Why Doesn’t My Endocrinologist Know All Of This?

Historically, relying on a consensus statement to treat or not to treat a particular patient has been shown to result in poor care and, as such, society consensus statements and practice guidelines are considered to be worst level of evidence in support of a particular therapy or treatment. A number of organizations, including the World Health Organization and others, have ranked the strength and accuracy of various types of evidence used in the medical decision process. In all scoring systems, the highest strength of evidence is randomized control trials and meta-analyses, with lower scores for other types of evidence. All grading systems place consensus statements and expert opinion by respected authorities (societies) as the poorest level of evidence, because historically they have failed to adopt new concepts and treatments based on new knowledge or new-found understanding demonstrated in the medical literature (1-6).

For instance, a recent study published in the 2009 Journal of the American Medical Association studied the evidence supporting the practice guidelines and consensus statements published by the American College of Cardiology and the American Heart Association. It was found that only 11% of the recommendations, practice guidelines and consensus statements were based on quality evidence and over half were based on poor quality evidence that was little more than the panel’s opinion. The review also found that even the strongest (Class 1) recommendations, which are considered medical dogma, cited as a legal standards and often go unquestioned as medical fact, were only supported by high quality evidence 19% of the time and not revised based on new evidence (6).

Similarly, the Endocrine Society, the American Association of Clinical Endocrinologists and the American Thyroid Association also have a long history of guidelines and recommendations that are not supported by the medical literature and fail to adjust or abandon recommendations when new understanding and knowledge contradicts their recommendations. A case in point is the recommendation by these societies that a normal TSH adequately rules out thyroid dysfunction, despite massive amounts of literature that demonstrate this not to be the case (see Diagnosis of Hypothyroidism) or that T4 only replacement is adequate for most patients. A doctor who simply follows outdated society treatment guidelines that relies on a simple laboratory test and ignores the clinical aspects of a patient is not practicing evidence-based medicine. (1-7). Such doctors may be adequate as lab technicians, but as doctors and clinicians they fall short (1-7). This method of practice is consistently rebuked as improper and poor medicine, but has become the standard used by a large percentage of endocrinologists and physicians who feel medicine can be related to simply reading “normal” or “abnormal” in a laboratory column.

Discussing the lack of scientific basis of most medical society’s consensus statements and treatment guidelines in Internal Medicine News, Dr. Diana Petritti states, “Expert opinion and consensus statements can be quite misleading when used as the basis for a practice. Expert opinions imply that there is something that the experts know that clinician doesn’t know. I don’t think it’s always appreciated that it’s only opinion. There is a tendency to make guidelines and recommendations seem authoritative. I believe that physicians think that there is a great deal more behind authoritative recommendations than there might be when you lift the lid of the box and see what’s underneath(8).”

There has been significant concern by health care organizations and medical experts that physicians are placing too much reliance on consensus statements and failing to learn of new information presented in medical journals. Thus, they lack the ability to translate this new information into treatments for their patients. The concern is that doctors fail to practice evidence-based medicine, erroneously relying on what they have previously been taught and on “expert” societies instead of changing treatment philosophies based on new information as it becomes available. This is especially true for endocrinological conditions, where physicians are very resistant to changing old concepts of diagnosis and treatment — despite overwhelming evidence to the contrary — because it is not what they were taught in medical school and endocrinology residency.

This concern is particularly clear in an article published in the New England Journal of Medicine entitled “Clinical Research to Clinical Practice: Lost in Translation” (9). The article was written by Claude Lenfant, M.D., Director of National Heart, Lung and Blood Institute, and it is well supported. He states that there is great concern that doctors continue to rely on what they learned 20 years before and are uninformed about scientific findings. According to Dr. Lenfant, medical researchers, along with public officials and political leaders, are increasingly concerned about physicians’ inability to translate research findings in their medical practice to benefit their patients. He says that very few physicians learn about new discoveries from reading medical journals or by attending scientific conferences; thus, they lack the ability to translate new knowledge in the field into enhanced treatments for their patients. He states that a review of past medical discoveries reveals how excruciatingly slow the medical establishment is to adopt novel concepts, noting that even simple methods to improve medical quality are often met with fierce resistance. “Given the ever-growing sophistication of our scientific knowledge and the additional new discoveries that are likely in the future, many of us harbor an uneasy, but quite realistic suspicion that this gap between what we know about disease and what we do to prevent and treat them will become even wider. And it is not just recent research results that are not finding their way into clinical practice; there is plenty of evidence that ‘old’ research outcome have been lost in translation as well (1).”

