold Severe PMS symptoms and/or heavy menstrual flow Hot flashes or night sweats Sexual dysfunctions such as lower libido, dry vaginal wall and/or poor lubrication Weight gain Depressed mood Poor skin, nail and hair quality Looking and feeling “old” Poor sleeping at night Declining physical endurance and exercise capacity Poor self-esteem ​ Testosterone For Women: ​ Even though testosterone is widely known as a male hormone, it is also a critically important hormone for women in that it plays a crucial role in the physical and emotional health of women. Too many women mistakenly think testosterone is only for men and resists the benefit of taking testosterone. Even many of the doctors who may prescribe estrogen and progesterone but failed to prescribe testosterone for women. The pharmaceutical industry was the first to realize the importance of this, and they have begun to market a combination estrogen and testosterone tablet which is, unfortunately, synthetic. The synthetic hormones can adversely affect the liver and should not be used. The safe, natural testosterone only should be used and is available from specialty compounding pharmacies. ​ Testosterone is produced both in the ovaries and adrenal glands of women and is an important hormone for normal female sexual development. Women also lose their libido as they age which is secondary to loss of serum testosterone. Lack of testosterone also contributes to symptoms of menopause and lack of libido and sexual responsiveness. Replenishment of testosterone in women contributes to the enhancement of sexual drive, relief of menopausal symptoms, restoration of energy, strengthening of bone, prevention of osteoporosis and improvement of an overall sense of well-being and zest for life. Many women do not realize that testosterone improves their skin, muscles, bones, tendons, and joints. Older patients commonly complain about their skin becoming so thin, primarily on their arms and hands. Most women are unaware that the best hormone for the skin to prevent thinning and wrinkles and increase collagen and elastin is testosterone. ​ Many physicians and women remain unaware that testosterone is much better for protecting against bone loss than estrogen, yet it is seldom mentioned as a treatment. A small amount of replacement with testosterone gel can make an incredible difference that many women have not been able to enjoy up until now. The correct dose of testosterone replacement will be determined by body weight, age and blood levels. Testosterone supplementation helps reduce obesity, raise lean body mass, normalize blood clotting and raise the good HDL cholesterol, all of which decrease the incidence of diabetes and cardiovascular disease. It also prevents cognitive decline and Alzheimer’s Disease even better than estrogen in women. A recent medical study showed testosterone reduced C-Reactive Protein levels (CRP) a measurement of inflammation in blood vessels. Testosterone protected against heart attacks and progression of heart disease. Yes, testosterone has been demonstrated to increase lifespan. A recent study from the Annals of Internal Medicine demonstrated that men with the higher levels of testosterone lived the longevity. ​ In summary, testosterone is a hormone secreted by the ovaries, adrenal glands and testes. It is both a male and female hormone. It contributes to increased muscle mass, strength, endurance, decreased fat, increased exercise tolerance, enhancement of well- being and mood. There is an increase in bone density and prevention of osteoporosis, improvement in skin tone and healing capacity, and increased libido and sexual performance. It prolongs the quality of life by slowing the diseases of aging such as cardiovascular disease by decreasing cholesterol and increasing HDL. Testosterone is a memory enhancer and protects against the formation of Alzheimer’s disease. It is equally as important and beneficial in females as well as in males. A recent study in JAMA explored all the benefits of testosterone and called it cutting edge medicine. The NEJM reviewed testosterone replacement for women and found it the best therapy for improving energy, along with estrogen and progesterone. Don’t confuse natural testosterone with the synthetic testosterone analogs. Use only the natural testosterone and not the synthetic. It’s healthy for you and you’ll feel good too. ​ Menopause: To Bleed or Not to Bleed: ​ Menopausal women taking hormones do not necessitate menstrual cycling. The hot topic for celebrity talk shows and celebrity books is bioidentical hormones. The media has highlighted the term “bioidentical hormones” thereby making it a familiar subject for both women and men, especially those coming to grips with the aging process. Now we can further define the term “natural” and specify & “bioidentical” which gives everyone a new understanding and appreciation for hormone replacement. ​ Out of this media frenzy have emerged new “experts” with “expert” opinions on the right way to take hormones. One of these “expert” methodologies of hormone replacement unfortunately has made many women apprehensive. Some are so displeased that they avoid taking hormones altogether. Some experts theorize that cycling (creating a period every month) is recommended and natural. The implication is that women menstruate while they are “young” and healthy. In order to maintain that same healthy status all menopausal women should continue to menstruate. This “cycling” is done by stopping progesterone for one week of each month and thereby creating a menstrual cycle. Most women find this recommendation unsatisfactory. If women believe that taking hormones requires that they have a period, most women choose to pass on hormone replacement. ​ What is cycling? It is the fall of women’s hormones that results in menstruation. If a woman stops the progesterone for a few days every month she will cycle and bleed. This is possible even if you have been years without a period, unless, of course, you have had a hysterectomy. Just because it is “natural” in younger women does not mean it is necessary or beneficial for menopausal women. ​ First of all, hormone replacement therapy does not put one in a state of pregnancy. During pregnancy the levels of estrogen might be in the hundreds. On estrogen replacement, ideal estradiol levels are typically 60-100 pg/dl, far from that seen in pregnancy. ​ Secondly, the reason a woman menstruates is to clean the uterus in preparation for the eventual implantation of a fertilized egg. If one is not interested in becoming pregnant, there is no physiologic reason or benefit to menstruate. ​ A recent article in the Obstetric/Gynecological literature claimed that unexpected vaginal bleeding was the most common reason women stopped taking HRT. The cessation of periods was one thing that women welcomed with menopause. The medical literature often addresses how to stop and prevent postmenopausal vaginal bleeding so that women will be comfortable in continuing HRT. We advocate increasing progesterone to prevent post-menopausal bleeding. With the appropriate balancing of estrogen and progesterone, women should not bleed and will be more satisfied with continuous use of HRT. Also, since estrogen and progesterone are so important, why take them for only three weeks per month and stop them to bleed in the fourth week? A woman would lose the protection and benefit of estrogen and progesterone for 25% of the time. ​ For years, women have been treated with birth control pills taken continuously and not cycled to control PMS. It is the fall of women’s hormones that takes place right before their periods that causes the symptoms of PMS. By taking birth control pills continuously, a woman can avoid this drop of hormones and the symptoms of PMS. The pharmaceutical industry has now caught onto this and promotes a new birth control pill that is cycled for bleeding only every four months instead of monthly. The researchers claim that while no menstruation is necessary, the cycling allows women to menstruate every four months to make them feel more “normal.” We now realize that even pre-menopausal women do not need to menstruate, let alone post-menopausal women. ​ Remember, cycling involves stopping the hormones for a week each month. Another reason not to cycle is the loss of protection that takes place when the progesterone is not present. Bioidentical progesterone protects the breasts and uterus against cancer. The bleeding that takes place with menstruation is not what protects the uterus against cancer. It is the direct effect of progesterone on the uterus that protects it. Stopping progesterone for a week means that the body is without the protective benefits of progesterone for those days. It makes no sense to lose the important protective benefits for seven days every month. ​ Recent studies have shown that Provera (medroxy-progesterone) increases the risk of breast cancer and increases the thickening of the breast tissue. It does this by direct stimulation (up regulation) of estrogen receptor sites in the breast. One study showed that Provera increased breast stimulation by 400% over baseline. The same study showed that bioidentical progesterone (different from Provera), does not stimulate breast tissue as it down regulates receptor sites in the breast. Therefore, why lose this protective effect of progesterone by stopping it for 25% of the month which means you lose 25% of the protection? There is a condition known as “endometrial hyperplasia.” This condition causes increased thickening of the endometrial stripe (uterine lining) which is a precursor to cancer. This condition must be treated to avoid the development of cancer. The treatment is high dose progesterone (or Provera by conventional physicians) to shrink this tissue. If repeat ultrasound does not show a decrease in endometrial lining, then the dose of progesterone is doubled. The shrinkage of the endometrial tissue is a result of the direct stimulation by progesterone. The protection does not occur because of the shedding of the lining. A constant sufficient dose of progesterone is the better protection against cancer. Progesterone should never be stopped for any reason! ​ In summary, women on hormone replacement therapy do not need to cycle (stop the progesterone) and bleed on a periodic basis. There is no substantiated benefit to the body to regularly bleed. And it certainly makes hormone replacement therapy and its many protective benefits a more attractive and convenient regimen for women. ​ Bioidentical Hormones: ​ You might ask, “If there are hormones available that are natural to my body, why do doctors prescribe synthetic hormones?” The explanation involves the powerful pharmaceutical industry in the United States, politics and economics. The molecule of the natural hormone is identical in structure to the hormone naturally found in the body, Pharmaceutical companies cannot patent natural or bioidentical compounds that already exist in nature. ​ However, they can patent chemically different molecules that are highly profitable. A patent will guarantee that a pharmaceutical company will have an exclusive right to manufacture and profit from their product. After the tremendous monetary investment that goes into developing and studying a pharmaceutical product, it is logical that the pharmaceutical companies would want their investment protected with an exclusive, patented product. Therefore, there is little research and minimal marketing of natural hormones. Where do these