Dr Fatiha ArhbalMBBS, FRACGP,DCH,DRANZCOG

Board Certified Anti Ageing Physician

Natural chemical regulators of cell physiology

Secreted into the blood by specialised glands and act at a distance on one or more target organs

Mechanisms-Peptides and proteins act at cell membrane

-Steroids enter nucleus and regulate genes

• Pituitary

• Pineal

• Thyroid

• Adrenal

• Sex Steroids

• Male

• Female

• Growth Hormone• Melatonin• TSH, T4, T3, rT3• Cortisol, DHEA,

Pregnenolone, Aldosterone

• Testosterone, DHT, Oestrogens, DHEA, Progesterone

• Oestrogens, Progesterone, Testosterone, DHEA, DHT

We age because our hormones decline, our hormones don’t decline because we age

Youth – ANABOLIC

Ageing – CATABOLIC

Getting old is natural, feeling old is optional

To prevent the morbidity of ageing

To prolong the healthy disease free lifespan

Compress morbidity to as few years as possible

To treat subtle hormone deficiencies as well as severe ones so that disease can be prevented and QOL maintained

Traditional medicine seeks to treat outcomes of ageing, not change the process.

Supplementation should be with the same hormone that is deficient

“Bio-identical”- identical structure to the hormones produced by the human

Some bio-identical hormones are available through pharmaceutical companies

Some hormones must be compounded for the individual

Synthetically produced

Prepare the substance required from an individualised prescription

Hormones can be made into capsules, creams, gels, troches

• Produced by Pineal Gland

• Highest as a child, declines in adulthood. At 80, the levels are 80% less

• Promotes sleep, sleep wake cycles, REM sleep

• Deep muscle and nerve relaxation

• Antispasmodic for GIT

• Mood

• Body Temperature regulation

• Immune system

• Antioxidant

• Reproductive Health

• Sleep disturbance- a superficial, agitated sleep with a lot of anxious thinking

• Easily waking during night• Restless legs• Fatigue• Premature Ageing• Tense muscles at night• Difficulty falling to sleep • Poor dreaming• Anxiety• Lack of peace of mind• Depression, irritability

Improved quality of life, better sleep, calmness

Improved health

Improved secretion of releasing hormones from brain

Increased longevity

No known side effects

Peak secretion at 3am

Test saliva between 10pm to 12am

Usual doses 0.5mg- 3mg sublingual

10- 20 mg has been shown to increase longevity and survival in some cancers

Increase naturally by bright sun in the morning, dark bedroom

5HT, SAMe, B6, phosphatidyl serine

• Major hormone with prominent roles

• Anabolic hormone

• Responsible for growth in childhood and puberty

• Growth of brain, skin, hair, muscles, bones, internal organs

• In adults, maintains the volume and tone of the skin, muscle and tissues

• Low GH causes accelerated ageing

• Function and repair of muscles, heart, lungs, liver, kidneys, joints, nerves and the brain

• Mental and emotional impact as it stimulates parasympathetic nerves (calming)

• Calming, inner peace, increased QOL, relieve depression, anxiety

Highest in the first 3-4 hours of sleep

Secreted by pituitary gland

Peaks in adolescence

Declines from age 30 at 1-3 % per year

IGF-1 is produced by the liver under the influence of GH and protein intake, and mediates GH effects

Measure IGF-1 as it is more stable than GH

• Sparse thin hair, thin skin• Droopy eyelids, sagging cheeks, thin lips, thin nose

pointing downward, thin jaw bones• Loose skin folds under chin• Thin muscles, small shoulders• Droopy triceps• Hands- thin muscles, thin fingers, vertical lines on nails,

small muscles• Prematurely aged, obese body• Fat droopy abdomen, stretch marks• Hunchback, increased subscapular skin, sagging back

muscles• Sagging inner thighs, fatty cushions above the knees• Flat feet• Lack of inner peace, reduced QOL, feel unwell, low self

esteem, social isolation, excessive emotions, poor stress tolerance, exhaustion with poor recovery, can’t recover from poor sleep, light sleep , excessive sleep, feeling of rapid ageing

Diseases that maydevelop more easily in people who are GH deficient

Cardiovascular disease- high cholesterol, heart failure, atherosclerosis, HT

Obesity

Type 2 Dm

Suspect in brain injuries

Head injuries

Cranial irradiation

PPH

GI haemorrhage

Hypopituitarism

Normal IGF-1 levels do not exclude AGHD

• IGF-1 fasting in the morning

• Men- 39-46

• Women 29-40

• Treatment can be with injections of GH

• 0.5-2 IU at night

• Lifestyle and diet

• Testosterone, Oestrogen, Progesterone, Thyroid hormone, Melatonin all increase GH levels; high cortisol reduces GH

