Archive for the 'BHRT Tutorials' Category

Tips on maintaining health through perimenopause and beyond

If you’d like an overview of hormonal changes that happen for women at mid-life, check out this presentation by Lisa Brent, ND. Dr. Brent is a naturopathic physician who is a specialist in women’s health. We were delighted to host Dr. Brent this summer at Koshland Pharm and to hear her presentation, “Mind Over Menopause: Maintaining Health Through Perimenopause and Beyond,” and to share it here in its recorded version.

-Krista Shaffer, Outreach Director at Koshland Pharm and Peter Koshland, PharmD




Bioidentical Hormone Therapy Team: Patient, Doctor and Pharmacist

APatel photoWe are pleased to have a guest post this week on our blog. We welcome your comments and feedback.

~ Krista Shaffer, Outreach Director at Koshland Pharm

Many people want to know the process involved for bioidentical hormone replacement before starting treatment. There are Whos, Whats, Whens, and Whys involved before starting any therapy and being informed helps each person feel more confident of the care they are receiving. Bioidentical hormone therapy is typically a team approach including the patient, the doctor, and the compounding pharmacist. Let’s start at the beginning.

When you book an appointment with your doctor, he or she will ask you a full health history and questions that are specific to the symptoms you’re experiencing. They often seek to explore how the symptoms are connected, what makes the symptoms feel better or worse, and which underlying hormones may be deficient, excessive, or out of balance in the body. Hormones work best when they are in concert with one another at healthy levels and ratios. For example, the body needs enough progesterone hormone to balance estrogen levels.  (To see an example of a symptom checklist, click here.)

Once the doctor has collected important information about your symptoms, health history, and lifestyle, he or she may decide to order salivary or blood hormone testing for confirmation. Patients sometimes worry that the results from one single hormone test may be skewed if it’s a bad day. Don’t worry, your doctor should put your comprehensive health intake and lab results side by side to make sure there is a correlation before writing a prescription. In addition, many providers re-test hormone levels at 3 or 6 months to monitor treatment.

After your doctor detects patterns in hormone imbalances, and if she determines an individualized prescription would work best for you, she will contact a compounding pharmacy. The pharmacist speaks to the doctor and can help advise on dosing, route of administration (cream or pill, for example), and other important prescription considerations. The pharmacy staff knows that hormone prescriptions need to be tailored to the individual, and they are there to help make that happen.

Once the compounding pharmacy has your prescription, they’ll give you a call to arrange pick-up or shipping and to answer any questions you may have. Don’t be shy—ask any questions that come to mind about how to use your bioidentical hormones. I recommend working with accredited and quality compounding pharmacies, which can be found nation-wide through the website of the Pharmacy Compounding Accreditation Board.

After you get your bioidentical hormone prescription and start using it, try to pay attention to how your body adapts to the medicine for the first couple of months. A quick update to your doctor can let them know that the dose you’re on is working for you, or it can alert them that you may need an adjustment. Your body knows best, so your detective skills can help you, the doctor, and the compounding pharmacist arrive at the best dose for your symptoms and overall health. If needed, during the first few months your doctor may work with the compounding pharmacy to tweak the prescription until it fits just right.

Good communication among the patient, the doctor, and the compounding pharmacist helps maximize the benefits that bioidentical hormone replacement can provide to your health and your life. You have a team at your disposal on the road to better hormone balance, increased energy and vitality, and improved health!

~ Aarti Patel, ND, Guest Author
Inner Balance Natural Health
Connecting the dots in health

Getting to the Root Cause of Symptoms

tree-rootsWe are fortunate through our work to get to meet physicians across the Bay Area who are committed to the health and well-being of their patients. We recently had the opportunity to interview one of these doctors, Dr. Todd Maderis, for our Prescriptions for Health newsletter. Dr. Maderis talked with us about his passion for getting to the root cause of symptoms:

Practice Approach

In my practice at Marin Natural Medicine, I’m keen on communicating two concepts with my patients. The first is education. I find that if patients are aware of the reasons behind their condition, they have a better chance of getting better.

