ja_mageia

2010-08-12 Kent Holtorf MD Hormone Replacement Therapy and the Bioidentical Debate

August 12, 2010, By Kirkham R. Hamilton, PA-C
© copyright 2010, Prescription 2000, Inc.

Download as PDF | Return To Audio Interview

KIRK HAMILTON: Hi, my name is Kirk Hamilton, your host of Staying Healthy Today, and our mission is simple: To provide you credible usable health information from interviews and our educational resources to help you Stay and Be Well in the busy modern world. Please take a few moments before or after listening to this interview to browse through the Prescription2000.com website, the home of Staying Healthy Today Radio, for our free educational services.

Today's show topic is "Hormone Replacement Therapy: The Bioidentical Debate. Are They Really Safer And More Effective Than Synthetic Hormones?" Our guest today is Dr. Kent Holtorf, founder and medical director of the Holtorf Medical Group in Torrance, California. For well over a decade he has specialized in evidence based therapies for hard to treat illnesses including hypothyroidism, complex endocrine dysfunction, chronic fatigue syndrome, fibromyalgia and chronic infectious diseases including Lyme disease and chronic viral illness. In 2009 in Postgraduate Medicine he published an article entitled the "Bioidentical Hormone Debate. Are Bioidentical Hormones Estradiol, Estriol And Progesterone Safer Or More Efficacious Than Commonly Used Synthetic Versions In Hormone Replacement Therapy?" This is going to be the focus of today's interview and with a little luck we will talk about hypothyroidism, as well.

Welcome, Dr. Holtorf. Thanks so much for coming on the show today.

DR. KENT HOLTORF: Hello. Thank you.

KIRK HAMILTON: Tell me how did you get into this whole field of bioidentical hormones? How did your traditional training lead you there, or were there some unique experiences that led you there?

DR. KENT HOLTORF: Well it's interesting. When I was in medical school like most physicians, you're basically taught that you know natural, there's no evidence to it, it's not scientific and doctors who do that are kind of quackery. And I really graduated with that sense. But I started getting very fatigued and it was very difficult to do my job, and they sent me to the doctors at the university, and they kept saying, "Oh you're depressed or you're stressed," and I'm like, "I'm not depressed." And it got to the point where really talking to a patient was so tiring to me I went into anesthesia. It was like hey, they're asleep I don't have to talk to them, and I could do that! I would go do my job and go home and sleep. I started doing more research and going to a number of different conferences and started going "Wow, you know, look at what these hormone optimization. I did my own hormones and I was low thyroid, so-called the normal range, low testosterone, low growth hormone, low adrenal function, replaced those hormones and like, "Oh my gosh, I'm a new person!" And that's when I went into family practice and started practicing that way. And really looking at the literature there's so much evidence based medicine in these natural therapies and things that are so-called "alternative" and doctors will say oh there's no research. Well there's no research if you don't look. And so I had to think it is a big difference you know, with this evidence based medicine gets perverted if it's not by a drug company. And there's great research in showing there's so many ways to treat people better than what's so-called conventional. And so I kind of went from the other side, from the dark side, over to this really more enlightened, I think now really even more evidence based approach.

KIRK HAMILTON: Well how did you get into bioidentical hormones? Because you wrote, what happened was my fellow PA in the practice dropped your article off on my desk. She has a very large women's practice and I do some bioidentical hormones myself, and you had that article in Postgraduate Medicine, the review article, which the title was the "Bioidentical Hormone Debate. Are Bioidentical Hormones Safer Or More Efficacious Than Commonly Used Synthetic Versions In Hormone Replacement Therapy." And I was wondering, first of all define what a bioidentical hormone is and your personal experiences were with bioidentical hormones.

DR. KENT HOLTORF: So bioidentical hormones, what does that mean? Bioidentical means exactly the same molecule that is in your body, that's in a woman's body. It's not synthetically altered. So typically what, the way medicine works, is to be patentable it has to be a unique compound. So they'll take, for instance, you know an estrogen or progestin or progestin progesterone, which is natural in a woman's body and tweak it. So now it's a new molecule that they can patent. Then they basically do a study and say ok it's approved for, they basically show it protects the uterus, that gets approved for that. But it has a lot of different effects. So there's been a lot of evidence saying, well bioidentical doesn't have the same risk as the synthetic versions. And then when the Women's Health Initiative Study came out, and said "Oh my gosh, you know, hormone replacement increases the risk for breast cancer, heart disease!" And then you get people saying well bioidentical hormone don't have the same risks. So I said, "OK!" You know you see here Oprah talking about it and Suzanne Sommers, and then so-called experts say well there's no evidence for that. So I said, "Okay, I'm going to go review all the evidence on bioidentical hormone and really see are they safer, more efficacious than standard synthetic hormones." And so I did that, published the results in Postgraduate Medicine and found yes, there are hundreds of studies all showing that bioidentical hormones reduce the risk for breast cancer instead of causing breast cancer like synthetic hormones. They reduce the risk for heart disease, women feel better on them, and so they have significantly different effects than synthetic hormones. If it showed it wasn't I would say that. I wouldn't use them if it shows they were, you know, they weren't as good. So that's where I really wanted to get the bottom of and say hey is this true?