natural hormones come from? The pure biologically identical (human identical) hormone is either extracted from plants or synthetically manufactured. What is most important is that the end product is a molecule identical to the hormone molecule found naturally in the body. This applies to all hormones — thyroid, estrogen, progesterone, testosterone and DHEA. One can get bioidentical hormones from compound pharmacies. ​ Aren’t health food store products natural? Products in health food stores provide people with a variety of natural options, usually from an herb or plant source. Folk medicine, naturopathy, and herbalists have become more popular as people seek alternatives to conventional, synthetic medicines. However, the products from compounding pharmacies are different in several ways. First, the medicine provided by a pharmacy requires a prescription. Health food store products are most often of a dose that is so low that it does not require a prescription. Usually the dose is so small that it is insufficient to produce a measurable difference in the body, based on laboratory tests. Second, the products from the compounding pharmacy utilize ingredients of a pure pharmaceutical grade that are micronized. Micronized means that the product is a fine grain that will be well absorbed. Third, the natural hormones from the compounding pharmacy can be prescribed as long-acting, or time release. This helps the body have a balanced hormone level instead of the highs and lows that come with quick acting, quickly absorbed or poorly absorbed products. In order to assure adequate replacement, hormone levels are monitored and then adjusted to maintain optimal levels of all hormones. HRT might be worthless unless monitoring and adjustment is done. ​ To summarize, a bioidentical hormone has a chemical structure that is identical to the hormone naturally produced by the body. We refer to them as natural because they are natural to the human body. Natural hormones cannot be patented by drug companies. Synthetic hormones have a structure similar to but not exactly the same as a hormone produced by your body. These chemical differences mean that the synthetic hormone acts differently and produces substantially different effects. Natural (bioidentical) and synthetic hormones should not be considered the same or used interchangeably. They are entirely different. A multitude of studies have demonstrated many harmful effects of synthetic hormones whereas the medical literature supports no harmful effects of natural hormones, only beneficial effects. ​ The Synthetic Hormone Controversy: ​ Recently there has been tremendous confusion and misunderstanding concerning the article published in JAMA, July 13, 2002, concerning the use of synthetic estrogen and progestin. The following is an in-depth review of the hormone controversy and the recent medical studies involving synthetic hormones. ​ The Women’s Health Initiative (WHI) Study demonstrated that the combination synthetic hormones, Premarin and Provera or PremPro, resulted in an increased risk of breast cancer and heart disease. However, the incidence was very low at less than 1 per 1,000 women. PremPro consists of a synthetic estrogen from the urine of pregnant horses and progestin (Provera), imitation progesterone. Experts from all fields of medicine are now calling for a discontinuation of all hormone replacement based on reported increases in heart disease, breast cancer and blood clots in this WHI trial. This is an inappropriate reaction to and incorrect interpretation of one study! There are other safe hormones, which were not included in this study, that have been incorrectly targeted. The information contained in this latest study is not new news and the conclusion of this study does not apply to natural biologically identical hormones. The JAMA article specifically addresses this issue. Unfortunately, the media will take things out of context and publish misinformation. Patients then misinterpret these findings because of the media confusion. The intent of this notice is to clarify this issue and the article. ​ An article appeared in JAMA in 2000, Jan 26; 283(4):485-91, which concluded that the risk of breast cancer increased 8 times with Provera. The July 2002 article is no different. It again demonstrates what has been known for some time, that Provera increases breast cancer risk, but it has never received the media attention and medical criticism as now. ​ Even though the WHI Trial evaluated Premarin and Provera, it was finally shown that it was primarily the synthetic progestin (Provera) that was the culprit in causing the harm. In the first arm of the WHI, Premarin-Provera caused an increased risk of breast cancer and heart disease. In the second arm of the study using estrogen alone, without Provera, the results were very different. There was no increased risk of breast cancer or heart disease. In fact, there was a decreased risk of cancer and heart disease in the estrogen only group. However, most physicians and the media misinterpret the data and conclude that estrogen is harmful when in fact it is not; it is progestin (Provera) that caused the harm. ​ The other inappropriate conclusion was that all hormones in women should be stopped just because Provera is harmful. This conclusion does not apply to all hormones. All hormones should not be stopped, just the Provera. What should women take in place of Provera? The answer is simply natural progesterone. However, many physicians may claim that it makes no difference, that all hormones are the same. This is simply incorrect. The natural hormone in the body is called progesterone; the synthetic, chemically altered hormone is a progestin (Provera) and is a completely different molecule. It is not the same. In recent studies, Provera has been shown to cause breast cancer; natural progesterone has been shown to decrease the risk of breast cancer. Provera increases breast density; progesterone decreases breast density. Provera stimulates breast tissue; Progesterone down regulates breast receptor sites. Provera raises cholesterol; progesterone lowers cholesterol. Provera is associated with a multitude of side effects. Progesterone has none. Progesterone is pro-gestational, the hormone that is necessary to maintain pregnancy. Provera is a teratogen (causes birth defects) and is absolutely contraindicated in pregnancy. These hormones absolutely are not the same. These are two completely different hormones with completely different effects. ​ The confusion stems from the generic name of Provera—medroxyprogesterone. Because the term progesterone is in the name some consider medroxyprogesterone to be the same as progesterone. As explained above, we know they are very much different, both in chemical structure and effect. As evidenced in the findings of the WHI Trials, one must understand each individual hormone. The WHI proved that the combination of Premarin and Provera was harmful. The estrogen-alone arm of the study determined that estrogen alone, without Provera, did not cause breast cancer or heart disease. (This study used Premarin as the form of estrogen. The chapter on estrogen explains the better option.) The WHI vindicated estrogen and showed Provera (progestin) to be the culprit. The safer bioidentical progesterone should be substituted in place of Provera or progestin. We should use bioidentical estrogen and bioidentical progesterone and avoid the problems associated with synthetic hormones. When our body loses hormones, it is critical for healthy aging that we put back in the same identical hormone instead of a hormone that is molecularly different. ​ The pharmaceutical companies are trying to manufacture progestins that more closely resemble the molecular structure of natural progesterone in order to avoid the side effects and complications associated with the synthetics. The pharmaceutical industry is putting considerable efforts into this development because natural progesterone is devoid of any side effects or complications. What begs for an explanation is if the natural hormone is so perfect in its lack of side effects and complications, why not simply use the natural progesterone? Again, the drug companies can’t patent or profit from a bioidentical product. However, patients sure can! There are two recent studies indicating that natural progesterone protects against breast cancer by decreasing epithelial cell proliferation in the breasts (Fertility Sterility 1998; 69:963-69). Another study showed that progesterone was more protective than Tamoxifen, which is a treatment for breast cancer (Japan Journal of Cancer Research 1985; 76: 669-04). And another document shows decreased ductal stimulation by progesterone by 400% (Fertility Sterility 1995; 63: 785-91). There are many studies that show that Provera increases the risk of breast cancer; progesterone decreases the risk. Again, progesterone is not Provera. In the PEPI trial, it was shown that estrogen and progestin increased the risk of heart disease, whereas estrogen and natural progesterone decreased the risk of heart disease. Provera increased cholesterol and clotting whereas progesterone caused the reverse thereby Protecting the heart. This July 3, 2002, study from JAMA (WHI) essentially shows the same. It amazes me that it still comes as a surprise to the medical community that progestins increase the risk of heart disease when it has been so well documented in the literature. Provera antagonizes the beneficial effects of estrogen on coronary artery atherosclerosis (Arterioscler Thromb Vasc Biol 1997 Jan; 17(1):217-21). By now it should be apparent that not only is progesterone not the same as Provera, it is completely the opposite. ​ An article in the medical journal American Family Physician showed that Provera and progestins cause significant side effects of swelling, fluid retention, breast tenderness, bleeding, depression and mood disorder. Progesterone is devoid of these side effects; it is the feel-good hormone of pregnancy. Provera is not a feel-good hormone. ​ The recent JAMA article stated that Premarin by itself did not increase the risk of breast cancer. The National Breast Institute and the National Institute of Health have emphatically stated that there is no conclusive evidence that Premarin (estrogen) alone causes an increased risk of cancer. Overall, 75% of all the studies in the medical literature show no increased risk of breast cancer and this article from JAMA is no different- the risk is from adding the synthetic progestin (Provera). However, there are a few studies that show a slight increased risk of breast cancer with Premarin. The overall risk from these few studies is still very low, but the risk significantly increases with the addition of a progestin. In summary, most studies show no increased risk of cancer and a few studies show a very low risk if any with use of Premarin by itself. However, in my opinion, we should still not use Premarin because of the metabolites it produces which can cause many side effects. ​ Premarin contains equilin which has been reported in 2 cancer research journals to cause cancer (Chem Res Toxicol 1999 Feb;12(12(:204-13). There is ample evidence now to implicate the synthetic estrogen with a small increased risk of cancer and the synthetic progestin with the much greater risk of breast cancer and heart disease. The July 2002 JAMA article emphatically states that the concern is with the synthetic progestins and does not include other hormones nor the natural estrogen or