• Secretagogues- Arginine, Ornithine, work best in the young: L- Glutamine 2g at night works in all ages

“Extensive studies of the outcome of GH replacement in childhood cancer survivors show no evidence of and excess of de novo cancers, and more recent surveillance of children and adults treated with GH has revealed no increase in observed cancer risk”

Jenkins PJ et al. Clin Endocrinol (Oxf). 2006 Feb; 64(2):115-21

Low dose GH treatment combined with dietary restriction resulted not only in a decrease of visceral fat but also in an increase of muscle mass with a consequent improvement of the insulin resistance observed in obese type 2 patients

Nam SY et al. Int J Obes Relat Metab Disord 2001 Aug;25(8);1101-7

DB randomised treatment

20mcg/kg/day

>75 years old, IGF returned to 50 year old levels

Return to pre fracture living 94% vs 75%

Statistically significant, well tolerated

Van Der Lely et al. Eur J Endocrinol 2000 Nov; 143(5): 585-592

50 yo man, obese, hyperinsulinaemia, fatigue, depression, low motivation, low muscle mass

3 years ago had oesophageal bleed which left him in a coma for 4 weeks in ICU

IGF-1 nmol/l < 3 (12-33)

Treatment 1 IU GH daily

Improvement in mood and energy

Two major thyroid hormones, T4 with four iodine atoms and T3 which has three

T3 is the most active and the most widely distributed in the body

T3 the main hormone within the target cells

T4 the most abundant in the blood, and is a precursor hormone that must be converted to T3

Increase blood flow, heart rate, heat production, metabolism, energy production and consumption, speed of thinking, intestinal motility, thirst, urination, HDL cholesterol, immune defense against infections and cancer

Decrease LDL, diastolic BP, fluid retention

• T4 80-100 mcg and T3 20 mcg secreted by thyroid gland

• T3 35 mcg is from peripheral conversion of T4, mainly in the liver

• High calorie diets, fruit and vegetables increase thyroid activity

• Sugar increases thyroid, but temporarily

• Eating too much protein or too little calories, lowers thyroid activity by reducing T4- T3 conversion and reducing hormone production by the thyroid gland

Levels decrease with age 10-20 % from age 25-75 and T3 by 25%

RT3 is an isomer of T3 which can block T3 activity at receptor sites

RT3 is increased under stress

Conversion of T4- T3 requires adequate zinc and selenium, reduced by old age, decreased calories, inflammation, illness, trauma, post op, increased cortisol

• Prone to ENT infections• Prone to easy weight gain,

difficult to lose• Overweight• Swollen• Morning fatigue and fatigue

when taking a rest• Feels best in the evening or

when physically or mentally active

• Lethargy• Intolerance to cold• Intolerance to heat, inability to

sweat• Snoring• Difficult to get out of bed in

the morning• Poor appetite• Excess coffee• Decreased thirst and urination• Dry hair

• Hair loss• Headaches• Tinnitus• Hoarse voice in the morning• Dry skin• Brittle nails• Bloated abdo, slow digestion,

constipation• Muscle and joint stiffness in

the morning• Muscle aches• Leg cramps at night• Carpal tunnel syndrome• Low back pain• Depression• Poor memory• Slow thinking• Easily distracted

Associated with development of cardiovascular disease, premature atherosclerosis, infertility, obesity, diabetes, depression, memory loss, Alzheimer’s disease, ENT infections, and possibly cancer

• Testing lacks sensitivity• TSH is not the best test• Free T3 the best clue• Look at the patient• TSH >2 indicates a high probability there is

hypothyroidism or it will develop• TSH >4 premature atherosclerosis• Optimal TSH 1• RT3 <400• Thyroid antibodies often positive, but may be

positive in general autoimmune disease, can act as “thyroid blockers”

Reduce by

Eliminating physical and mental stress

Treating with thyroid

Growth hormone

Selenium

Iodine

Whole Thyroid- from Pig glands

“Armour” or compounded equivalent

1 grain/60 mg- T4 38mcg/T3 9mcg

T4 and T3 treatment more beneficial than T4 alone

T4 and T3 synthetic but bioidentical

Treatment with both T4 and T3 has been shown to be more beneficial to patients than T4 alone

• Zinc 30 mg

• Selenium 200 mcg

• Iodine up to 12.5 mg- Lugol’s or Iodoral

• Tyrosine 500- 1000mg

• “Thyroid formulas”

• Adrenal support- low thyroid is a stress situation and will cause increased cortisol. When treated with T4 only, and less T3 conversion, the stress response gets worse and leads to adrenal fatigue

“The adrenals first, the adrenals last and the adrenals inbetween” James Wilson

Most people have a degree of Adrenal Stress or Fatigue

If cortisol is increased, it decreases hormones levels and their activity.