KIRK HAMILTON: When you talk about bioidentical hormones studies, are there any really long-term studies? In other words, I understand let's say three to five years' worth, but I mean I know really in the literature how long have people been using bioidentical hormones in the literature? Not just a clinician that I know of that I've trained from or whatever that's been doing it in practice, but in the literature how long have we been using you know topical, compounded bioidentical hormones in combination, singularly? We don't have long term studies with those kinds of agents, do we?

DR. KENT HOLTORF: Right. And you know here's the thing. So we know, what is evidence based medicine? It's been very perverted. What does that mean? Many doctors believe that it means they can be very lazy and not look at any study until it's you know 10 years long and has thousands of patients. That is not evidence based medicine because every study has its flaws, its problems with not you know, people are not studies. They're individuals. If you try to use the studies to best treat your patients. So when you look at even just physiologic studies, you look at let's say progesterone versus progestin. Now they both protect the uterus and that‘s how progestins got approved. But on the breast tissue they have completely opposite effects. The progesterone protects against breast cancer, while progestins cause it. So right there, you know, which one do you want to use? And you look at, for instance, does that fit with other conditions. For instance pregnancy. Very high in pregnancy, 50 times higher than normal. Estriol goes 1000 times normal levels. So if those hormones cause breast cancer, you think pregnancy would be a big problem and increase the risk of breast cancer. What's one of the best things to do to reduce your breast cancer risk, is to be pregnant a number of times. So you look at first physiologic data. Do they have a different effect? It's like saying well, you know, we can't say there's any difference between aspirin and morphine. You know it's just - they have totally different physiologic effects. You know why not initially use the one that has the, basically prevents cancer. Then you look at, I mean there's studies going back 30, 40 years, all showing the same thing. Now typically a long term study is considered five years and you can see how it is very difficult to do a number of 20-years studies. I mean you know we don't have time to wait. But you look at every study as shown that it reduces the risk and does not increase the risk, so why not use them, where people were surprised by the Women's Health Initiative studies. They go, "Oh my gosh, it caused breast cancer!" That was shown over and over and over and before that study came out. It was an expected outcome but people didn't read the studies. They said well there's no definitive study. Well, I don't care. If you do ten studies that aren't perfect, it's going to be much better than one so-called perfect study, because there are no perfect studies.

KIRK HAMILTON: Was that expectation because of the use of Provera in -

DR. KENT HOLTORF: Yeah. The biggest problem is the progestins. So the Provera. You're really going to increase your risk. But then you add the Premarin, which is the horse estrogen and multiple estrogens including a equiniline, now you're adding fuel to the fire. So you've taken a bad drug and made it worse. So it really was a bad combination and no one should be using that.

KIRK HAMILTON: I've been to a variety of doctor education seminars and assessment has always confused the heck out of me because you know one speaker that is into serum will do serum testing, another will be into saliva, another will be into urine. And they'll come up with three different doses for the same person. So I think that - and also delivery systems, they give different approaches. For example, my understanding and my experience has been if you give a progesterone cream it doesn't raise the serum levels that much, unless you use a lot of it.

DR. KENT HOLTORF: Correct.

KIRK HAMILTON: So the question is do you assess? Number one, how do you assess? Two, are you, if you do assess, do you try and get youthful levels or middle-age levels or ‘feel-good' levels? Or do you just shoot from the hip and do by symptoms?

DR. KENT HOLTORF: Right. That's a very good question, and you'll get a lot of different - you have five different doctors, you have six different opinions on that. And it's interesting, you know, standard medicine uses serum and then you get people - you know, "Oh you gotta use saliva" and so I did basically on every patient I did 24-hour urine, saliva and serum levels on patients for about two years and compared the results. And I found serum and 24-hour urine correlated pretty well, and saliva was all over the board. Now all tests have their limitations and that's what you have to understand. And people will hang their hat on a certain test and say this is what I believe. And so you have to be realistic. Does it basically correlate with symptoms? Now the problem with saliva tests seem to be okay for baseline symptom, but when now they become a problem is when you do for instance a transdermal cream like you said, you get saliva levels go very high, serum does not go up, so the question is what's going on in the tissue. A couple of studies did a nice thing. They did biopsies of endometrial tissue with people on progesterone cream. Saliva levels are very high, serum levels low. Which one was right? They found there was no endometrial progestin activity, progesterone activity. So it showed that saliva goes up very high with transdermal with no cellular activity. So you've gotta be very careful basing on saliva test when you're on for instance a transdermal cream. And it also goes to, let's say you give a person a hormone. They're still taking estrogen, they're still having hot flashes, and saliva level is showing high, it just doesn't make sense. And we'll get a lot of people come in, they go to their doctor and do a saliva test. They keep testing, testing, testing, and they're still having terrible symptoms. So really you want to know what's going on in the cellular level. Symptoms are key. Yes, you use levels to you know confirm that and adjust doses, but if you really know what you're looking for, symptoms are number one. And we do want to get a certain level, we know which levels are protective, for instance with estrogen. So we use basically serum levels, but you have to understand the standard ranges are not very good. A lot of times they'll say normal is zero to something. You know, how could zero be normal? And so I think all tests have their limitations and I find a lot of problems with saliva testing, especially when someone's on a transdermal cream.