progesterone. ​ The original intent of using the bio-identical natural hormones is to avoid the side effects and complications of the synthetics that we have known about for years. Why all the sudden media attention is not known. What needs to be clarified is that the concern should be only with the synthetic progestin, whereas the media and newspapers misquote that all hormones are damaging. The solution to the problem is the same that we have been recommending for years —natural, bio-identical estrogen, progesterone, and testosterone. The deterioration starts at menopause when our hormones decline. Avoid the harm by simply replacing our hormone levels back to the levels we enjoyed before menopause. The landmark papers that document the importance of this therapy over the problematic synthetic hormones are: Infertility and Reproductive Medicine Clinics of North America Vol 6, number 4, Oct 1995, and Obstetrics and Gynecology Clinics of North America Vol 21, number 2, June 1994. ​ The final nail in the coffin for the synthetic hormones comes with three recent European studies. The purpose of the studies was to demonstrate the difference, if any, between the synthetic hormones and natural hormones and the method of administration. The exact results were confirmed in all three studies, the largest of which consisted of 100,000 women studied for ten years. The synthetic hormones were responsible for an increased risk of breast cancer. The natural estradiol and the natural progesterone were protective and demonstrated no increased risk of cancer. This was the longest and most powerful study to date demonstrating the safety and superiority of bioidentical hormones over the problematic, side effect prone, synthetic hormones. ​ None of these new studies provide any new information to me nor does it affect the way I prescribe hormones. All of this information has been in the literature for years. Where was the media then? These recent studies are finally the eye opener for both patients and doctors to avoid the synthetic hormones and replace only those hormones that normally occur in the human body. Menopause results in a tremendous increased risk of heart disease, osteoporosis, urogenital atrophy and cerebral deterioration — all that can be prevented by simply maintaining hormone levels. And in spite of the health benefits, we should not ignore the symptomatic improvement and quality of life issues that are the primary reason to use the hormones in the first place. Just use the right hormones in the right dose and monitor the levels. I hope that this clarifies all the issues. Remember, stop synthetic hormones that are harmful. Do not stop the beneficial, biologically identical hormones. Testosterone For Men Testosterone For Women Thyroid Thyroid Hormone: ​ "I hear so many times that patients kept going from doctor to doctor searching for the cause of fatigue and feeling lousy. The doctors always told them that their thyroid was 'normal' but they knew it wasn’t. After being on the right dose and the right kind of thyroid, they finally feel normal." —Dr. Jonathan Lee, M.D. ​ Thyroid hormone is a metabolic hormone secreted by the thyroid gland. It regulates temperature, metabolism, and cerebral function, which results in increased energy, temperature and warmth. It increases fat breakdown resulting in weight loss as well as lower cholesterol. It protects against cardiovascular disease by lowering cholesterol. It improves cerebral metabolism and prevents cognitive impairment. It relieves symptoms of thin, sparse hair, dry skin, and thin nails. Thyroid affects every cell in the body. ​ People who suffer from low thyroid function tend to experience fatigue and low energy, slowness in their thinking and actions, forgetfulness, mental confusion, depression, arthritis-like pain and susceptibility to colds and infections. Many of these aspects are considered normal aging. However now we know that it is secondary to thyroid insufficiency. The thyroid hormone can be an indispensable component of your hormone regimen. Thyroid production declines as we age, similar to other hormones. This is not considered to be true hypothyroidism but rather a thyroid insufficiency, which has in the past been thought to not require hormone replacement. Research has now shown that improving thyroid levels will alleviate many of the symptoms of thyroid insufficiency and allow our system to function more effectively and efficiently. ​ Thyroid hormone initially is produced in the thyroid gland as T-4. Once in the body, this circulating T-4 is converted to the active form of thyroid called T-3. As we age, this conversion becomes less effective. In addition, the production of T-4 also diminishes thereby resulting in less stimulation of the cells. Our body needs thyroid hormone for metabolism. If metabolism is low due to an inadequate supply of thyroid hormone it will adversely affect every organ and system in the body. We will have less energy as well as the symptoms of thyroid insufficiency. In addition, the conversion of T-4 to the active form of T-3 also diminishes, resulting in less stimulation of the cells. Mitochondria need thyroid hormone to burn oxygen and produce ATP, which is the fuel that runs the body. If the mitochondria are weakened due to an inadequate supply of thyroid hormone, then we will not be able to burn up proper amounts of oxygen thereby giving us less energy and symptoms of thyroid insufficiency. In addition, we will be unable to keep up mentally and physically as we once did. Also, our immune system becomes weaker and less effective. Physicians have been hesitant to supplement thyroid hormones largely due to a lack of understanding of the importance of optimal thyroid levels and the relationship to improving the quality of daily life. ​ Over the years I have seen hundreds of patients that complain of fatigue, lack of energy, weight gain and all the typical symptoms of low thyroid. Every time these patients have been seen by their doctors; they are told that there is no problem with their thyroid because their tests are normal. Patients seem to know that there is a problem with their thyroid, but physicians refuse to acknowledge this. Many patients treated with synthetic T-4 products will still experience hypothyroid symptoms even though the laboratory test values appear normal to their physician. This is because a physician tends to rely on one thyroid test, the TSH or thyroid stimulating hormone, which is an indirect measurement of thyroid function. The new paradigm is to measure the free hormones in our body, which is the Free T-3 level. The free hormones are the active hormones and are a more accurate indication of the body’s metabolism of the hormone. Correcting these deficiencies of thyroid hormone to optimal levels with natural thyroid results in optimal blood levels, improved metabolism and resolution of symptoms. Even though thyroid levels might vary, symptoms might not improve until optimal levels are reached, levels similar to those present in our younger years. This is a concept not understood by most physicians, yet wholeheartedly embraced by patients. ​ Just because laboratory values fall within a normal range does not mean the levels are optimal or the best they can be. We believe there is room for improvement. Normal levels for a test are an average for the population. People might be low or high and this determines normal levels. But normal for a middle-aged person is low in comparison to a younger person. So, a middle-aged level is just as low as everyone else at that age, rather than optimal for a younger person. Physicians call it normal for your age. Patients call it feeling lousy for your age. By optimizing thyroid levels, symptoms of low thyroid can be alleviated, and health benefits assured. ​ Thyroid hormone in higher doses has been shown to be an effective treatment of chronic fatigue syndrome (CFS). It helps patients with severe bouts of low energy. Treatment with optimal amounts of thyroid is the best way to improve how one feels and functions. ​ As for those who are taking thyroid, most physicians prescribe only synthetic T-4 medications. Unfortunately, many symptoms persist despite normal thyroid levels. The problem is a lack of conversion of T-4 to the active hormone, T-3. This is commonly seen in patients taking synthetic T-4 thyroid hormone. Due to inadequate conversion of T-4 to T-3, patients frequently experience low thyroid symptoms even though their doctors report “normal” TSH and T-4 levels. By using a combination of both T-4 and T-3 in a natural form, optimal levels of T-3 are obtained. A recent study in the NEJM proved that the synthetic T-4 by itself did not eliminate symptoms. It was only the combination of T-4 and T-3 together that resulted in clinical improvement and resolution of symptoms. We find the synthetic thyroid (T-4) replacements are not as effective as the natural replacements, which mimic the hormone normally produced by the body. Natural thyroid with T-3 is the only way to optimize all thyroid measurement levels. Patients who switch from the synthetic to the natural usually notice an improvement in their symptoms similar to the NEJM study. In spite of the evidence that natural thyroid is much more efficacious, physicians will often prescribe only the T-4 due to drug company influence and habit. ​ Thin hair, brittle nails, dry skin are all related to low thyroid. Many women who suffer from hair loss and thin hair are usually told by their physicians there is nothing that can be done. In spite of normal thyroid tests, women often can stop hair loss, increase hair growth and increase hair thickness by optimizing their thyroid levels. All hormones are beneficial; low levels are detrimental. ​ Estrogen: ​ For more than 40 years, doctors have been prescribing estrogen for women who suffer with menopausal symptoms such as hot flashes and insomnia. Many women felt so healthy and invigorated on estrogen that they continued to take this hormone indefinitely. ​ Study after study documents the astonishing effect that estrogen makes women not only feel better but healthier. Estrogen vastly improves the quality of day-today life for women by making them more youthful and energized. Women have better muscle tone, fewer wrinkles, stronger, shinier hair, and a more enjoyable, satisfying sex life after menopause. Estrogen users stand taller and straighter and do not suffer the typical bone loss of osteoporosis. Estrogen users have half the risk of heart disease and stroke in comparison with those that do not use estrogen. Estrogen users have an extremely low incidence of Alzheimer’s disease and senility. Estrogen users are not subject to vaginal dryness, urogenital atrophy and the concomitant infections that can become debilitating. Estrogen is one of the few hormones that women demand from their physicians. Over 10,000,000 women take estrogen in the United States, and it was the most widely prescribed medicine in the United States. Actually, it is through estrogen supplementation that we have learned the importance of optimal hormone supplementation and the synergy from replenishing all the hormones. It is not until women lose estrogen that they start to experience heart disease, bone loss and deterioration. Simply by replacing this hormone, all this detriment can be prevented. ​ However, on July 17, 2002, the news media alarmed the public by reporting that hormones have been shown to increase the risk of heart disease and breast cancer. Unfortunately, the media