The biggest hot spot in ageing

DHEA is the most abundant hormone produced at puberty leading to development of axillary and pubic hair

Declines from age 30

Lifelong adrenal cortex deficiency leads to allergies, thin body, inflammation, poor response to stress

• Are present throughout the day

• Worse with physical activity

• Moderate fatigue

• Anxiety and depression

• Low resistance to stress and noise

• Decreased libido

• Dry eyes, dry skin

• Loss of axillary and pubic hair, lateral calf

• Poor muscle development

Blood- Optimal level for men 9, women 7

Saliva 20- 25

DHEA orally men 20-55 mg, women 5-30 mg

• Enhances immune system, may have an anti cancer role

• Reduces risk of age related disorders, including cancer, CVD and osteoporosis

• Improved BSL and helps prevent diabetes

• Weight loss and increased muscle mass

• Important in autoimmune illness, AIDS, chronic fatigue

• Treat depression, menopause, memory

• Increase life expectancy

• Stimulates protein breakdown to amino acids

• Lipid breakdown in fatty tissue

• Promotes synthesis of glucose in the liver from the above

• Makes glucose available to the brain by using other tissues

• Normally, the breakdown (catabolism) of tissues is followed by the building up (anabolism) of androgens (DHEA, TT)

• As we age, excess catabolic:anabolic hormones develops and this results in the breakdown of organs and tissues, the loss of ability to repair damage

• This also occurs under chronic severe stress and contributes to ageing

• Stressed/anxious/irri-table/nervous

• Crave sugar and sweets

• Weight gain

• Depressed

• Loss of memory

• Foggy thinking

• High blood pressure

• Puffiness under eyes

• Weight gain easily, especially in the waist

• Loss of muscle

• Low sex drive

• Hair loss

• Thinning skin

• Bruise easily

• Lower level of energy/fatigued

• Difficulty waking up in the morning

• Fatigued increases late afternoon

• Resistance to stress is low• Resistance to infection is

low, prone to illnesses• Allergies/sensitivity to

chemical• Foggy thinking• Crave salty foods• Crave sugar and sweets• Suffer from arthritis, joint

pain• Excessive sensitivity to pain• Nausea• Appetite is poor

• Low blood pressure, sometimes orthostatic

• Conjunctivae reddened

• Dark circles under eyes

• Appearance of age spots

• Wet/sweaty palms

• Thin, undernourished body

• Thinning hair

• Hollow cheeks

• Dry skin/eczema

• Brown palmer folds

• Weakness, fatigue• GI symptoms

• Nausea• Vomiting• Constipation

• Abdominal pain• Diarrhoea• Anorexia

• Salt craving• Dizziness• Muscle and joint pain

• Weight loss• Hyperpigmentation

• Hypotension• Loss of scalp hair• Excess facial or body

hair

• Vitiligo

Serum Cortisol in the morning- optimal 500

Saliva cortisol throughout the day- 8am, 12pm, 4pm, 10pm

24 hour urinary cortisol

Cortisol

DHEA

• Eat early and never skip breakfast

• Have a glass of water in the morning with ½ to 1 teaspoon of salt

• Avoid sugary fruits (all juices,oranges, citrus, ripe bananas)

• Avoid starchy foods (all grains, bread, potatoes, rice, popcorn, pasta)

• Avoid coffee or other caffeine containing beverages

• Avoid trans-fat (they are in everything processed)

Cardio: 3 times a week for 30 minutes

Low weight high reps: This helps improve metabolism and maintain muscle strength and mass

Flexibility, improves circulation, reduces stress, and lessens chance of injury

Exercise should leave you energized not wiped out

• Stop watching TV and using the computer by7pm

• No work after 7pm

• Sleep by 10 p.m.