The second concept, and the premise of my practice, is getting to the root cause of a patient’s symptoms.  Sleep is a great example of this. If a patient comes in complaining of insomnia, she might say, “I’m taking all of these wonderful supplements like melatonin and kava, and I’m still not sleeping.” In response, I might say, “Melatonin and kava are nice, and I like them…but let’s figure out what’s going on with you. What has changed in your life that might cause the insomnia?” We look at age, and the way hormones might have shifted, to see if there is a connection. The patient may not necessarily have a melatonin deficiency; she may have a hormonal imbalance.

I often talk with patients about correcting menopausal symptoms such as insomnia with hormonal balancing. The goal is to mimic nature in how we administer hormones. When we get patients back to their normal physiological range of hormone production, they often feel better and move through the world with greater ease. Ultimately, if we can identify and treat the root cause of their symptoms, the results are more sustainable over time.

Compounding Success Story

There was a woman who had had open heart surgery a few years before coming to see me, and she had been feeling very fatigued ever since. She had a low-grade depression, and wasn’t doing the activities she liked to do, such as playing the piano or reading. It took everything she had to get up and out of the house each day. Because she was clinically presenting with low estrogen and progesterone, I prescribed a topical bi-est (80%estriol/20%estradiol) cream and progesterone capsules from Koshland Pharm. Two or three months into her prescription, she felt a bit better. I had her do a follow-up urine test, and it turned out that her testosterone was also very low. Once testosterone was added to her prescription, she went from feeling 70 percent better to feeling 100 percent better. She started playing the piano and reading again; she got her life back.

Current Inspirations

It is the stories of patients improving the quality of their lives that keeps me inspired. I am also inspired by learning from experts in different fields, and then bringing that knowledge back to my patients in Marin County.

For example, last year I did a physician training with Ray Stricker, M.D. and the International Lyme and Associated Disease Society. I became interested in Lyme because there was always a subset of patients I treated with symptoms of chronic fatigue syndrome who did not respond to typical therapies.

I find that the American health care system is being burdened today not by acute illnesses but by chronic, debilitating conditions such as chronic fatigue, chronic pain and depression. Oftentimes, people are put on multiple drugs to address their different symptoms, but the cause is never approached.

Most patients with chronic conditions didn’t get sick overnight, and they are definitely not going to get better in one day. It’s a process.  I recall a saying I heard from a mentor of mine: “In the same way we do not light a room by removing darkness, we do not achieve health by removing disease.” If I can help at least one patient every day to move further away from disease, and closer to good health, then I’m doing my job. That’s my passion.

For more information about Dr. Maderis and Marin Natural Medicine Clinic, see Marin Natural Medicine Clinic’s webpage.

As always, we welcome your comments and feedback.

~Krista Shaffer, Outreach Director at Koshland Pharm and Peter Koshland, PharmD

Thyroid Health

Thyroid Health - CopyI get a lot of questions as a  pharmacist about thyroid medications.  This is not surprising, considering that an estimated 11 million people worldwide are affected by hypothyroidism.  Common symptoms include low energy, fatigue, cold in the extremities, and constipation.  Hypothyroidism means that the body’s thyroid gland is producing too little thyroid hormone.

The body’s thyroid gland produces two types of peptide hormones.  Liothyronine (T3) is the active thyroid molecule, the form that exerts its effects on the body’s cells. The body also produces levothyroxine (T4) and converts it to T3 in the blood vessels.

The conventional treatment of hypothyroidism starts a patient off on T4 alone (i.e. Synthroid, Levoxyl). For many patients, this is an effective treatment, but it assumes that they efficiently convert T4 to T3.  For patients who do not respond well to T4, desiccated porcine thyroid (i.e. Armour Thyroid, Nature-throid), which contains T3 and T4 in roughly physiological doses, can be a viable option.