does not know how to interpret the medical literature. Medical studies have reported for some time that synthetic estrogen and synthetic progesterone cause an increased risk of heart disease and cancer, but only when supplemented in the synthetic form. The natural hormones do not pose the same risk. This is exactly why we have been such strong advocates of natural hormone replacement and not synthetic. This information is not new. An almost identical article appeared in the same medical journal (JAMA) the year before and revealed the same conclusion — synthetic hormones increase the risk of breast cancer, although it is a very slight increase in risk. The media did not sensationalize the research until the 2002 publication. ​ But this poses a question: If a lack of hormones causes heart disease, how can taking the same hormones make it worse? It doesn’t! Taking the chemically altered, different hormone is what makes it worse. Natural or biologically identical hormones do not. This is what the media misrepresented. The culprits were synthetic hormones, not natural hormones. The identical ones that we lack are exactly what we should replace, although this is not what most physicians do. Most physicians prescribe only the synthetic hormones (Premarin, Provera, PremPro) and not the ones that are most appropriate. For years, many physicians have laughed and scorned the natural hormones and the physicians who prescribe them. This 2002 report has them scrambling, looking for an explanation and options for their patients. And what’s worse, women who need the beneficial effects of hormone replacement are quitting because their physicians tell them to stop all hormones. When they stop they suffer the consequences of estrogen deficiency. ​ Physicians should be telling their patients to stop the synthetic hormones that have been demonstrated to be harmful. Physicians should then be educating women that loss of our own natural hormones results in significant deterioration and illness. We should be encouraging estrogen replacement with bioidentical estrogens. Many women fear estrogen due to the media reports on the negative studies of synthetic hormones. This is unfortunate. Women should be educated to fear the harmful effects of loss of our natural estrogen. The detrimental effects of the synthetic hormones should not be extrapolated to include our natural hormones which are so beneficial. In the past physicians routinely removed a woman’s ovaries with hysterectomy. This eliminated key hormone production. Once physicians realized the suffering and harmful effects from the loss of hormones, they now try to save ovaries whenever possible. If hormones are so harmful, we would surgically remove ovaries at an early age. Instead, we try to preserve ovary function and beneficial hormone production for as long as possible. And when menopause occurs and hormone levels fall, we simply need to replace the lost hormones back to pre-menopausal levels with the same identical hormone instead of with a completely different hormone with a different chemical structure. The pharmaceutical industry doesn’t admit there is a difference, but the human body sure knows there is a difference. ​ Estrogen is produced in the ovaries and adrenal glands. Men actually produce estrogen from conversion of testosterone, although this is an extremely small amount. There are three types of estrogen found in a woman’s body: Estrone, estradiol and estriol. The levels of all of these hormones fall dramatically at the onset of menopause, which is responsible for the symptoms and detrimental health effects of menopause. The symptoms characteristic of menopause are hot flashes, insomnia, vaginal dryness, bladder problems, difficulty concentrating, and anxiety. Unfortunately, the disease processes, such as cardiovascular disease, stroke, osteoporosis, and Alzheimer’s, only increase in the absence of estrogen. ​ The rapid loss of bone after menopause has been attributed to the decline in the production of estrogen, which is essential for bone growth. Osteoporotic fractures are one of many of the diseases of aging that result in significant morbidity and mortality. In addition, the loss of estrogen results in the development of heart disease, which is the number one killer of both men and women. When a woman’s estrogen level drops, the risk of heart disease soars. Postmenopausal women on estrogen have a 70% decrease in mortality from heart disease. Estrogen also has been shown to lower total blood cholesterol and raise HDL, the good cholesterol. Not only does estrogen protect vessels of the heart, it also protects vessels of the brain and protects against Alzheimer’s disease. Over 100 articles in the medical literature over the last 30 years have documented the cardiovascular benefits of estrogen. There was one recent study, The Women’s Health Initiative (WHI) study, in which a combination of synthetic estrogen and progestin (Premarin and Provera) showed an increased risk of breast cancer and heart disease. However, in the estrogen-only trial there was no increased risk of cancer or heart disease. It was the synthetic progestin (Provera) that was to blame and not estrogen. Most physicians, the media and patients, misunderstand this. Again, it is the synthetic progestin that causes the increased health risks. Estrogen alone is not the culprit. ​ There is no doubt that estrogen can protect a woman against many of the diseases of aging and that postmenopausal women on estrogen typically feel better and stay healthier. Unfortunately, most of the estrogen that is prescribed to women is in the form of a synthetic estrogen or an estrogen that is not natural to the body. Since these synthetic estrogens are not natural to the body, many women develop side effects or do not feel well on the synthetic, non-bioidentical hormones. A healthy trend these days is to avoid the synthetic estrogens that have been used for years and instead use natural estrogens. Human receptor sites were designed to accept the natural estrogen and not a synthetic analog. A recent article in the New England Journal of Medicine proved by meta-analysis that long term use of synthetic estrogens and Progestins (the main culprit) increase the risk of breast cancer. These medical studies have utilized the most commonly prescribed estrogen, Premarin, which is derived from the urine of pregnant mares (thus the contraction: Pregnant mare’s urine). Premarin contains many estrogens found in horses only and not in humans. Many women cannot tolerate the side effects created by taking the chemically different horse estrogen. More importantly, Premarin contains the horse estrogen equilin, which can cause many side effects. It is astonishing that so many physicians do not understand why some women refuse to take Premarin. ​ In summary, estrogen protects against heart disease, stroke, osteoporosis, Alzheimer’s disease and memory disorders. It protects against vaginal atrophy, urinary incontinence, and urinary tract infections. It prevents symptoms of menopause and improves overall well-being. Estrogen deficiency results in urogenital atrophy, incontinence, sagging skin, sagging breasts, increased skin wrinkles, fatigue, depression, mood swings and decreased libido, all of which can be corrected by estrogen replacement. I absolutely recommend estrogen, and replacement must be in the form of a natural, biologically identical estrogen, of which there are several forms. ​ A recent article from UCLA demonstrated that postmenopausal women without ovaries suffered increases in heart disease, strokes, osteoporotic fractures, and increased mortality in comparison with women that had ovaries. This is one of hundreds of medical studies proving beneficial effects of our hormones and the problems and deterioration that occur when we lose our hormones. Our own hormones are beneficial until we lose them. Thus, we should replace them with the same identical hormone that was there before. Do not replace them with chemically altered, harmful hormones that are completely different than what we naturally had before. Premarin dramatically increases thrombosis, heart attacks and strokes whereas estradiol was shown to have none of these effects (JAMA, Oct. 6, 2004:1581). Premarin contains over 10 different estrogens that are not found in the human body and that have adverse effects on breast tissue and blood vessels. This again is another example of a study that demonstrates harmful effects of the conjugated chemically altered estrogens, whereas the use of estradiol had no adverse effects at all. (JAMA 2004; 292:1581-87) ​ Never equate the synthetic estrogen with the natural estrogens. The media might lump them together, but they are not equal. It is not until the body lacks the natural hormones that we see the problems and deterioration. This can be avoided by simply putting back in the same identical hormone that was there before. This is the molecule that the body recognizes, metabolizes, and uses as if it was its own. If you are a woman without estrogen, either because of menopause or surgical menopause (complete hysterectomy), you should be taking estrogen (and progesterone). If you are taking synthetic estrogen, you should change to natural estrogen. Put back into your body the same identical hormones to levels similar to what you had when you were younger so that you feel and function as you did before menopause as well as prevent the significant deterioration that occurs' from loss of estrogen. ​ Progesterone: ​ Women in menopause lose progesterone, which protects against uterine cancer, breast cancer, osteoporosis and heart disease. Unfortunately, most doctors do not replace the lost progesterone with progesterone, but use a synthetic, chemically different drug called medroxyprogesterone or the brand name Provera. Even though Provera shares a similar name to progesterone, medroxy-progesterone, it is molecularly and biologically different than progesterone. This section explains how Provera is so problematic and harmful and how progesterone is so safe and beneficial, even though most physicians think that they are one and the same. ​ Progesterone stands for pro-gestational or the hormone of pregnancy. It is absolutely necessary for the initiation and maintenance of pregnancy. Provera, a progestin or synthetic progesterone, is a teratogen. It causes birth defects and is absolutely contraindicated in pregnancy. Obviously, these hormones are opposites of each other and are structurally, metabolically and physiologically two completely different hormones. Most physicians, however, do not comprehend this and will therefore prescribe Provera. They should not be used interchangeably. Almost all medical studies evaluate only the synthetic progestin, Provera, and have found Provera to be harmful in many ways. The medical studies evaluating natural progesterone have never found it to be harmful. Most physicians do not understand the difference, and even the medical literature does not clearly differentiate between progesterone and Provera (medroxyprogesterone). ​ Progesterone is another female hormone of equal importance as is estrogen for the aging woman, although it is commonly overlooked. Progesterone is a hormone produced by the ovaries and is used in nature to balance estrogen. It too can safely and effectively relieve menopausal symptoms, protect against cancer, prevent osteoporosis, and improve overall well-being. In the past, physicians had been accustomed to prescribing the synthetic progestin (brand name