Dr. Lenfant discusses the fact that the proper practice of medicine involves the combination of medical knowledge, intuition and judgment and that physicians’ knowledge is lacking because they don’t keep up with the medical literature. He states that there is often a difference of opinion among physicians and reviewing entities, but that judgment and knowledge of the research pertaining to the patient’s condition is central to the responsible practice of medicine. “Enormous amounts of new knowledge are barreling down the information highway, but they are not arriving at the doorsteps of our patients. (9).”

These thoughts are echoed by physicians who have researched this issue as well, such as William Shankle, M.D., Professor, University of California, Irvine. He states, “Most doctors are practicing 10 to 20 years behind the available medical literature and continue to practice what they learned in medical school….There is a breakdown in the transfer of information from the research to the overwhelming majority of practicing physicians. Doctors do not seek to implement new treatments that are supported in the literature or change treatments that are not (10).”

This view is echoed by the Dean of Stanford University School of Medicine who states that in the absence of translational medicine the delivery of medical care would remain stagnant and uninformed by the tremendous progress taking place in science and medicine (11).

This concern has also received significant publicity in the mainstream media. An example is an article by Sidney Smith, M.D., former president of the American Heart Association, published in 2003 in the Wall Street Journal entitled “Too Many Patients Never Reap the Benefits of Great Research.” Dr. Smith is very critical of physicians for not seeking out available information and applying that information to their patients, arguing that doctors feel the best medicine is what they’ve been doing and thinking for years. They discount new research, Dr. Smith says, because it is not what they have been taught or practiced, and they refuse to admit that what they have been doing or thinking for many years is not the best medicine. He states, “A large part of the problem is the real resistance of physicians…; many of these independent-minded souls don’t like being told that science knows best, and the way they’ve always done things is second-rate (12).” The National Center for Policy Analysis also expresses concern for the lack of ability of physicians to translate medical therapies into practice (13).

A review published in The Annals of Internal Medicine found that there is clearly a problem of physicians not seeking to advance their knowledge by reviewing the current literature, believing proper care is what they learned in medical school or residency and not basing their treatments on the most current research. The review found that the longer a physician is in practice, the more inappropriate and substandard the care (14). Thus, it is not a surprise that the scientific evidence as expressed in the literature is often opposite to what is continually repeated as dogma by most physicians and those considered to be “experts.”

Another example is a study published in the Journal of the American Medical Informatics Association (15). In reviewing the study, the National Institute of Medicine reports that there is an unacceptable lag between the discovery of new treatment modalities and their acceptance into routine care: “The lag between the discovery of more effective forms of treatment and their incorporation into routine patient care averages 17 years.” (16) In response to this unacceptable lag, the Business and Professions Code passed an amendment relating to the healing arts. This amendment — CA Assembly Bill 592; An Act to Amend Section 2234.1 of the Business and Professions Code — states: Since the National Institute of Medicine has reported that it can take up to 17 years for a new best practice to reach the average physician and surgeon, it is prudent to give attention to new developments not only in general medical care but in the actual treatment of specific diseases, particularly those that are not yet broadly recognized [such as the concept of tissue hypothyroidism, chronic fatigue syndrome and fibromyalgia] (17).

The Principals of Medical Ethics adopted by the American Medical Association in 1980 states that a physician shall continue to study, apply, and advance scientific knowledge, make relevant information available to patients, colleagues, and the public (18). This has, unfortunately, been replaced with a goal of providing merely “adequate” care. The current insurance reimbursement system in the United States fosters this thinking, as the worst physicians are financially rewarded by insurance companies. While it is true that the best physicians are continually fighting to provide cutting edge treatments and superior care that the insurance companies deem not medically necessary, even these physicians eventually get worn down and are forced to capitulate to the current system that promotes substandard care.

