December 2013 Newsletter

GOODHORMONEHEALTH NEWS
VOLUME 3-December 2013
www.goodhormonehealth.com
The purpose of GOODHORMONEHEALTH NEWS is to disseminate new information to Dr.
Friedman’s patients and others who signed up to receive his newsletter before posting on his
website. We encourage you to visit www.goodhormonehealth.com and to make an appointment
to see Dr. Friedman to discuss your medical condition. Please contact his office at
mail@goodhormonehealth.com to suggest a future topic for GOODHORMONEHEALTH
NEWS or to schedule an appointment. Be sure to schedule a follow-up appointment. Follow-up
appointments are available in person, by telephone (20 min.), drive by (15 min.), email or
FaceTime. We are running a special on email appointments at $130.
Order your “I’ve been to see the Cushing’s Wizard” car magnets and sweatshirts and other
Cushing’s gift items at http://www.cafepress.com/sk/zebraesque.
Dr. Friedman will be hosting “meet-ups” in which patients meet with Dr. Friedman to obtain
information about endocrine conditions. Live meet-ups will be in Los Angeles and
audioconferenced meet-ups can be arranged throughout the country.
Dr. Friedman talked on Hypothyroidism and hair loss in women on HER Radio on November 28,
2013. Listen to the broadcast at http://radiomd.com/show/her-radio/item/16359-tired-weak-ordepressed-you-may-have-hypothyroidism AND http://radiomd.com/show/her-radio/item/16368thinning-hair-the-reasons-for-your-hair-loss
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Replacement for Trans-D-tropin
Dr. Friedman prescribed Trans-D-tropin for patients with a low IGF-1 (marker for growth
hormone), who did not meet criteria for growth hormone deficiency. Trans-D-tropin was
composed of amino acids that stimulated growth hormone secretion, but was removed from the
marker by the FDA. Dr. Friedman found a replacement product called TdttropinPlus that seems
similar to Trans-D-tropin. It costs about $175/month, doesn't need a prescription and can be
obtained at http://www.collegepharmacystore.com/product_p/amp_tdttropin.htm or
http://tdttropinplus.com/
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Earn $$ for Adult Growth Hormone Deficiency
The purpose of this research is to obtain your feedback on the design of a new pen-injector and
the instructional materials. No injections or medication will be given during the research session;
this is strictly an observational research project, and all responses will be kept confidential.
Qualified participants will receive a total stipend of $250. This study will take place over 2 days,
1 hour each day.
If you or someone you know fits this description and lives in the San Francisco, Los Angeles,
Dallas, Philadelphia or the San Diego area, please call:
Trotta Associates (San Francisco/Los Angeles)- Michelle @ 310-306-6866 x65
Dallas by Definition (Dallas)- Jessie @ 1-800-336-1417
Group Dynamics (Philadelphia)- Alice @ 610-822-1010
Taylor Research (San Diego)- Ben @ 858-810-8400 x203
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Dr. Friedman congratulates R.M., a patient whom Dr. Friedman diagnosed with Cushing’s
disease in 2012. She underwent successful pituitary surgery in NY in March 2012. Since surgery,
she feels great, lost 795 pounds and was able to fit into a beautiful wedding dress. R.M. said
“With the help of Cardio every day and eating right and phentermine as well and more
importantly feeling great, I am now healthy!”
Here are her pre-op (September 2011) and wedding pictures (October 2013). Way to go R.M.
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Power of Juicing
Dr. Friedman believes healthy eating can complement hormonal optimization to achieve good
hormone health. has advocated a vegetable-based diet for many years, but was recently inspired
to personally take up and advocate juicing for his patients after watching Fat, Sick and Almost
Dead, a documentary about the power of juicing. In this newsletter, he highlights L.H and his
wife N.H. who have improved their health by juicing. L.H. has hypopituitarism and has been
seeing Dr. Friedman for about 10 years. With pituitary hormone treatment, his health improved,
but he still wasn’t able to turn the corner and become truly healthy until he changed his diet and
started juicing. Here is their juicing recipe: 3 cups water, 1 bunch romaine hearts, two handfuls
of kale, two handfuls of deep green blends (kale, chard, spinach), 1 big cucumber with skin, 1
cup yogurt, 1.5 cups mixed frozen fruit (mango, papaya, strawberries, pineapple). It completely
fills their Vitamix container which is at least 68 oz. They divide equally and drink within 15
minutes of making it. Below is L.H. with his grandson and their juicing ingredients.