Provera). These synthetic progestins cause significant problems and side effects as do the synthetic estrogens and do not provide the benefits produced by natural progesterone. The recent study cited in JAMA (July 23, 2002) was a large hormone study utilizing different combinations and forms of estrogen and progestin. A portion of this study was terminated early because of the statistically significant increased incidence of breast cancer. This WHI study demonstrated that it was actually the progestin (Provera) that was responsible for the increased incidence of breast cancer even though estrogen is thought to be the culprit. A most important but not widely published fact is that the estrogen- only arm of the WHI study demonstrated a decreased incidence of cancer. Estrogen is not to blame, progestin (Provera) clearly is the culprit. More importantly, recent studies consistently demonstrate that progesterone protects against breast cancer. ​ There was no problem with Premarin or the estrogen only arm of the study. The media either misrepresented that all hormone replacement is risky or that Premarin was the problem. The media also stated that the progesterone was the problem which was also incorrect because Provera is not progesterone; it is a progestin. Again, the progestin (Provera) is not the same as progesterone. The confusion stems from the fact that the generic name for Provera is medroxyprogesterone, which doctors interpret to be progesterone. However, progestin (Provera) and progesterone have completely different molecular structures and are physiologically different. Progesterone has no harmful effects, whereas progestin is riddled with problems. Unfortunately, neither the media nor the public understands the difference, even though the medical literature proves them to be entirely different. They definitely are not the same. ​ Natural progesterone enhances the action of estrogen as these two hormones were meant to work together to maintain normal hormonal balance. The lack of progesterone causes similar disease processes as does lack of estrogen. These include osteoporosis, heart disease, decrease in libido and a significantly diminished quality of life. The combination of natural progesterone and estrogen can prevent this downward spiral by keeping women vital, strong and healthy. ​ Most women complain of the many side effects of the synthetic progestins and now demand the natural progesterone supplementation instead. Studies have shown the tremendous health benefits of the natural progesterone; however, it is usually prescribed only at the insistence of well-educated, well-informed women. Natural progesterone allows women to feel much better than they do on any of the synthetic progestins. We used to explain how the synthetic progestin caused bloating, swelling, breast tenderness, bleeding and depression, whereas the natural progesterone does not. Now that we have such strong evidence that Provera causes breast cancer, it seems meaningless to even debate that synthetic progestins should ever be used. Anyone that continues to prescribe or take Provera or synthetic progestins is taking a risk they don’t need to take. Natural progesterone should be the definite choice—due to the protective benefits and no side effects. ​ Even though natural progesterone is better for women, the medical community still has little knowledge of this. This is probably because natural progesterone cannot be patented and, therefore, is not produced by most pharmaceutical companies. Natural progesterone is available commercially as Prometrium in a capsule form. It is important to do blood tests to assure levels are optimal. ​ Natural progesterone is a very beneficial treatment for premenstrual syndrome (PMS), which includes moodiness, irritability, bloating, and headaches. The symptoms are due to falling progesterone levels. Natural progesterone helps to balance both pre-menopausal and post-menopausal levels of estrogen and hormone induced symptoms such as emotional instability, headaches and mood swings. The natural progesterone has a mild tranquilizing effect and enhances overall well-being. Natural progesterone also offers protection against uterine cancer as well as breast cancer as evidenced by European studies, whereas Provera increases breast stimulation and breast density as seen on mammograms. Two recent Japanese studies showed how progesterone prevents breast stimulation, whereas Provera does not. A different study showed that progesterone was better than Tamoxifen in protecting against breast cancer. This is an extremely important study because up to this point there had been nothing shown to decrease the risk of breast cancer. Progesterone inhibits growth of breast cancer cells, whereas progestins stimulate growth of cancer cells (European Journal of Cancer). ​ Progesterone levels are high during pregnancy and are essential in carrying to term. These high progesterone levels are often responsible for women reporting how great they felt during pregnancy and why many symptoms associated with PMS disappear during pregnancy. It is the sudden decline of progesterone after giving birth that causes post-partum depression. Treatment with natural progesterone in the post-partum period can help new mothers cope while their hormones re-balance. ​ Natural progesterone also results in a greater reduction of cholesterol levels and an increase of HDL or the good cholesterol. This is in contrast to the synthetic progestin, which does the opposite (PEPI Trial, JAMA 1998). Unfortunately, the overwhelming majority of physicians who write prescriptions for progestin are unaware that there is a safer, better tolerated progesterone that is available. In addition, the natural progesterone has been shown to halt progression of osteoporosis. Progesterone stimulates osteoblasts, which are the cells that grow new bone. Estrogen will only prevent bone loss. ​ For those women who are unable to take natural estrogen, natural progesterone can be prescribed to treat many of the common symptoms of menopause and prevent the diseases associated with menopause. The PEPI Trial evaluated the use of estrogen and Provera or estrogen and natural progesterone. The Provera arm of the study showed that those women had an increased risk of heart disease and elevated cholesterol levels. The natural progesterone arm of the study resulted in less heart disease and lower cholesterol levels. This study was completed years ago. No wonder the recent July 2002 JAMA study showed that Provera increased the risk of heart disease. Why do researchers continue to use progestin when numerous studies already pinpoint significant problems? ​ Natural progesterone comes in many forms, most commonly topical creams, the oral capsule and the sublingual tablet. In my experience, the best bioavailable form that results in sustained therapeutic levels is the sublingual form. Over-the-counter progesterone creams contain a minimal amount of progesterone and will not bring blood levels to therapeutic ranges. Proponents of progesterone creams claim that saliva testing proves the efficacy. However, saliva tests do not correlate with blood tests. Blood tests are the true indicator of a progesterone level that is sufficient to be protective of the uterus, breasts, bone and heart. Adequate levels are attained through the use of a prescription dose. If over-the counter creams had adequate doses, the FDA would require that it be dispensed only by prescription, as with all drugs. Progesterone levels should be measured by blood tests and then evaluated by a physician to assure that the level is within the therapeutic range of 10 to 20 mg/dl. ​ In summary, natural progesterone protects against breast cancer, is a natural tranquilizer, promotes feelings of well-being, enhances the beneficial actions of estrogen, relieves menopausal symptoms, and stimulates new bone formation as well as protect against osteoporosis and cardiovascular disease. Provera does none of that. Even if a woman does not have a uterus, all women should take progesterone for the above benefits found throughout the body, not just in the uterus. Recent studies have demonstrated the benefits of progesterone in protecting against breast cancer. No other therapy has demonstrated this! All menopausal women should be taking progesterone. Period (No pun intended.) ​ HGH (Human Growth Hormone): ​ ​ HGH is vital to all organs, tissues, and systems. It is for restoration of youthful immune function, Increases strength of bones by increased function of osteoblasts, and results in faster healing of wounds. Deficiency of HGH causes fatigue, poor muscle development, excess body fat, lack of drive and initiative, decreased endurance and strength, poor healing, decreased immunity, increased hyperlipidemia and insulin resistance. Deficiency also results in osteopenia or thin bones, sagging muscles, increased wrinkles, thin hair that is slow to grow, sagging skin, breast, increased truncal love handles and cellulites, cardiovascular disease secondary to atherosclerosis, and decreased renal function. ​ As a result, HGH deficient person may experience Increased exhaustion and fatigue, poor self-esteem, low assertiveness, low sociability, laziness, loss of concentration, memory difficulties, Irritability, and mood disorder, poor response to stress, decreased ability and desire to exercise, decreased sense of well-being, diminished sleep, and lack of drive and initiation. Having HGH supplementation results in increased energy level, elevated mood, physical, and psychological wellbeing. Optimal HGH level would result in improved lipolysis, decreased atherosclerotic plaque, increased fibrinolysis—clot dissolution, increased cardiovascular function, increased cardiac output Increased energy and increased exercise capacity, and improved quality of life secondary to increased vitality. HGH replacement results in improved wound healing and protein synthesis, increased REM and stage IV sleep which results in improved sleep, improved sense of well-being, increased immunity with resultant decrease in disease and cancer. HGH results in increased life expectancy and quality of life by disease prevention, increased tightness of skin, decreased wrinkles secondary to increased collagen and elastin, feel good benefits, health benefits, and aesthetic benefits. ​ Despite many evidences of benefits of HGH, it is one of the most misunderstood and feared hormones. When it is understood and used properly, it is one of the most safe and beneficial hormones. It is extremely important to have the physician who is well trained and experienced in HGH replacement therapy to explain and educate patients regarding HGH. It is one of the most expensive hormones and in most cases, economics is the main reason the patients defer HGH therapy. It is an unscheduled drug by DEA at the federal level, but some states designated as schedule III control drug, such as testosterone. ​ DHEA (Dehydroepiandrosterone): ​ Dehydroepiandrosterone is a hormone produced by the adrenal glands and is derived from cholesterol. (Remember, any hormone that is derived from cholesterol or sterols is called a steroid. DHEA, estrogen, progesterone and testosterone are all beneficial, natural steroids.) It is the most abundant steroid hormone in the body. DHEA has many beneficial effects. It is the building block that is necessary to make estrogen, progesterone and testosterone. For many years DHEA was felt to have no particular value other than as a precursor to our sex hormones. Researchers