• Sleep in as late as possible, and twice a week until you wake on your own

• Avoid getting over-tired

• Do the things that you like

• Laugh several times a day

• Vitamins• B complex B-5, once or twice daily • Vitamin C 1000mg• Magnesium 300mg• Adaptogens• Siberian Ginseng 250 to 500mg 1 or 2 times daily• Ashwagandha (Indian Ginseng)/Withania 250 to

500mg 1 or 2 times daily• Rhodiola (Rhodiola rosea) 100 to 250mg 1-3 times

daily• Glandulars• Thorne Cortrex• Rest Augmenters• Phosphatidyl Serine 100 mg 1-3 tablets at 6pm for

sleep• L-Theanine 100-200mg 1-4 times daily.• Melatonin 0.5-3mg at night

Hormones

Progesterone transdermal 3%-6%

DHEA orally 5-50mg

Pregnenolone 50-100 mg

Hydrocortisone 5-15mg at 7am and 2.5-10mg at noon

Fludrocortisone 50-100mcg

A hormone also made by the adrenals

Responsible for retention of water and maintaining blood pressure by making the kidneys retain sodium

Higher during day when you are upright

Higher on low salt diet- able to compensate less as get older

Can be very low in adrenal fatigue

• Feel better lying down

• Need to move around all the time when standing

• Drowsiness, zombie like feeling when standing

• Easily distracted

• Difficulty with vision focus

• Salt cravings

• Thirsty and urinate a lot

Pale face, absent minded look

Low BP less than 110/60

Blood pressure drops when standing

Hollow face, sharp wrinkles

Soft eyeballs

Dehydrated

Tongue indentations

Blood Sodium- optimal 141 low <138

Blood Potassium 4.3 High >4.8

Aldosterone >415

Fludrocortisone 50-200 mcg daily with adequate water and salt

• Pregnenolone is the precursor of all steroid hormones

• It is made from cholesterol in the mitochondria

• Functions also as a neurotransmitter, especially in the part of the brain that deals with memory

• 50% who take > 50mg daily report improvement in memory

• Anti rheumatic

• Produced by brain and adrenal glands

• Declines with age

Poor memory especially under stress

Reduced colour vision

Reduced artistic awareness

Fatigue

Dry skin

Joint pains

Deficiencies of other steroid hormones

Test other hormones

“Pregnenolone steal” syndrome occurs under stress

Pregnenolone 50-150 mg daily

Dementia and Autoimmune disease up to 200-400 mg daily

Oestradiol, Oestrone, Oestriol

Progesterone

Testosterone

• Oestradiol is the strongest oestrogen and it is converted to oestrone and oestriol

• Delicate balance between oestrogen and progesterone

• Have opposite and complimentary effects

• Oestrogen retains fluid, progesterone is a diuretic

• Oestrogen increases menstrual loss, progesterone decreases it

• Oestrogen stimulates SNS increasing alertness, but if no PG , then can get very nervous

• Progesterone is calming as it stimulates the PNS

• Oestradiol feminises the body

• Reddens the skin

• Proliferation of uterine lining

• Vaginal lubrication

• Libido

• Female voice

• Initiates ovulation

• 10-200 mcg daily in 18-30 year olds

Prepares the uterus for implantation of fertilised egg

Essential for pregnancy

1-2 mg daily (from adrenals)in the first half of the cycle and 20-40 mg (from ovary after ovulation) in the second half

Prolonged physical activity and intense stress can suppress the production

Protein and fat increase

Sugar and high fibre grains decrease

All women become hormonally deficient over time when no good eggs remain at menopause

Progesterone usually the first hormone to become deicient

Oestrogen DeficiencyProgesterone Deficiency/Oestrogen Excess

• Fatigue

• Depression

• Poor libido

• Poor memory

• Hot flushes and night sweats

• Droopy breasts

• Menstrual irregularity, light or absent

• Vaginal dryness

• Painful intercourse

• Bladder infections

• Joint aches

• Nervous tension• Irritability, aggression• Anxiety, rage• Increased sensitivity to

pain• Insomnia with nervous

tension• PMT, swollen tender

breasts• Bloating• Heavy periods• Fluid retention

Oestrogen deficiency Progesterone Deficiency

Infertility

Premature ageing

Osteoporosis

CVDAlzheimer’s Disease

• Breast cysts• Breast cancer• Ovarian cysts• Endometriosis• Endometrial cancer• Uterine fibroids• Enlarged uterus• Heavy bleeding• Infertility• Miscarriage

• Blood- “Day 21” oestradiol and progesterone• Ratio 5:1• Salivary hormone testing Day 21• Ratio 200:1• Vitex can be a useful herb and has

progestagenic effects, esp in younger women• Treatment- Biest cream

- Oestradiol alone- Progesterone as a cream in the

second half of the cycle, or as a troche or capsule

• Osteoporosis, 67 yoa

• Oestradiol (E2) < 50 pmol/L

• Anxiety, depression, overweight , 42 yoa

• Oestradiol (E2) 1041 pmol/L

• Blood shows bound and unbound hormones, up to 98% of hormone can be bound to binding proteins

• Transdermal progesterone cream does not show up in serum levels

• Salivary hormone testing will show transdermal and unbound fraction

Called progestins

Progestins are synthetic modifications of the progesterone molecule. Several different ones are prescribed .

