presents Pioneering Nutz & Boltz Technologies of BHT: For Lifestyle Male Case Based Studies Medicine with Dr. Paul Savage, MD
o Founder of Power2Practice Integrative Medicine EMR o Founder and Director of Agenixs (Chicago Medical Practice) o Practiced Integrative Medicine over 15 years Pioneering Technologies For Lifestyle Based Medicine o Certified in Integrative Medicine at George Washington University o Fellow of the University of South Florida Stem Cell Therapy o Fellow of the American Academy of Dr. Paul Savage MD Anti-Aging and Regenerative Medicine
CASE 1 LOW T CLASSIC 55 y/o WM presents with the complaint of stress, fatigue, and gaining weight. Goals Improve sex drive Improve fatigue Lose weight
SYMPTOMS Fatigue Weight gain Low libido Depression/anxiety off my game
PAST MEDICAL HISTORY
PAST MEDICAL HISTORY
MEDICATIONS None
SUPPLEMENTS Anti-Aging DHEA 25mg 2 capsules Detox/Prevention Vitamins Multivitamins Brain Heart Fish oil Gut
LABS
INITIAL TREATMENT
TREATMENT PLAN Nutrition: Healthy eating & nutritional counseling Exercise: Any! Sleep: Monitoring device (Fitbit) Mindfulness: 8-minute meditation (Davich)
MEDICATIONS New Testosterone Cypionate 200mg/mL 0.4ml injected intramuscularly every 7 days Maintained Discontinued
SUPPLEMENTS Anti-Aging DHEA 25mg 2 capsules Detox/Prevention EstroDIM Vitamins Alpha Base without Iron Vitamin D3 Heart Whey Protein Powder MCT Oil OmegaGenics 720 Brain Adapten-all Gut UltraProstatagen OrthoBiotics
RETURN VISIT 55 y/o WM presents with the complaints of stress, fatigue, and weight gain. Goals: Improve sex drive Improve fatigue Lose weight CC: Improved energy, focus, libido, erections, muscle gain, fat loss, improved sense of well-being - feel great
LABS
TAKEAWAYS PERILS AND PEARLS Testosterone Cypionate (or Enanthate) Can be given weekly, bi-weekly or monthly Most men do better on weekly injections Can be done at home or in office (financial) Major concerns are PSA elevations, HCT increases and breast tenderness Done in conjunction with healthy eating and exercise!
PATIENT PRESENTATIONS
CASE 2 - HCG 41 y/o BM presents with goals of improving work outs and gaining more muscle mass. Goals Keep exercising and working on my mobility to obtain full range of motion in all my joints (for injury prevention) and equally balanced strength and health throughout my whole body. I'd also like to get my body fat to around 10% and keep it there. Maintain healthy testosterone levels to support the goals above.
SYMPTOMS Joint aches and pains Not lean anymore Fatigue Insomnia
PAST MEDICAL HISTORY
PAST MEDICAL HISTORY
MEDICATIONS None
SUPPLEMENTS Anti-Aging True Grit Test Booster Vitamins Alpha JYM Jym Postworkout Animal Flex BSN Noxplod ZMA Heart Detox/Prevention Warrior Greens Brain Gut
LABS
INITIAL TREATMENT
TREATMENT PLAN Nutrition: Body builder bulking per patient Exercise: He is a personal trainer Sleep: Monitor Mindfulness: 8-minute meditation (Davich)
MEDICATIONS New HCG 10,000IU/10mL inject 0.25-0.4mL SQ qam Maintained Discontinued
SUPPLEMENTS Anti-Aging True Grit Test Booster Vitamins Alpha JYM Jym Postworkout Animal Flex BSN Noxplod ZMA Heart Detox/Prevention Tongkat Ali Resveratrol Grape seed Extract Boron Zinc EstroDIM Brain Gut
FOLLOW UP VISIT
RETURN VISIT 41 y/o BM presents with goal of improving work outs and gaining more muscle mass. Goals Keep exercising and working on my mobility to obtain full range of motion in all my joints (for injury prevention) and equally balanced strength and health throughout my whole body. I'd also like to get my body fat to around 10% and keep it there. Maintain healthy testosterone levels to support the goals above.