then discovered that DHEA dropped steadily as we aged and could be used as a biomarker to measure the aging process itself. A recent study from the National Institute of Health, published in 2002, showed that the only factors in humans that have been shown to prolong lifespan are caloric restriction and elevated levels of DHEA. Indeed, a study in the New England Journal of Medicine in 1992 proved that low levels of DHEA were associated with increased mortality from cardiovascular disease and cancer; higher levels were protective against heart disease and cancer. Conclusion: maintain optimal DHEA levels for optimal health. ​ DHEA improves the function of the immune system, improves brain function, relieves stress, and has been shown to be a very potent anti-cancer supplement. DHEA also increases energy and reduces body fat and cholesterol, thereby preventing heart disease. Most of these effects are a result of a shift from a catabolic state to an anabolic or protein building state. There has been a significant amount of research published on its critical role in our health and well- being, which is why it is the focus of some of the most exciting medical research in this country. ​ DHEA has been shown to increase insulin sensitivity, which means that less insulin is required. This in turn results in protection against diabetes, and greater control for those with diabetes. It has also been shown to have a significant effect in treating connective tissue disorders Such as Lupus, which is a disease that tends to have minimal improvement from standard therapy. Pharmaceutical DHEA will soon be FDA approved as a drug to treat Lupus. ​ Most of the tremendous effects seen from DHEA are based on its ability to stimulate protein synthesis within the cell, which in turn results in an increase in cell regeneration and an improvement of immune function which forestalls disease processes. DHEA is an antioxidant as it appears to prevent the formation of free radicals. ​ Insulin resistance has led to over 14,000,000 Americans having some form of diabetes. Insulin resistance, or inability of insulin to do its job, results in increased glucose, increased weight, obesity, and heart disease. A decline in DHEA precipitates insulin resistance' that can lead to damage of the cardiovascular system. Diabetics that have been given DHEA have shown a slight decrease in insulin resistance which prevents the harmful effects of insulin on the vasculature. Two recent studies in the Journal of Clinical Endocrinology and Metabolism have proven the beneficial effects of DHEA in preventing cardiovascular disease. ​ The Journal of Clinical Endocrinology and Metabolism in 1995 stated that there are over 2500 published papers documenting DHEA’s multiple benefits. This important paper acknowledges that we produce half of the DHEA at age 40 than we did when we were 20. Some elderly people produce no DHEA whatsoever which puts them at a significant risk. DHEA was shown to improve the quality of life and postpone many of the unpleasant effects of aging such as fatigue and muscle weakness. Patients receiving DHEA slept better, had more energy, and were better equipped to handle stress compared with a placebo group not receiving DHEA. Other potential benefits of DHEA include immune enhancement, anti- cancer effects, anti-atherosclerotic effects and cognitive enhancement. ​ DHEA is available over the counter and is common in drug stores, grocery stores and health food stores. Unfortunately, many of the over-the-counter products come from foreign countries and contain contaminants and preservatives and therefore are not entirely pure pharmaceutical grade DHEA. The half-life of DHEA from over-the-counter sources is approximately six hours, which would require that one take the supplement three times a day. DHEA should be prescribed in a sustained release, micronized form, which allows for complete absorption as well as a sustained level over a 24-hour period, thereby foregoing the need to take the supplement three times a day. In addition, DHEA by prescription should be of a pure pharmaceutical grade that is compounded by a pharmacy to assure a 100% pure pharmaceutical product. ​ Melatonin: ​ Melatonin is a hormone secreted by the pineal gland, which is located in the center of the brain. It regulates our circadian rhythm as well as regulates the deep stages of sleep. It is in these deep stages of sleep that our immune system is stimulated. A recent book published called The Melatonin Miracle regarded the pineal gland as a master regulator of the endocrine system and, as such, controls most of the immune system’s responses. The pineal gland controls the activities of virtually every cell in the body, affecting such diverse functions as reproduction, body temperature, kidney function, immunity, sleep, growth and development. The pineal gland uses melatonin to maintain the body’s balance, equilibrium and homeostasis. ​ The pineal gland’s primary role is to control the production and use of energy throughout the body through the release of melatonin and perhaps other compounds. The pineal directs energy production so that it goes where it is needed at precisely the right time, whether it is needed to repair or respond to injury or make hormones, enzymes or antibodies. Melatonin directs the cells in the body to do whatever it takes to keep the body running in a state of homeostasis. As with all other hormones, there are many health benefits to melatonin. ​ On January 16, 1997, the New England Journal of Medicine published the most extensive review about melatonin that has ever been published in a conventional medical journal. This article extolled many of the virtues of melatonin including the powerful antioxidant effects, the potential benefit in preventing and treating cancer, its immune enhancing properties, and its ability to promote better sleep and avoid jet lag. Melatonin has been shown to have a role in the biologic regulation of circadian rhythms, sleep, mood, reproduction, tumor growth and as an antioxidant. As with DHEA, there have been hundreds of studies published showing the tremendous beneficial effects of melatonin. If published scientific studies show a natural hormone supplement can boost immune function, scavenge free radicals, fight cancer, induce youthful sleep patterns, and possibly slow the aging process, then we feel that most people should be taking melatonin as a supplement. ​ Melatonin is available both by prescription and over the counter. Most of the OTC preparations are from China and possibly contain contaminants. The pharmaceutical grade from a compounding pharmacy is 100% pure; over-the-counter preparations are not as reliable. Taking melatonin that is compounded by a special pharmacy is the only way to assure that you are receiving pure melatonin. The standard dose is 3 mg. Many patients might have to take up to 30 mg in order to get the desired effect. The simple way to judge the correct amount necessary is by trial and error. The only side effect from melatonin might be excessive morning sleepiness and headache. If this is encountered, then the dose should be reduced. Some people are sensitive to melatonin and require a much smaller dose such as 1 mg, while the majority of people tolerate 3 to 9 mg without difficulty. Again, since melatonin is such an important protective hormone to take the maximum dose tolerable should be taken. The optional dose is simply the amount that can be taken without causing excessive morning grogginess and that which results in restful sleep without significant awakening. ​ I’ve discovered one intriguing benefit to melatonin, which is the reduction in nocturia or urinary frequency at night. Many men think that they have prostate problems because they awaken to urinate, although they usually urinate small amounts. Melatonin usually diminishes this nighttime awakening with the urge to urinate which in turn improves the supposed prostate problem. And, yes, it is equally effective in women. Melatonin has recently been shown to be an effective therapy to decrease migraine headaches and lower blood pressure. ​ Why would anyone not want to take this safe, natural, effective, cheap, cancer-protective, immune-enhancing therapy for sleep that has stood the test of time? I personally take 12 mg. of melatonin, sleep like a baby, dream more than before and awake refreshed. No one should take sleeping pills until they have tried this natural, healthy, sleep-enhancing hormone that avoids the risks and side effects of pharmaceutical drugs. Estrogen Progesterone HGH DHEA Melatonin

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    Privacy Policy: Website Privacy Policy: ​ We respect the right to privacy of all visitors to the Doctor Jonathan Lee (DJL) Clinic website. We do not collect information that would personally identify you unless you choose to provide it. The personal information that you submit, by registration or email, such as an appointment request, is shared only with those people at the DJL Clinic who need this information to respond to your question or request. We do not save personal information to use for other purposes, nor do we provide it to any other organizations. Your information is never given to a third party. ​ We have taken reasonable steps to ensure the integrity and confidentiality of personally identifiable information that you may provide. You should understand, however, that electronic transmissions via the Internet are not necessarily secure from interception, and so we cannot absolutely guarantee the security or confidentiality of such transmissions. ​ Except for authorized law enforcement investigations or other valid legal processes, we will not share any personally identifiable information we receive from you with any parties outside of the DJL Clinic. We will never pass on your email address to any third party. On every group email there will be an Unsubscribe link. © 2024 Doctor Jonathan Lee (DJL) Clinic, (formerly, Expert Laser Clinic, LLC). All rights reserved. ​ Health Information and HIPAA: We understand that information about you, your health, and that of your family is personal and sensitive in nature. We are committed to protecting the privacy of this information. Each time you or your family visit the DJL Clinic, we create a record of the care and services you receive. We need this record to provide you with quality care and to comply with certain legal requirements. The DJL Clinic is committed to ensuring that your medical information is private and secure. The DJL Clinic protects medical information as required by state laws and the federal privacy rules of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). References Support & References: I am indebted to Dr. Neal Rouzier, who has sparked my passion for Hormone Replacement Therapy. I have benefitted tremendously from educational training through World Link Medical courses and ongoing support from Dr. Rouzier as well as other brilliant physician colleagues. Books & Courses: ​ How to Achieve Healthy Aging, Second Edition, Neal Rouzier, M.D. Bio-identical Hormone Replacement Therapy for Men and Women, Neal Rouzier, M.D. World-Link Medical, Mastering Protocols for Optimization of Hormone Replacement Therapy Longevity & Bioidentical Hormones: ​ Friedrich N, Haring R, Nauck M, et al. Mortality and serum insulin-like growth factor (IGF)-I and IGF binding protein 3 concentrations. J Clin Endocrinol Metab. 