Another option is a compounded, or customized, thyroid capsule that has T3 and T4 in a sustained-release form. This product is similar to the off-the-shelf products like Synthroid (T4) and Cytomel (T3) with two distinct advantages. First, T3 and T4 can be combined into a single dose and customized to a strength that perfectly suites a patient’s profile. Secondly, by making these capsules sustained-release, it prolongs the activity of the T3, which has a short half-life.  This allows the T3/T4 capsule to be taken once daily for most patients.

For patients taking any thyroid medication, it is important to know that this type of medication interacts with most foods, drugs, and supplements.  Therefore, it is important to take the capsule one hour before any food or drug, and four hours before any supplement containing minerals like iron, calcium, or zinc.

To see a thyroid symptom rating form that helps to screen for thyroid imbalance, see Koshland Pharm’s new webpage about thyroid treatments.  The webpage also addresses quality considerations for compounded thyroid medications.


The Role of Our Thoughts in Healing

Check out this great article by naturopathic doctor Connie Hernandez, who writes about the importance of our thoughts as part of the healing process:

Of Words and Woes

 Connie HernandezI’ve often told the story of my perimenopausal struggles with insomnia. At a certain point in the menopausal transition, I became unable to sleep. Remedy after remedy proved successful with my patients, but failed to transform my own sleepless situation. Any one of you who has suffered prolonged periods of sleeplessness knows the length to which a person might go to find a remedy….

My story was that I never slept and that I felt horrible all of the time because of it.

One day, a certain wise shaman asked me to explain my problem. My response was that I was not able to sleep. The shaman responded by asking why that was a problem, and by suggesting that night would be a wonderful time to meditate. I explained that when I didn’t sleep, I felt terrible. The shaman agreed that that was indeed a problem, if it was true, and asked me to explore whether or not it really was true that I was feeling badly all the time because of it.

I started looking into every moment, and I discovered that my story was not only not true, but was creating an unfavorable reality. When I moved into the present moments of my experience, I found that there were many moments in which I was just fine. There were some moments in which my eyes were tired, or I felt nauseous, or my head hurt. But those moments were definitely in the minority.

Little by little, and with a supreme act of will, I was able to refute the definition of myself as an insomniac, the false story that I consequently always felt terrible, and the sister thought that I would never sleep again. I stopped speaking of myself as an insomniac. I stopped obsessing about my “condition,” and I started affirming the sleep and well being that I did enjoy. “I slept 3 hours last night!”, rather than “I hardly slept at all last night.” Little by little, I slept normally once again, and I almost always feel well even when I don’t.

We can choose to emphasize the moments, experiences and conditions of being that are as we would like them to be or we can choose to emphasize those that are not. Sri Yogananda explains that when we concentrate on the gripping power of disease rather than the possibility of a cure, we permit the illness to be a mental as well as a physical habit. These “idea habits” create vibrational grooves in the brain and strengthen our tendencies towards sickness or well being.

One way to transform idea habits is through effective affirmation, affirmation that permeates the subconscious mind. As Yogananda says, if you affirm “I am well”, but think in the background of your mind that it is not true, the effect is the same as if you took a helpful medicine and at the same time swallowed a drug that counteracted the effects of the medicine. Wrong thoughts neutralize right thoughts, and you don’t get the desired effect. (If you’re doing affirmations, and not getting the desired effect, chances are you are doing the affirmations incorrectly. There IS a science to it. See the booklet Scientific Healing Affirmations.)

Thoughts are remarkable in their power. In fact, mental reality creates physical reality. Mind governs all physiologic processes and all living cells. Mind has the power to effect healing. And mind has the power to effect dis-ease or imbalance.

This certainly does not mean that we should feel guilty when we are ill. We are subjected not only to our individual consciousness, but also to the collective consciousness, as well as to that myriad of factors mentioned above in the musings.