Dr. Friedman’s juicing recipe is kale, shredded carrots, one tomato, fresh ginger, frozen
blueberries and frozen mango.
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The 15% Rule of Who Should Get T4/T3 Combination
The thyroid makes two hormones, T4 which has a long half life meaning it can be given once a
day. T4 gets converted to T3 which is the active form of the hormone and has a short-half life,
meaning it has to be given frequently. Most patient with hypothyroidism are treated with
levothyroxine, which is T4. There are many brands of levothyroxine that include Synthroid,
Unithroid, and Levoxyl. However, two very important recent articles suggested that about 15%
of patients with hypothyroidism do not convert T4 to T3 properly and should be on a T4/T3
combination or on desiccated thyroid that contains T4 and T3. I wish to highlight both of these
papers as they are very interesting and important studies.
One study came from the United Kingdom that looked at the prevalence of the gene that converts
the T4 to T3. This is called the type 2 deiodinase. In this study, 15% of the population had an
alteration in the gene that converts T4 to T3, the alteration is called a polymorphism. This
polymorphism means the DNA is changed so that this enzyme works less effectively. The
patients with this polymorphism required higher T4 dosing and had more psychological
problems than those that did not have the deiodinase polymorphism. They did not examine
whether these patient would benefit from T4/T3 combination and also did not actually measure
the enzyme, they only looked at the gene coding for this enzyme.
Another very intriguing article came out in Italy that initially examined patients that had a
thyroid nodule but were not on a thyroid medicine and did not have any other problems with
their thyroid. Examining several thousand of these healthy patients, they were able to establish
normal values for free T4, free T3, and TSH in this Italian population. Once these normal values
were obtained, the researchers then took patients that had their thyroid completely removed for
thyroid cancer, but did not get any other procedures done to the thyroid such as radioactive
iodine. The patients with the thyroid cancer who had the thyroid removed were then placed on
T4 or levothyroxine therapy and their free T4, free T3, and TSH were measured. All the patients
had a normal TSH and that was the criteria for being in the study. However, approximately 15%
of the people had a low serum free T3 that was below the range previously established. An
additional 5% of the patients had a free T4 above the range that was established. This shows that
about 15% of the people do not convert the T4 to T3 properly. This was based on serum T3
levels and is a very good indication that these 15% of the people would need T3 in addition to T4
to get both levels in a normal range. This study suggested that measuring serum free T3 is quite
helpful in patients that are treated with T4 for hypothyroidism, an evaluation that is not normally
done. This paper did not measure reverse T3, which some alternative doctors use to determine
that the T4 to T3 conversion does not occur and actually this paper suggested that the
measurement of serum free T3 itself can be used to determine which patients need T4/T3
combination treatment.
These 2 intriguing papers challenge the idea that all patients with hypothyroidism should be
treated with T4. Dr. Friedman uses different thyroid medicines to treat patients with
hypothyroidism including T4/T3 combinations, and desiccated thyroid that contains T4 and T3.
Dr. Friedman interprets this data that the majority of hypothyroid patients do fine on T4 alone
including himself, who takes only T4. Approximately 15% of the population does need T4/T3
combination to have an optimal effect on the thyroid. Dr. Friedman feels these patients are the
vocal minority who are not doing well on T4 treatment and would benefit from seeing a thyroid
specialist like Dr. Friedman.
For more information about Dr. Friedman’s practice or to schedule an appointment, go to
www.goodhormonehealth.com.
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Mild Growth Hormone Deficiency Versus Mild Cortisol Deficiency - Which One Should
You Treat?
The pituitary makes several hormones, and if the pituitary is damaged, such as in cases of
surgery, radiation, a pituitary tumor, or if the pituitary is small from conditions like Sheehan's
syndrome and empty sella syndrome, hormone deficiencies occur. There is a set order of these
hormone deficiencies, and growth hormone is the first hormone deficiency to occur in cases of
hypopituitarism. The second one is usually LH and FSH, which leads to low estrogen and
testosterone. The third hormone to be affected is TSH, which leads to low thyroid hormones
(central hypothyroidism), and the last hormone to become deficient, which requires extensive
damage to the pituitary, is ACTH, and when that is affected, low cortisol occurs.