Progestins are not progesterone.

Progestins do not reproduce the same actions of natural progesterone.

Progestins worsen cancer risk

• Testosterone important in women for mood and assertiveness

• Improve bone density, muscle strength and skin oil production

• Female genitalia- sensitivity

• Protection against atherosclerosis

• Production is 20-30 times lower than men

• Mostly from DHEA

• 40 yo have half the TT of 21 yo

• Nervous irritable

• Lack of mental firmness, indecisive

• Poor memory

• Depression, anxiety

• Excessive emotions and sensitivity to stress

• Ageing appearance, abdominal obesity

• Muscle laxity

• Fatigue, low energy

• Dry skin, easily sunburnt

• Decreased or absent libido and orgasm

• Painful intercourse

• Cellulite

Aim serum TT in upper range

Saliva 80-90

TT cream 1mg/g daily

Injections

Troche

Testosterone

Dihydrotestosterone

Oestradiol

The predominant male hormone, converts to dihydrotestosterone, the most potent male hormone

If does not convert to DHT, will convert to oestradiol

Andropause is more gradual than menopause

• Protects against CAD, decreases BP, thins blood

• Protects against obesity and diabetes, increases lean muscle mass

• Maintains reproductive health

• Supports brain by increasing connection of neurones and increasing blood supply

• Improves mood and memory and decreases anxiety

Daily production is 7 mg daily

Higher in the morning

Leydig cells make testosterone and every four seconds, one dies, so when 70, have only a third left cf 18

Over time, become deficient and suffer symptoms

• Ageing appearance• Obesity• Headache, ear buzzing• Palpitations, shortness of breath on exertion• Decreased muscle strength and size• Muscle pains, poor recovery after exercise• Easily sunburned• Constipation• Fatigue, worry, low motivation• Hot flushes, sweating• Prostatism• Decreased libido, erections, morning erections• Lack of decisiveness• Depression• Excessive emotions• Lack of interest in life• Social isolation

• Cardiovascular disease

• Infertility

• Obesity

• Type 2 Diabetes

• Depression

• Memory loss

• Alzheimers disease

• Osteoporosis

• Poor wound healing

Blood testosterone, SHBG, free testosterone

Ideally in upper third of the range depending on size

Oestradiol

Testosterone gel

Injection

Implants

Oestradiol (E2) 213 pmol/LTestosterone 14.3 nmol/LSHBG 73 nmol/LFree Androgen Index 19.6 %Calculated Free Testosterone 0.16 nmol/L **

Reference Intervals

CalculatedTestosterone SHBG FAI FreeTestos.

Adult Male 8.0 - 30.0 10 - 45 30 - 120 0.20-0.60 Pubertal Male 6 - 30Prepubertal Male <6

A metabolite of TT

The strongest androgen

Used in Europe predominantly

Is a useful aromatase inhibitor and also a 5 alpha reductase inhibitor, reducing the metabolism of testosterone to both oestradiol and DHT

Oestradiol is made from testosterone

Abdominal obesity and inflammation increase this conversion

Men need some oestradiol for brain, bone, heart and libido

Too much will cause gynaecomastia, possibly BPH and prostate cancer

Weight loss, zinc, progesterone

Testosterone and prostate cancer

HRT and breast cancer

Cortisone use

Thyroid and osteoporosis

Healthy diet

Healthy GIT

Healthy detoxification

Avoid xeno oestrogens

Supplementation and lifestyle

THEN appropriate hormone supplementation when required with bio identical hormones

Good health doesn’t come from a pill or an injection

www.acnem.org

www.a5m.net

www.aima.net.au

www.worldhealth.net

www.a4m.org

www.intlhormonesociety.org

Also I have a facebook fan page Dr Fatiha Arhbal

Dr Simeon in the 1950’s developed a weight loss programme using the pregnancy hormone human chorionic gonadotrophin

Inject small amounts daily

Calorie restriction to 500 cals daily

Resets weight set point in the hypothalamus

No rebound weight gain

Can lose up to 15kg in 40 days without exercise!