2009 May;94(5):1732-9. ​ Malkin CJ, Pugh PJ, Morris PD, et al. Testosterone replacement in hypogonadal men with angina improves ischaemic threshold and quality of life. Heart. 2004 Aug;90(8):871-6. ​ Besson A, Salemi S, Gallati S, et al. Reduced longevity in untreated patients with isolated growth hormone deficiency. J Clin Endocrinol Metab. 2003 Aug;88(8):3664- 7. Laughlin GA, Barrett-Connor E, Criqui MH, Kritz-Silverstein D. The prospective association of serum insulin-like growth factor I (IGF-I) and IGF-binding protein-1 levels with all cause and cardiovascular disease mortality in older adults: the Rancho Bernardo Study. J Clin Endocrinol Metab. 2004 Jan;89(1):114-120. ​ Moffat SD, Zonderman AB, Metter EJ, et al. Free testosterone and risk for Alzheimer disease in older men. Neurology. 2004 Jan 27;62(2):188-193. ​ Khaw KT, Dowsett M, Folkerd E, et al. Endogenous testosterone and mortality due to all causes, cardiovascular disease, and cancer in men: European prospective investigation into cancer in Norfolk (EPIC-Norfolk) Prospective Population Study. Circulation. 2007 Dec 4;116(23):2694-701. ​ Malkin CJ, Pugh PJ, Jones RD, et al. The effect of testosterone replacement on endogenous inflammatory cytokines and lipid profiles in hypogonadal men. J Clin Endocrinol Metab. 2004 Jul;89(7):3313-3318. ​ Selvin E, Feinleib M, Zhang L, et al. Androgens and diabetes in men: results from the Third National Health and Nutrition Examination Survey (NHANES III). Diabetes Care. 2007 Feb;30(2):234-238. ​ Hak AE, Witteman JC, de Jong FH, et al. Low levels of endogenous androgens increase the risk of atherosclerosis in elderly men: the Rotterdam study. J Clin Endocrinol Metab. 2002 Aug;87(8):3632-3639. ​ Maggio M, Lauretani F, Ceda GP, et al. Relationship between low levels of anabolic hormones and 6-year mortality in older men: the aging in the Chianti Area (InCHIANTI) study. Arch Intern Med. 2007 Nov 12;167(20):2249-54. ​ Shores MM, Matsumoto AM, Sloan KL, Kivlahan DR. Low serum testosterone and mortality in male veterans. Arch Intern Med. 2006 Aug 14-28;166(15):1660-1665. Asvold BO, Bjøro T, Nilsen TI, et al. Thyrotropin levels and risk of fatal coronary heart disease: the HUNT study. Arch Intern Med. 2008 Apr 28;168(8):855-60. ​ Giovannucci E, Liu Y, Hollis BW, Rimm EB. 25-hydroxyvitamin D and risk of myocardial infarction in men: a prospective study. Arch Intern Med. 2008 Jun 9;168(11):1174-80. ​ Schumacher M, Guennoun R, Ghoumari A, et al. Novel perspectives for progesterone in hormone replacement therapy, with special reference to the nervous system. Endocr Rev. 2007 Jun;28(4):387-439. ​ Nilsen J, Brinton RD. Impact of progestins on estrogen-induced neuroprotection: synergy by progesterone and 19-norprogesterone and antagonism by medroxyprogesterone acetate. Endocrinology. 2002 Jan;143(1):205-212. ​ Enomoto M, Adachi H, Fukami A, et al. Serum dehydroepiandrosterone sulfate levels predict longevity in men: 27-year follow-up study in a community-based cohort (Tanushimaru study). J Am Geriatr Soc. 2008 Jun;56(6):994-998. ​ Fukui M, Kitagawa Y, Nakamura N, et al. Serum dehydroepiandrosterone sulfate concentration and carotid atherosclerosis in men with type 2 diabetes. Atherosclerosis. 2005 Aug;181(2):339-344. ​ New study finds removing ovaries during hysterectomy increases risk of death, outweighs benefits. Business Wire. 2009 April 20. Accessed from Removing-Ovaries-Hysterectomy-Increases-Risk ​ Parker WH, Broder MS, Chang E, et al. Ovarian conservation at the time of hysterectomy and long-term health outcomes in the nurses’ health study. Obstet Gynecol. 2009 May;113(5):1027-37. ​ Shoupe D, Parker WH, Broder MS, et al. Elective oophorectomy for benign gynecological disorders. Menopause. 2007 May-Jun;14(3 Pt 2):580-585. ​ Mäkinen J, Järvisalo MJ, Pöllänen P, et al. Increased carotid atherosclerosis in andropausal middle-aged men. J Am Coll Cardiol. 2005 May 17;45(10):1603-8. ​ Rivera CM, Grossardt BR, Rhodes DJ, et al. Increased cardiovascular mortality after early bilateral oophorectomy. Menopause. 2009 Jan-Feb;16(1):15-23. ​ Parker WH, Manson JE. Oophorectomy and cardiovascular mortality: Is there a link? Menopause. 2009 Jan-Feb;16(1):1-2. ​ Laughlin GA, Barrett-Connor E, Bergstrom J. Low serum testosterone and mortality in older men. J Clin Endocrinol Metab. 2008 Jan;93(1):68-75. ​ Kapoor D, Goodwin E, Channer KS, Jones TH. Testosterone replacement therapy improves insulin resistance, glycaemic control, visceral adiposity and hypercholesterolaemia in hypogonadal men with type 2 diabetes. Eur J Endocrinol. 2006 Jun;154(6):899-906. ​ Rice D, Brannigan RE, Campbell RK, et al. Men’s health, low testosterone, and diabetes: individualized treatment and a multidisciplinary approach. Diabetes Educ. 2008 Nov-Dec;34 Suppl 5:97S-112S. ​ Calle EE, Miracle-McMahill HL, Thun MJ, Heath CW Jr. Estrogen replacement therapy and risk of fatal colon cancer in a prospective cohort of postmenopausal women. J Natl Cancer Inst. 1995 Apr 5;87(7):517-23. ​ Zandi PP, Carlson MC, Plassman BL, et al. Hormone replacement therapy and incidence of Alzheimer disease in older women: the Cache County Study. JAMA. 2002 Nov 6;288(17):2123-2129. ​ Harden CL. The mysterious effect of reproductive hormones on cognitive function: scientific knowledge in search of an application. J Gend Specif Med. 2000 Oct;3(7):33- 37. ​ Loret De Mola JR. Effects of estrogen use on the risk of alzheimer’s disease. Biomedicina. 2000 Jan;3(1):6-7. ​ Hodis HN, Mack WJ. Postmenopausal hormone therapy and cardiovascular disease in perspective. Clin Obstet Gynecol. 2008 Sep;51(3):564-580. ​ Saunders-Pullman RJ. Another potential benefit from HRT: Slowing Parkinson’s. Geriatrics. 1998 Jun;53(6):91. ​ Malkin CJ, Pugh PJ, West JN, et al. Testosterone therapy in men with moderate severity heart failure: a double-blind randomized placebo controlled trial. Eur Heart J. 2006 Jan;27(1):57-64. ​ Salpeter SR, Cheng J, Thabane L, et al. Bayesian meta-analysis of hormone therapy and mortality in younger postmenopausal women. Am J Med. 2009 Nov;122(11):1016-1022. ​ Dobnig H, Pilz S, Scharnagl H, et al. Independent association of low serum 25- hydroxyvitamin d and 1,25-dihydroxyvitamin d levels with all-cause and cardiovascular mortality. Arch Intern Med. 2008 Jun 23;168(12):1340-9. Review of WHI & HERS Trials: ​ Klaiber EL, Vogel W, Rako S. A critique of the Women’s Health Initiative hormone therapy study. Fertil Steril. 2005 Dec;84(6):1589-1601. ​ Gambrell RD. The women’s health initiative reports: Critical review of the findings. The Female Patient. 2004;29:25-41. ​ Mishell DR, McNeille LG. Hormone Therapy and Coronary Heart Disease: Evolving evidence from clinical trials. J of Family Practice. 2007 Nov;15(2):S1-S6. ​ Salpeter SR, Walsh JM, Greyber E, et al. Mortality associated with hormone replacement therapy in younger and older women: a meta-analysis. J Gen Intern Med. 2004 Jul;19(7):791-804. ​ Wood MJ, Cox JL. HRT to prevent cardiovascular disease. What studies show, how to advise patients. Postgrad Med. 2000 Sep 1;108(3):59-60, 63-6, 69-72. ​ Brzyski RG. Hormone replacement therapy and cardiovascular disease. Biomedicina. 2000 Jan;3(1):126-128. ​ Dubey RK, Jackson EK, Gillespie DG, et al. Medroxyprogesterone abrogates the inhibitory effects of estradiol on vascular smooth muscle cells by preventing estradiol metabolism. Hypertension. 2008 Apr;51(4):1197-202. ​ Booth EA, Lucchesi BR. Medroxyprogesterone acetate prevents the cardioprotective and anti-inflammatory effects of 17beta-estradiol in an in vivo model of myocardial ischemia and reperfusion. Am J Physiol Heart Circ Physiol. 2007 Sep;293(3):H1408- 15. ​ Review of Different BHRT: ​ Cirigliano M. Bioidentical hormone therapy: a review of the evidence. J Womens Health. 2007 Jun;16(5):600-631. ​ Lemon HM. Pathophysiologic considerations in the treatment of menopausal patients with oestrogens; the role of oestriol in the prevention of mammary carcinoma. Acta Endocrinol Suppl. 1980;233:17-27. ​ Lauritzen C. Results of a 5 years prospective study of estriol succinate treatment in patients with climacteric complaints. Horm Metab Res. 1987 Nov;19(11):579-584. ​ Head KA. Estriol: safety and efficacy. Altern Med Rev. 1998 Apr;3(2):101-113. Takahashi K, Okada M, Ozaki T, et al. Safety and efficacy of oestriol for symptoms of natural or surgically induced menopause. Hum Reprod. 2000 May;15(5):1028-1036. Teoh H, Quan A, Leung SW, Man RY. Vascular effects of estrone and diethylstilbestrol in porcine coronary arteries. Menopause. 2009 Jan-Feb;16(1):104-109. ​ Karim R, Mack WJ, Lobo RA, et al. Determinants of the effect of estrogen on the progression of subclinical atherosclerosis: Estrogen in the Prevention of Atherosclerosis Trial. Menopause. 2005 Jul-Aug;12(4):366-73. ​ Pratt JH, Longcope C. Estriol production rates and breast cancer. J Clin Endocrinol Metab. 1978 Jan;46(1):44-7. ​ Lippman M, Monaco ME, Bolan G. Effects of estrone, estradiol, and estriol on hormone-responsive human breast cancer in long-term tissue culture. Cancer Res. 1977 Jun;37(6):1901-1907. ​ Siiteri PK, Sholtz RI, Cirillo PM, et al. Prospective study of estrogens during pregnancy and risk of breast cancer. Public Health Institute. 2002. ​ Vooijs GP, Geurts TB. Review of the endometrial safety during intravaginal treatment with estriol. Eur J Obstet Gynecol Reprod Biol. 1995 Sep;62(1):101-106. ​ Nachtigall LE. Bioidentical versus nonbioidentical hormones. Proceedings from the postgraduate course presented prior to the 17th annual meeting of the North American Menopause Society. 2006 October 11;15-19. ​ Hormones & Cancer: ​ Fuhrman B, Barba M, Schünemann HJ, et al. Basal growth hormone concentrations in blood and the risk for prostate cancer: a case-control study. Prostate. 2005 Jul 1;64(2):109-15. ​ Devi GR, Sprenger CC, Plymate SR, Rosenfeld RG. Insulin-like growth factor binding protein-3 induces early apoptosis in malignant prostate cancer cells and inhibits tumor formation in vivo. Prostate. 2002 May 1;51(2):141-52. ​ Melmed S. Acromegaly and cancer: not a problem? J Clin Endocrinol Metab. 2001 Jul;86(7):2929-34. ​ Carter HB, Pearson JD, Metter EJ, et al. Longitudinal evaluation of serum androgen levels in men with and without prostate cancer. Prostate. 1995 Jul;27(1):25-31. ​ Chen C, Lewis SK, Voigt L, et al. Prostate carcinoma incidence in relation to prediagnostic circulating levels of insulin-like growth factor I, insulin-like growth factor binding protein 3, and insulin. Cancer. 2005 Jan 1;103(1):76-84. ​ Rhoden EL, Morgentaler A. Medical Progress: Risks of Testosterone-Replacement Therapy and Recommendations for Monitoring. N Engl J Med. 2004 Jan; 350:482- 492. ​ Morgentaler A, Rhoden EL. Prevalence of prostate cancer among hypogonadal men with prostate-specific antigen levels of 4.0 ng/mL or less. Urology. 2006 Dec;68(6):1263-7. ​ Scherr DS, Pitts WR Jr. The nonsteroidal effects of diethylstilbestrol: the rationale for androgen deprivation therapy without estrogen deprivation in the treatment of prostate cancer. J Urol. 2003 Nov;170(5):1703-8. ​ Eaton NE, Reeves GK, Appleby PN, Key TJ. Endogenous sex hormones and prostate cancer: a quantitative review of prospective studies. Br J Cancer. 1999 Jun;80(7):930- 4. ​ Shabsigh R, Crawford ED, Nehra A, Slawin KM. Testosterone therapy in hypogonadal men and potential prostate cancer risk: a systematic review. Int J Impot Res. 2009 Jan- Feb;21(1):9-23. ​ Savage L, Widener A. Sex Hormones Unrelated to Prostate Cancer Risk. JNCI. 2008;100(3):157. ​ Page JH, Colditz GA, Rifai N, et al. Plasma adrenal androgens and risk of breast cancer in premenopausal women. Cancer Epidemiol Biomarkers Prev. 2004 Jun;13(6):1032-6. ​ Heikkilä R, Aho K, Heliövaara M, et al. Serum testosterone and sex hormone-binding globulin concentrations and the risk of prostate carcinoma: a longitudinal study. Cancer. 