LABS
TAKEAWAYS PERILS AND PEARLS HCG More expensive than Testosterone Cypionate Need to be used daily in the morning May cause headache, increased blood pressure, peritoneal dull pain, joint aches or rash Increases sperm count Usual dose is 250-500IU daily The older, the higher the SHBG the more HCG will be needed The older the man, the less likely that HCG will work (needs intact Leydig cells)
CASE 3 DOSED LATE 53 y/o BM seeks an overall health assessment, and to develop healthier lifestyle program. Goals Weight Loss Increased Energy Cardiovascular Health
SYMPTOMS Fatigue Weight gain Low libido Depression/anxiety
PAST MEDICAL HISTORY
PAST MEDICAL HISTORY
MEDICATIONS None
SUPPLEMENTS Anti-Aging Detox/Prevention Vitamins Brain Heart Gut
LABS
INITIAL TREATMENT
TREATMENT PLAN Nutrition: Nutritional counseling & heart healthy diet Exercise: Walking Sleep: Monitoring device (Fitbit) Mindfulness: Relaxation breathing
MEDICATIONS New Testosterone Cypionate 200mg/mL 0.35ml injected intramuscularly every 7 days Maintained Discontinued
SUPPLEMENTS Anti-Aging Vitamins Alpha Base without Iron Vitamin D3 Heart Whey Protein Powder MCT Oil OmegaGenics 720 Detox/Prevention EstroDIM Brain Serenagen 2 tid Gut UltraProstatagen OrthoBiotics
FOLLOW UP VISIT
RETURN VISIT 53 y/o BM sought an overall health assessment and wanted to develop a healthier lifestyle program. Goals Weight Loss Increased Energy Cardiovascular Health CC: Weight loss, much improved energy, increased sense of wellbeing, improved libido
LABS
TAKEAWAYS PERILS AND PEARLS Testosterone Cypionate (or Enanthate) Know when the shot is given (see drop in Testosterone level in this 3 rd example) Lower the SHBG, the lower the dosage Free Testosterone levels come in handy PSA generally increases by 10% with addition of testosterone Growth hormone (IGF-1) generally increases with healthy living, testosterone and health improvements
PATIENT PRESENTATIONS
CASE 4 OLDER MALE ON T-GEL 66 y/o WM presents with the complaint of "Blood test to ensure I have the right bio-identical hormones. Goals Take advantage of bio-identical hormones to be able to keep my vigor. Lose a bit of weight off my belly and pec region. Safeguard against cancer, ALS, dementia that plague people growing old.
SYMPTOMS Low libido Fatty breasts, nipple tenderness
PAST MEDICAL HISTORY
PAST MEDICAL HISTORY
MEDICATIONS Testosterone Gel 180mg/mL per day
SUPPLEMENTS Anti-Aging Vitamins D3 5000 Vit K2 Total B Complex Heart Natural Vit E Ubiquinol 100mg Carlson s Finest Fish oil Detox/Prevention Resveratrol Brain Melatonin 3mg Gut 50 Billion Probiotic
LABS
INITIAL TREATMENT
TREATMENT PLAN Nutrition: Nutritional counseling Exercise: Walking Sleep: Monitoring device (Fitbit) Mindfulness: Relaxation, Tai-Chi
MEDICATIONS New Testosterone Cypionate 200mg/mL 0.30ml injected intramuscularly every 7 days Maintained Discontinued Testosterone Gel 180mg/mL per day
SUPPLEMENTS Anti-Aging Vitamins D3 5000 Vit K2 Total B Complex Heart Natural Vit E Ubiquinol 100mg Carlson s Finest Fish oil Whey Protein Powder Detox/Prevention Resveratrol Brain Melatonin 3mg Serenagen 2 tid Phosphotidyl Serine 150mg qhs Gut 50 Billion Probiotic
FOLLOW UP VISIT
RETURN VISIT 66 y/o WM presents with the complaint of "Blood test to ensure I have the right bio-identical hormones. Goals Take advantage of bio-identical hormones to be able to keep my vigor. Lose a bit of weight off my belly and pec region. Safeguard against cancer, ALS, dementia that plague people growing old. CC: Much better libido, no nipple
LABS
TAKEAWAYS PERILS AND PEARLS Testosterone Cypionate (or Enanthate) Testosterone Gel not monitored well with serum blood testing High physiologic dosing gives spill over to estrogens Estradiol is not the only estrogen and is often normal even though symptoms of high estrogen (think Estrone) Physiologic dosing of gels is important to treat the patient safely
PATIENT PRESENTATIONS
CASE 5 COMPLEX 19 y/o WM present with history of viral infection 2/2015 after which he started to experience hypersensitivity to tip and ventral of penis, fatigue, loss of testicular and penile size, inability to gain muscle even though working out hard daily, depression, anxiety and erectile dysfunction. Has been seen by urology who ruled out prostatitis, interstitial cystitis and urethritis. Normal male development which has noted regression of teste size and penile size in past 14 months.
Goals: Raise my testosterone levels and regain my normal function and be able to build muscle. This is a priority for me. I do not want to be broken or end up infertile. I want to have a normal sex life and I want to be strong and physically fit. Heal my penile tip pain and pelvic pain so I can enjoy being active and being social. I feel uncomfortable with movement. The pain changes in intensity but never goes away. I have flare ups that make me feel I will never heal from this. Help me to have normal sleep patterns. I want to have overall good health so I can get stronger and go back to being an athlete. I want to feel good again and have a future of good health.