Nor does it mean that we can ignore physical reality. Until we transcend it, we live our lives bound by the laws of physical reality. That physical reality is impacted by and reflects all energy input, whether from internal or external sources. Where there is dis-ease, we seek and utilize synergistic healing modalities, whether they be based on thought, light, sound, physical, biochemical, or energy medicines. What an array of ways we have to heal ourselves and transform our realities!

Good health is more than the state of not being ill! It is a radiant state of inner well-being. Physical illnesses may be cured by medicines. No medicine, however, can induce that boundless energy which comes when every cell in the body cooperates with the mind willingly, joyfully, in all that it seeks to do.Such radiant well being comes after the mind has been cleared of every shadow of unwillingness, of fear, and of doubt; when one has learned to say yes to life; and when one has learned to love. ” — Affirmations for Self Healing by Swami Kriyananda

Dr. Hernandez is one of the naturopathic doctors we’ve been fortunate to meet through our work at Koshland Pharm.  To find out about Dr. Hernandez’s consulting services, see her webpage at, or to learn about the work of more California naturopathic physicians, see Koshland Pharm’s referral page.  Be well!


Recent Trial (KEEPS) Shows Benefits of Hormone Therapy in Newly Menopausal Women

The researchers who conducted the KEEPS trial (Kronos Early Estrogen Prevention Study) presented initial findings to the North American Menopause Society on October 3, 2012, summarized in the statement:

“Estrogen/progesterone treatment started soon after menopause appears safe and relieves many of the symptoms menopausal women face as well as improving mood and markers of cardiovascular risk.”  (KEEPS press release, “Hormone Therapy Has Many Favorable Effects in Newly Menopausal Women,”10-3-12)

This four year, randomized, double-blinded, placebo-controlled clinical trial (the gold standard in clinical trials) compared oral vs. transdermal estrogen in conjunction with cyclic progesterone.  The participants were healthy women aged 42-58 who started therapy within three years of the onset of menopause.  The oral estrogen used was conjugated equine estrogen (Premarin), and the transdermal estrogen was a bioidentical, estradiol patch (Climara).

The researchers are still analyzing the data, but have so far concluded that “The results provide reassurance for women who are recently menopausal and taking HT for short-term treatment of menopausal symptoms.  KEEPS also highlights the need for individualized decision making about hormone therapy, given that oral conjugated equine estrogen and transdermal estradiol  have different profiles of effects and different women have different symptom profiles and priorities for treatment”  (KEEPS press release, “Hormone Therapy Has Many Favorable Effects in Newly Menopausal Women,” 10-3-12).  The different profiles of effects include an association with the use of oral conjugated equine estrogen with an increase in HDL (“good”) cholesterol, a decrease in LDL (“bad”) cholesterol, and an increase in triglyceride levels (a lipid fraction that is of uncertain significance), and an association between the use of bioidentical transdermal estradiol with with improved insulin sensitivity (lower insulin resistance).  For more information, see:

These initial findings support our understanding of existing studies that estrogen therapy, started close towards the beginning of menopause, can be an effective treatment of menopausal symptoms without  posing a risk to cardiovascular health.


Factors to Consider for Hormone Therapy

I was recently interviewed for a Huffington Post article (December 2011) about hormone replacement therapy.  The article discusses the recent history of hormone therapy for women in the U.S., and addresses the following questions:

  • Why were concerns raised about hormone therapy in the early 2000’s?
  • How are synthetic hormones different from bioidentical hormones?
  • Why does the dosage form of a hormone (for example, a capsule vs. a patch) make a difference?
  • Why is age an important factor to consider when prescribing or taking hormone therapy?

In the article, two California gynecologists, Dr. Susan Podolsky and Dr. Ricki Pollycove, also weigh in on the topic. I hope that you find it helpful!  ~Peter

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