This was clearly demonstrated in a study published in the March 2006 edition of The New England Journal of Medicine entitled “Who is at Greater Risk for Receiving Poor-Quality Health Care.” The study found that the majority of individuals received substandard, poor-quality care, and that there was no significant difference among different income levels or whether or not the individual was covered by insurance. It used to be the case that only those in low socioeconomic classes without insurance received poor-quality care. But insurance company restrictions on treatments and diagnostic procedures have made the same poor care afforded to those of low socioeconomic status the new standard-of-care for society at large (19). An example of this is a physician’s failing to spend the time to adequately assess a potential hypothyroid patient and instead simply does a TSH test.

Most physicians will satisfy their required amount of continuing medical education (CME) by going to a conference a year, usually at a highly desirable location that has skiing, golf, boating, etc. Physicians are rarely monitored as to whether or not they actually showed up for the lectures or went skiing instead. One must also understand that the majority of conferences organized by medical societies are in fact sponsored by pharmaceutical companies. These payments by pharmaceutical companies are called unrestricted grants, so that the society has free reign to do what they want with the money and thus can claim there is no influence of lecture content by the companies. The problem, however, is that if the society wants to continue getting these “unrestricted” grants, they must think twice about providing content that the sponsoring pharmaceutical company might disapprove of. Consequently, ground breaking research that goes against the status quo and does not support the drug industry receives little attention.

Evidence-based medicine involves the synthesis of all available data when comparing therapeutic options for patients. Evidence-based medicine does not mean that data should be ignored until a randomized control trial of a particular size and duration is completed. A physician who tries to avoid the need of being a physician and is fine with just being a technician or health care provider will adamantly defend the “one-size fits all” method of diagnosis and treatment. But the best doctors who truly practice evidence-based medicine and not merely the perception of such will not rely on consensus statements to best provide their patients. Instead of relying on old dogma, the best physicians will seek out and translate both basic science results and clinical outcomes to decide on the safest, most efficacious treatment for their patients. Further, the best physicians will continually assess the current available data to decide which therapies are likely to carry the greatest benefits for patients and involve the lowest risks.

References

 

The Truth About Low T: Men, Middle-Age and More

I admit it. Those low T commercials are great marketing. The middle-aged man dancing with his testosterone shadow, all his strength, energy and vigor restored. His simple solution? Testosterone supplementation. It paints an oversimplified picture of men, as if we are nothing but testosterone sponges. When we get low, we just stop off at the local testosterone dispenser and we are good to go. However, the truth is not that simple about low T.

Low testosterone is a very common problem in men today. But it is much more complex than just adding testosterone to solve the problem. Men are complex. (And you thought only women were complex!) Looking at the specific causes of low T in an individual is a critical part of creating a plan to solve the low T problem.

What is testosterone? Testosterone is the predominate hormone in men. From the moment of conception, it is the key to male development. It is what makes a man a man. It is what gave us Tim “the tool man” Taylor.

What is low T? Quite simply, it is low testosterone. Symptoms include fatigue, reduced libido, estrogen dominance, weight gain, and loss of confidence and motivation. Low T is, in many ways, the middle-aged man suffering the dreaded “mid-life crisis.” Think about it. At the same time that women experience menopause, men are experiencing their own life change. Men are just as hormonal as women; however, the symptoms of change are different.

Low testosterone is a lot more common than you think. Approximately 40 million US men suffer from low testosterone. Only a fraction of these men are symptomatic, which means most men with low T don’t even know it.

Not only is low T a silent problem, it is a growing problem. Men are discovering low T at younger ages, too. I’ve seen men as young as their mid-20’s with low testosterone. Typically, however, most men living with low T are in their 40’s and beyond.