1999 Jul 15;86(2):312-5. ​ Jancin B. HRT Safe for Survivors of Early-Stage Breast Ca. Family Practice News. 2001 Jun 1. ​ Goldman EL. ERT shows no risk in breast cancer survivors. (Unable to find full reference.) ​ Johnson K. ERT Does Not Increase Breast Cancer Recurrence or Mortality. Family Practice News. 1999 May 15. ​ Campagnoli C, Clavel-Chapelon F, Kaaks R, et al. Progestins and progesterone in hormone replacement therapy and the risk of breast cancer. J Steroid Biochem Mol Biol. 2005 Jul;96(2):95-108. ​ Lea R, Bannister E, Case A, Levesque P, et al. Use of hormonal replacement therapy after treatment of breast cancer. J Obstet Gynaecol Can. 2004 Jan;26(1):49-60. ​ Decker DA, Pettinga JE, VanderVelde N, et al. Estrogen replacement therapy in breast cancer survivors: a matched-controlled series. Menopause. 2003 Jul- Aug;10(4):277-85. ​ Suriano KA, McHale M, McLaren CE, et al. Estrogen replacement therapy in endometrial cancer patients: a matched control study. Obstet Gynecol. 2001 Apr;97(4):555-60. ​ Schairer C, Lubin J, Troisi R, et al. Menopausal estrogen and estrogen-progestin replacement therapy and breast cancer risk. JAMA. 2000 Jan 26;283(4):485-91. ​ Jancin B. Adding progestin to estrogen multiplies breast cancer risk. Family Practice News. 2001 Mar 15. ​ Walling AD. Does HRT Increase the Risk of Breast Cancer? Am Fam Physician. 2002 Mar 1;65(5):947. ​ Durna EM, Wren BG, Heller GZ, et al. Hormone replacement therapy after a diagnosis of breast cancer: cancer recurrence and mortality. Med J Aust. 2002 Oct 7;177(7):347-51. ​ O’Meara ES, Rossing MA, Daling JR, et al. Hormone replacement therapy after a diagnosis of breast cancer in relation to recurrence and mortality. J Natl Cancer Inst. 2001 May 16;93(10):754-62. ​ Bergkvist L, Adami HO, Persson I, et al. The risk of breast cancer after estrogen and estrogen-progestin replacement. N Engl J Med. 1989 Aug 3;321(5):293-7. ​ Stefanick ML, Anderson GL, Margolis KL, et al. Effects of conjugated equine estrogens on breast cancer and mammography screening in postmenopausal women with hysterectomy. JAMA. 2006 Apr 12;295(14):1647-57. ​ James-Enger K. Cancer prevention breakthrough. Redbook. 2001 Mar;196(3):132. ​ Gizard F, Robillard R, Gervois P, et al. Progesterone inhibits human breast cancer cell growth through transcriptional upregulation of the cyclin-dependent kinase inhibitor p27Kip1 gene. FEBS Lett. 2005 Oct 24;579(25):5535-41. ​ Levgur M. Hormone therapy for women after breast cancer. J of Reprod Med. 2004 Jul;49(7):510-26. ​ Natrajan PK, Gambrell RD. Estrogen replacement therapy in patients with early breast cancer. Am J Obstet Gynecol. 2002 Aug;187(2):289-94. ​ Campagnoli C, Abba C, Amgroggio S, Peris C. Pregnancy, progesterone and progestins in relation to breast cancer risk. J of Steroid Biochem & Molecular Biol. 2005;97:441-450. ​ O’Meara ES, Rossing MA, Daling JR, et al. Hormone replacement therapy after a diagnosis of breast cancer in relation to recurrence and mortality. J Natl Cancer Inst. 2001 May 16;93(10):754-62. ​ Meurer LN, Lená S. Cancer recurrence and mortality in women using hormone replacement therapy: meta-analysis. J Fam Pract. 2002 Dec;51(12):1056-62. ​ Dimitrakakis C, Jones RA, Liu A, Bondy CA. Breast cancer incidence in postmenopausal women using testosterone in addition to usual hormone therapy. Menopause. 2004 Sep-Oct;11(5):531-5. ​ Dew JE, Wren BG, Eden JA. Tamoxifen, hormone receptors and hormone replacement therapy in women previously treated for breast cancer: a cohort study. Climacteric. 2002 Jun;5(2):151-5. ​ Decker DA, Pettinga JE, VanderVelde N, et al. Estrogen replacement therapy in breast cancer survivors: a matched-controlled series. Menopause. 2003 Jul- Aug;10(4):277-85. ​ Guidozzi F. Estrogen replacement therapy in breast cancer survivors. Int J Gynaecol Obstet. 1999 Jan;64(1):59-63. ​ Peters GN, Fodera T, Sabol J, et al. Estrogen replacement therapy after breast cancer: a 12-year follow-up. Ann Surg Oncol. 2001 Dec;8(10):828-32. ​ Vassilopoulou-Sellin R, Cohen DS, et al. Estrogen replacement therapy for menopausal women with a history of breast carcinoma: results of a 5-year, prospective study. Cancer. 2002 Nov 1;95(9):1817-26. ​ Vassilopoulou-Sellin R, Asmar L, Hortobagyi GN, et al. Estrogen replacement therapy after localized breast cancer: clinical outcome of 319 women followed prospectively. J Clin Oncol. 1999 May;17(5):1482-7. ​ Durna EM, Wren BG, Heller GZ, et al. Hormone replacement therapy after a diagnosis of breast cancer: cancer recurrence and mortality. Med J Aust. 2002 Oct 7;177(7):347-51. ​ Natrajan PK, Soumakis K, Gambrell RD Jr. Estrogen replacement therapy in women with previous breast cancer. Am J Obstet Gynecol. 1999 Aug;181(2):288-95. ​ Guidozzi F. Announcing the winner of the IJGO prize paper award for 1999. Estrogen replacement therapy in breast cancer survivors. Int J Gynaecol Obstet. 2000 May;69(2):101-2. ​ Eisen A, Lubinski J, Gronwald J, et al. Hormone therapy and the risk of breast cancer in BRCA1 mutation carriers. J Natl Cancer Inst. 2008 Oct 1;100(19):1361-7. ​ Chen WY, Manson JE, Hankinson SE, et al. Unopposed estrogen therapy and the risk of invasive breast cancer. Arch Intern Med. 2006 May 8;166(9):1027-32. ​ Rock CL, Flatt SW, Laughlin GA, et al. Reproductive steroid hormones and recurrence-free survival in women with a history of breast cancer. Cancer Epidemiol Biomarkers Prev. 2008 Mar;17(3):614-20. ​ Lyytinen H, Pukkala E, Ylikorkala O. Breast cancer risk in postmenopausal women using estrogen-only therapy. Obstet Gynecol. 2006 Dec;108(6):1354-60. ​ Wood CE, Register TC, Lees CJ, et al. Effects of estradiol with micronized progesterone or medroxyprogesterone acetate on risk markers for breast cancer in postmenopausal monkeys. Breast Cancer Res Treat. 2007 Jan;101(2):125-34. ​ Foidart JM, Colin C, Denoo X, et al. Estradiol and progesterone regulate the proliferation of human breast epithelial cells. Fertil Steril. 1998 May;69(5):963-9. ​ Fournier A, Berrino F, Riboli E, et al. Breast cancer risk in relation to different types of hormone replacement therapy in the E3N-EPIC cohort. Int J Cancer. 2005 Apr 10;114(3):448-54. ​ de Lignieres B. Endometrial hyperplasia. Risks, recognition and the search for a safe hormone replacement regimen. J Reprod Med. 1999 Feb;44(2 Suppl):191-6. Vashisht A, Wadsworth F, Carey A, et al. A study to look at hormonal absorption of progesterone cream used in conjunction with transdermal estrogen. Gynecol Endocrinol. 2005 Aug;21(2):101-5. ​ Calle EE, Miracle-McMahill HL, Thun MJ, Heath CW Jr. Estrogen replacement therapy and risk of fatal colon cancer in a prospective cohort of postmenopausal women. J Natl Cancer Inst. 1995 Apr 5;87(7):517-23. ​ Kaaks R, Berrino F, Key T, et al. Serum sex steroids in premenopausal women and breast cancer risk within the European Prospective Investigation into Cancer and Nutrition (EPIC). J Natl Cancer Inst. 2005 May 18;97(10):755-65. ​ Micheli A, Muti P, Secreto G, et al. Endogenous sex hormones and subsequent breast cancer in premenopausal women. Int J Cancer. 2004 Nov 1;112(2):312-8. Chlebowski RT, Kuller LH, Prentice RL, et al. Breast cancer after use of estrogen plus progestin in postmenopausal women. N Engl J Med. 2009 Feb 5;360(6):573-87. Stefanick ML, Anderson GL, Margolis KL, et al. Effects of conjugated equine estrogens on breast cancer and mammography screening in postmenopausal women with hysterectomy. JAMA. 2006 Apr 12;295(14):1647-57. ​ L’hermite M, Simoncini T, Fuller S, Genazzani AR. Could transdermal estradiol + progesterone be a safer postmenopausal HRT? A review. Maturitas. 2008 Jul- Aug;60(3-4):185-201. ​ Kaunitz AM. HT and breast cancer: does the type of progestin matter? OBG Management. 2007 June;19(6):31-35. ​ Barbieri RL. More data on hormone therapy risks arrive to reshape practice. OBG Management. 2008 Aug;20(8). ​ Holmberg L, Iversen OE, Rudenstam CM, et al. Increased risk of recurrence after hormone replacement therapy in breast cancer survivors. J Natl Cancer Inst. 2008 Apr 2;100(7):475-82. ​ Fournier A, Berrino F, Clavel-Chapelon F. Unequal risks for breast cancer associated with different hormone replacement therapies: results from the E3N cohort study. Breast Cancer Res Treat. 2008 Jan;107(1):103-11. ​ de Lignieres B, de Vathaire F, Fournier S, et al. Combined hormone replacement therapy and risk of breast cancer in a French cohort study of 3175 women. Climacteric. 2002;5:332-340. ​ Kaaks R, Berrino F, Key T, et al. Serum sex steroids in premenopausal women and breast cancer risk within the European Prospective Investigation into Cancer and Nutrition (EPIC). J Natl Cancer Inst. 2005 May 18;97(10):755-65. ​ Mauvais-Jarvis P, Kuttenn F, Gompel A. Antiestrogen action of progesterone in breast tissue. Breast Cancer Res Treat. 1986;8(3):179-88. ​ Chang KJ, Lee TT, Linares-Cruz G, Fournier S, de Ligniéres B. Influences of percutaneous administration of estradiol and progesterone on human breast epithelial cell cycle in vivo. Fertil Steril. 1995 Apr;63(4):785-91. ​ Hughes S. Endocrinologist association encourages hrt in younger women. Heartwire. 2008 Jan 7. ​ Formby B, Wiley TS. Bcl-2, survivin and variant CD44 v7-v10 are downregulated and p53 is upregulated in breast cancer cells by progesterone: inhibition of cell growth and induction of apoptosis. Mol Cell Biochem. 1999 Dec;202(1-2):53-61. ​ Moe BG, Vereide AB, Orbo A, Sager G. High concentrations of progesterone and mifepristone mutually reinforce cell cycle retardation and induction of apoptosis. Anticancer Res. 2009 Apr;29(4):1053-8. ​ Wang H, Zhou L, Gupta A, Vethanayagam RR, et al. Regulation of BCRP/ABCG2 expression by progesterone and 17beta-estradiol in human placental BeWo cells. Am J Physiol Endocrinol Metab. 2006 May;290(5):E798-807. ​ Yu S, Lee M, Shin S, Park J. Apoptosis induced by progesterone in human ovarian cancer cell line SNU-840. J Cell Biochem. 2001;82(3):445-51. ​ Cleary MP, Grossmann ME. Minireview: Obesity and breast cancer: the estrogen connection. Endocrinology. 2009 Jun;150(6):2537-42. ​ Eisen A, Lubinski J, Gronwald J, et al. Hormone Therapy and the Risk of Breast Cancer in BRCA1 Mutation Carriers. JNCI J Natl Cancer Inst. 2008;100(19):1361- 1367. ​ Testosterone & Breast Cancer Prevention: ​ Radosh L. Drug treatments for polycystic ovary syndrome. Am Fam Physician. 2009 Apr 15;79(8):671-6. ​ Secreto G, Venturelli E, Meneghini E, et al. Testosterone and biological characteristics of breast cancers in postmenopausal women. Cancer Epidemiol Biomarkers Prev. 2009 Nov;18(11):2942-8. ​ Schneider ME. Metformin regimen found to quell acne in polycystic ovary syndrome. Skin & Allergy News. 2007 October 1. ​ Somboonporn W, Davis SR, et al. Testosterone effects on the breast: implications for testosterone therapy for women. Endocr Rev. 2004 Jun;25(3):374-88. ​ Panzer C, Guay A. Testosterone replacement therapy in naturally and surgically menopausal women. J Sex Med. 2009 Jan;6(1):8-18. ​ Dimitrakakis C, Zhou J, Bondy CA. Androgens and mammary growth and neoplasia. Fertil Steril. 2002 Apr;77 Suppl 4:S26-33. ​ Burgess HE, Shousha S. An immunohistochemical study of the long-term effects of androgen administration on female-to-male transsexual breast: a comparison with normal female breast and male breast showing gynaecomastia. 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