Dr. Friedman is very interested in optimizing hormone replacements in hypopituitarism and is
surprised at the recent guidelines and articles that state that only severe cases of growth hormone
deficiency should be treated. There was an article in the Journal of Clinical Endocrinology and
Metabolism in June 2013 that suggested that idiopathic (without a clear cut cause) growth
hormone deficiency does not exist. This article suggested that growth hormone deficiency should
only be treated if it is severe and if the patient has other pituitary hormone deficiencies. In fact,
many insurance companies require that the patient has at least 2 to 3 other pituitary hormone
deficiencies before treatment. To me, this makes no sense because the growth hormone
deficiency is the first pituitary deficiency to occur. So the question is why is it recommended that
mild growth hormone deficiency not be treated.
On the other hand, almost everybody treats mild cortisol deficiency. In medicine, we looks at the
benefits and risks of treatment, and the treatment for cortisol deficiency is giving hydrocortisone
or Cortef. Certainly, if hydrocortisone is needed it should be given, but in many borderline cases
it is unclear whether hydrocortisone needs to be given. Giving exogenous cortisol shuts down the
adrenal glands from making its own cortisol and therefore, once you start cortisol, it is may be
very hard to stop it. Additionally excess cortisol, and it can be very hard to give the right amount
of cortisol, leads to weight gain, diabetes, infections, and osteoporosis (thin bones). Many
endocrinologists erroneously feel that patients can die suddenly from cortisol deficiency. This is
based on old literature and occurred only in patients with severe cortisol deficiency. More recent
literature suggests that patients with mild cortisol deficiency do not die suddenly, do not
necessarily need to be treated with hydrocortisone, and the benefits of treating with exogenous
hydrocortisone most likely outweigh the risk unless the cortisol deficiency is severe.
Additionally, hormonal replacement should be guided by symptoms. Patients with low cortisol
have nauseousness, vomiting, diarrhea, abdominal pain, joint pains, and weight loss. Most
patients with fail their cortisol stimulation test and are told they have mild cortisol deficiency do
not have those symptoms. In fact, many patients with hypopituitarism have more symptoms of
excess cortisol such as weight gain, than cortisol deficiency.
In contrast, patients with growth hormone deficiency do have weight gain. They have trouble
sleeping. They have psychological and psychiatric problems including depression, mood swings
and irritability. Their quality of life and functionality is much lower. All these symptoms are
improved with growth hormone replacement. Growth hormone replacement has very few side
effects. The main side effects are joint pain and edema. Some patients on growth hormone
replacement can get worsening glucose control, but in general the patients feel so much better on
growth hormone replacement, they exercise more and feel better and their blood sugar improves.
Dr. Friedman has found that patients with mild growth hormone deficiency do just as well on
growth hormone replacement as those with severe. He is in the process of trying to study this,
but he has found that growth hormone deficiency in patients that have a growth hormone
stimulation test such as a glucagon stimulation test that peaked between 3 and 8 benefit from
growth hormone replacement, just as the ones that would have severe growth hormone
insufficiency such as those that have a growth hormone peak after a stimulation test of less than
3.
Dr. Friedman suspects that the real reason why mild growth hormone deficiency is not treated
while mild cortisol deficiency is treated has to do with cost and insurances. Growth hormone
replacement is quite expensive and can cost over $1000 a month while cortisol replacement is
quite inexpensive. Because of the cost of growth hormone replacement , most people need their
insurances to pay for it, and insurance companies are getting more and more reluctant to cover
growth hormone replacement, possibly because of the cost. Because Dr. Friedman is very
interested in improving the patients' quality of life, especially those with hypopituitarism, he tries
to fight to have patients with mild growth hormone deficiency covered by their insurance and so
those patients could benefit from growth hormone replacement.
For more information about Dr. Friedman’s practice or to schedule an appointment, go to
www.goodhormonehealth.com.
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