What is the cause of low T? It would be convenient if the answer was simply low testosterone production. But look at our bodies. We are complex creations. In most cases, low T results from a combination of issues.

Cause #1: Excess weight. Today, we eat so many items that suppress the body’s natural testosterone production. Just look at the American diet. Americans eat up to 200 pounds of refined sugar, 90 pounds of fats, 63 dozen donuts, 60 pounds of cakes and cookies, 23 gallons of ice cream, 22 pounds of candy, and 15 pounds of chips, popcorn, and pretzels annually. Obviously, this leads to excess weight.

Excess weight, especially around the mid-section, becomes a major estrogen-producing factory. Not only does the associated weight gain help produce more estrogen, but the enzyme that converts testosterone to estrogen increases as we age as well. We become estrogen dominant. Increased weight = increased estrogen and decreased testosterone.

Cause #2: The environment. The environment is full of hormone-like chemicals. Xenoestrogens are environmental estrogens. They range from pesticides and insecticides to plastics to hormone-laden meat and dairy products. Although not native to the body, the body views them as estrogens nonetheless. Xenoestrogens = increased estrogen and decreased testosterone.

Cause #3: Hormones. That’s right. Even giving testosterone to some men can be a problem. A 27-year male patient came to me after he was given testosterone for a suspected low T problem by another physician. The testosterone replacement made him feel worse. Why? He was already estrogen dominant, and the additional testosterone was like throwing gasoline on the fire. His proposed cure, testosterone supplementation, turned out to be the source of his problem: excess estrogen. Too much testosterone = increased estrogen.

What is the answer to low testosterone? There is no single answer. Answers are found through customized testing which determines exact hormone levels. From these results, we can create an individualized therapy plan. Because we are all created uniquely, causes can vary. Likewise, your therapy plan should be unique. Your symptoms are clues to the underlying problem. By uncovering the problem’s root cause, an effective treatment plan can be developed which will solve those health issues and eliminate your symptoms.

The truth about low T? Only a few men really need testosterone. The majority of men need weight loss, reduction of estrogen, and the elimination of environmental xenoestrogens. It is easier to simply supplement testosterone. But that will NOT treat the problem at the source and achieve true healing.

Now that you know the truth about low T, what will you do about it? If you have symptoms and need answers or more information, call our office at 318-255-3223.

 

Who needs Hormones?

Who needs hormones? The answer is: not everyone. Some need hormones, and some don’t. Additionally, a need for hormone therapy is not unique to women. Men can benefit from hormone therapy as well.

If you have symptoms of hormone imbalances, then hormone replacement therapy may be right for you. However, a “one size fits all approach” is never appropriate. Each individual’s hormone needs are as unique as his or her thumb print.

Hormone testing will help determine the specific hormone imbalances and direct treatment.

What symptoms indicate hormone imbalance?

The symptoms of low estrogen include…

• hot flashes
• night sweats
• vaginal dryness
• urinary frequency
• depressed feeling
• sleeping difficulty
• no interest in sex
• no periods

The symptoms of low testosterone include…

• fatigue
• lack of drive
• lack of initiative
• less assertive
• decline in sense of well being
• general depressed moods
• irritable
• lack of self-confidence
• difficulty in setting goals
• decline in mental sharpness
• no stamina/endurance
• loss of muscle mass, strength, or tone
• increased body fat around waist
• elevated cholesterol
• decreased libido
• decreased sexual ability
• sleep apnea

The symptoms of low thyroid include…

• general fatigue or afternoon fatigue
• elevated cholesterol
• difficulty losing weight
• cold hands and feet
• sensitivity to cold
• difficulty thinking clearly
• difficulty concentrating
• poor short term memory
• depressed moods
• hair loss
• constipation
• dry, itchy skin
• fluid retention
• recurrent headaches
• restless sleep
• tingling or numbness in hands and feet
• decreased sweating
• infertility or recurrent miscarriages
• recurrent infections
• muscles aches
• joint pain
• thinning of eyebrows and eyelashes
• enlargement of tongue and teeth indentations
• decreased body hair
• hoarse voice
• slow heart rate
• low blood pressure
• low body temperature
• sleep apnea

The symptoms of high estrogen/low progesterone include…

• premenstrual breast tenderness
• premenstrual mood swings
• premenstrual fluid retention and/or weight gain
• migraine headaches
• severe menstrual cramps
• heavy periods with clotting
• irregular menstrual cycles
• uterine fibroids
• fibrocystic breasts
• endometriosis
• history of infertility
• history of miscarriages
• joint pain
• muscle pain
• decreased libido
• anxiety and/or panic attacks

What hormones will I need and how do I take them?