SYMPTOMS Penile tip sensitivity Peroneal discomfort Fatigue Depression/anxiety Low libido Erectile dysfunction Unable to gain muscle
PAST MEDICAL HISTORY
PAST MEDICAL HISTORY
MEDICATIONS None
SUPPLEMENTS Anti-Aging Detox/Prevention Vitamins Alpha Base multi-vitamin Free & Easy Wanderer Pluss Corydalis Methyl B Complex Vitamin D 50,000IU Heart Fish Oil Brain Gut Prostate Formula Polyporus & Dianthus Ortho-Biotic
LABS Heavy Metals: Negative MRI pituitary: Negative Karyotype: 46, XY Sperm: low viability
INITIAL TREATMENT
TREATMENT PLAN Nutrition: Nutritional counseling Exercise: Walking Sleep: Monitoring device (Fitbit) Mindfulness: Relaxation, Tai-Chi
MEDICATIONS New Testosterone Cypionate 200mg/mL 0.30ml injected intramuscularly every 7 days Maintained Discontinued Testosterone Gel 180mg/mL per day
SUPPLEMENTS Anti-Aging Vitamins D3 5000 Vit K2 Total B Complex Heart Natural Vit E Ubiquinol 100mg Carlson s Finest Fish oil Detox/Prevention Resveratrol Brain Melatonin 3mg Serenagen 2 tid Phosphotidyl Serine 150mg qhs Gut 50 Billion Probiotic Whey Protein Powder
FOLLOW UP VISIT
RETURN VISIT 19 y/o WM present with history of viral infection 2/2015 after which he started to experience hypersensitivity to tip and ventral of penis, fatigue, loss of testicular and penile size, inability to gain muscle even though working out hard daily, depression, anxiety and erectile dysfunction. Has been seen by urology who ruled out prostatitis, interstitial cystitis and urethritis. Normal male development which has noted regression of teste size and penile size in past 14 months.
RETURN VISIT Goals Raise my testosterone levels and regain my normal function and be able to build muscle. This is a priority for me. I do not want to be broken or end up infertile. I want to have a normal sex life and I want to be strong and physically fit. Heal my penile tip pain and pelvic pain so I can enjoy being active and being social. I feel uncomfortable with movement. The pain changes in intensity but never goes away. I have flare ups that make me feel I will never heal from this. Help me to have normal sleep patterns. I
LABS Heavy Metals: Negative MRI pituitary: Negative Karyotype: 46, XY Sperm: low viability
TAKEAWAYS PERILS AND PEARLS Young males with low Testosterone Consider prior steroid use (including OTC steroids) Consider Endocrinologist evaluation Do: Prolactin, Karyotype, Sperm Analysis, Magnetic resonance imaging (MRI) Do not: Be shy about treating with HCG and if necessary, Testosterone
THE BIG PICTURE TAKEAWAYS PERILS AND PEARLS Hormone replacement therapy with testosterone implants is superior to oral and topical (both the patch and gel) hormone replacement therapy for bone density (Savvas 88, 92, Davis 95, Anderson 97). Testosterone pellets were generally well tolerated. (McCullough, AR. A Multi-institutional observational study of testosterone pellets) Hormone replacement therapy with pellet implantation has an extremely low incidence of side effects (Cardoza 84, Barlow 86, Ganger 89, Pirwany 02) and high compliance rate (Gambrell 06). For delivering a consistent dose over the long term, pellets are the best option. Pellets deliver consistent, physiologic levels of hormones and avoid the fluctuations of hormone levels seen with other methods of delivery (Greenblatt 49, Thom 81, Cantrill 84 Stanczyk 88). Testosterone pellet implants release testosterone at a steady rate of 1.3 mg/200 mg implant/day. (Kelleher, S. Testosterone release rate and duration of action of testosterone pellet implant).
THE BIG PICTURE TAKEAWAYS PERILS AND PEARLS Hormones delivered by the subcutaneous implants bypass the liver, do not affect clotting factors and do not increase the risk of thrombosis (Notelovitz 87, Seed 00). Testosterone delivered subcutaneously by pellet implant is cardiac protective (Sands 97, Worboys 00). Testosterone delivered by pellet implantation, does not adversely affect blood pressure, lipid levels, glucose or liver functions (Burger 84, Farish 84, Fletcher 86, Barlow 86, Notelovitz 84, Stanczyk 88, Davis 95, 00, Sands 97, Seed 00,Cravioto 01). The pellets not only prevent bone loss but also actually increase bone density (Savvas 88, Studd 90, Garnett 91, Savvas 92, Naessen 93, Holland 94, Studd 94, Davis 95, Anderson 97, Seed 00, Panay 00). Testosterone replacement with long-acting Testopel pellets had a lower rate of infection (0.3%) as compared with historical data from the Organon testosterone pellet (1.4 6.8%). The rate of pellet extrusion was substantially lower (0.3%) as compared with historical data (8.5 12%). Patient satisfaction was high and serum hormone values were improved. (Cavender 2009)
THE BIG PICTURE TAKEAWAYS PERILS AND PEARLS Testosterone pellets Start with T200mg x4 Increase by 200mg if younger, leaner, more stressed, more active, higher SHBG Decrease by 200mg if older, fatter, less active, more illnesses, lower SHBG Repeat labs 1 month after first implant Usual testosterone 5-10mg/day burn rate
THE BIG PICTURE TAKEAWAYS PERILS AND PEARLS Adverse Reactions Pellet extrusion 0.3-12% Pain at insertion site: 5-8% Infection at the site of insertion 0.3-6.8% Nipple tenderness 3-5% Bleeding at insertion site 0.3-1.5%
Paul Savage MD, FACEP FFARM THANK YOU! (855) 667-1967