Bio-identical hormones are available in creams, ointments, sub-lingual drops, vaginal suppositories, pills, and injections. So you have a lot of options on how you can take them.

As to what hormones you will need, this will depend on the individual. Your hormone needs are as unique as your fingerprints. A one size fits all approach is not appropriate in hormone therapy. Therapy will be specifiic to your hormone deficiency.

We use salivary testing from DiagnosTechs Laboratory to determine what hormones you need. Over 300 studies have been published validating the accuracy of hormone salivary testing.

Once we’ve determined what hormones you need, bio-identical hormone therapy draws upon 6 type of hormones:

• Estrogens
• Progesterone
• Testosterone
• DHEA
• Cortisol
• Thyroid

You can read more about the different types of hormones in my post “Menopause and Hormones 101.”

What are bioidentical hormones?

One of the most frequent questions we here is: “Hey! What is the difference between bioidentical hormones and synthetic hormones like premarin, prempro, premphase, and provera?”

I’m glad you asked! Synthetic hormones include conjugated equine (that’s horse in English) estrogens and progestins. (My wife is not a horse, and I’m pretty sure you aren’t either!)

The key difference between bioidentical and synthetic hormones is molecular structure. In an effort to fully replicate the function of the hormones produced by your body and to minimize the side effects, the molecular structure of the hormones must be identical to those produced in your body.

Synthetic hormones are similar but not identical. These structural differences lead to metabolism by-products that increase the frequency and intensity of unwanted side effects.

Bioidentical hormones are structurally and chemically identical to the hormones your body produces.

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You may have heard that there are not many studies about bioidentical hormones. Certainly, there have not been as many studies of bioidentical hormones as synthetic hormones. But, here’s why.

Pharmaceutical companies fund research for synthetic hormones through profitable patents and mass production. Bioidentical hormones cannot be patented, and thus there are limited funds for research. There are some European studies of bioidentical hormones, but they are small in number and limited in scope.

Related articles by Zemanta and Seasons

• Bioidentical hormones: What does the scientific evidence say?
• The Bioidentical Hormone Debate (www.postgradmed.com)
• Abstract: Are Bioidentical Hormones (Estradiol, Estriol, and Progesterone) Safer or More Efficacious than Commonly Used Synthetic Versions in Hormone Replacement Therapy? (holtorfmed.com)
• Study: Hormone therapy caused breast cancer for thousands (cnn.com)

What risks are associated with hormone replacement?

After reading many of our posts on Bioidentical Hormones, you may be thinking bioidentical hormones are risk free.

Unfortunately, they aren’t. The same risks associated with the synthetic hormones can be extrapolated to bioidentical hormones. However, limited studies already suggest that bioidentical hormones cause fewer side effects and risks than synthetics.

You may have heard that hormone therapy causes breast cancer. It doesn’t

Hormone therapy may accelerate the growth of pre-existing breast cancer, but patients taking hormone therapy are actually diagnosed at an earlier stage of disease when compared to those not taking hormone therapy.

If you want to know the exact risks for both synthetic and bioidentical hormones, here they are:

Cardiac Event: 7 new cases/10,000 women (26% increase)
Breast Cancer: 8 new cases/10,000 women (23% increase)
Stroke: 8 new cases/10,000 women (41% increase)
Pulmonary Embolus: 8 new cases/10,000 (200% increase)
Blood Clot: 18 new cases/10,000 (213% increase)
Alzheimer’s Dementia: (200% increase)