KIRK HAMILTON: Well let me ask you this, because I did a similar kind of case study with you. I did saliva and serum on everybody. And I use a lot of saliva and I understand when it can be made high. But here's I guess my confusing point. And what I've observed from most clinicians. They pick out anyone of these approaches of assessment for initially, and initially they'll all relatively tell you somebody's low and then eventually they treat the symptoms. They don't - serum people - I don't see them treating to serum levels down the road because sometimes it doesn't make sense either.

DR. KENT HOLTORF: Right.

KIRK HAMILTON: And I see them treating to symptoms all the time. So I think to me that's the confusing part and to me most practitioners I see end up treating to symptom after their first initial assessment, I mean truthfully, that's my experience but maybe -

DR. KENT HOLTORF: Yeah, I think that is true and that's the thing. So the labs are a tool to get extra information. And I think if they don't correlate with the clinical picture you have to say okay, which one is giving the right information.

KIRK HAMILTON: Let me ask you this then. Are you in the camp that you're trying to raise hormone levels or move hormones - or give hormones to reduce symptom, or are you trying to do some anti-aging thing such as a Suzanne Sommers approach, or are you a Jonathan Wright that says you know mid 40s is the optimal shot? Where are you trying to go?

DR. KENT HOLTORF: I think it's kind of all the above. Yeah, it is. I think when you kind of get dogmatic about it, I think it becomes problematic. So I want to give everyone the upper 25% and that's where you're going to for antiaging and certainly optimal hormones reduces age-related disease, so-called aging. We have the term antiaging because it just, people have a bad connotation now. It's like oh what does that mean? But yeah, you want to optimize hormone levels. And you get another variable in there, is that for let's say one estrogen level, one woman's perfect, another was dying of hot flash, another woman is bloated and blown up like a balloon. So you know what level did that woman need and when she was younger for instance, the woman who are more full figured, you know large breasted, typically grew up with more estrogens, they're going to need more estrogen. So I think a combination. You typically you know higher levels. Typically maybe shoot - you know the more progesterone the better because it's very cancer preventive. You know even bioidentical estrogen, you don't want to be estrogen dominant. I think you know risk for breast cancer, so I will tend to shoot, you know the lowest amount of estrogen that's protective or reduces symptom. Want to overshoot on progesterone if anything, not under deliver, and then other ones are pretty much symptomatic. For instance, testosterone, really a little bit for some women works very well, other women need higher levels. So you know I think with your question it's kind of a variation of them all and depends on the patient.

KIRK HAMILTON: Well let me ask you this then. What are your favorite delivery systems? I mean you probably have a few pet ones. Do you start with progesterone creams or do you use an oral progesterone capsule micronized or...let's talk about progesterone?

DR. KENT HOLTORF: Yeah, I typically like oral progesterone and that's another. You know you've touched on a lot of so-called controversies and people you know are kind of in one camp or the other. We use both and I find for instance and which one's more effective. I'm certainly - I'm more - if I can do oral progesterone you get higher levels, because I think it's that's what you want to do to prevent cancer that you know you can really show that it's protective. And I know that oral progesterone's going to be more effective for things like PMS, that I can get higher levels and more effectiveness so it gives me certainly a higher comfort level that hey, we're delivering enough progesterone to those cells. Negative with oral progesterone is that you'll get metabolites and some women can get, you know sleepy. Occasionally some will be sensitive and get depression symptom. Other women it's very calming and you give it at night so they can sleep better. So you could use the so-called side effect as a benefit or a side effect.

KIRK HAMILTON: So what would be your typical doses for oral estrogens...progesterone excuse me.

DR. KENT HOLTORF: 200 mg try to do. You know so it's typically on the higher end because I think really, you want to make sure you get that protective effect of the progesterone.

KIRK HAMILTON: If you used a transdermal cream, what would be a ballpark range?

DR. KENT HOLTORF: I still try to do the 200. Yeah, but again you can't, you know - you can measure saliva. Does that really tell you what's going on? The serum levels are low, so certainly I use oral unless there's a reason not to.

KIRK HAMILTON: Tell me about your deliveries of estrogen and do you use combination estrogens, you just use plain bioidentical estradiol. What do you do?

DR. KENT HOLTORF: Yeah, so I'll use a Bi-Eest and I've found that in most people we use an 80/20. So of estriol, so estriol is the - you know for the listeners the estrogen that's a weaker estrogen but it's also evidence that it prevents breast cancer. Is there a - basically there's two different estrogen receptors, estrogen receptor alpha and beta. The beta prevents breast cell proliferation and reduces the risk for breast cancer, where alpha stimulates that, potentially can cause. Now you get things like Premarin, they'll get more of an alpha stimulator where estradiol is kind of basically 50/50. So you want to add that Estriol in there for extra protection, but it also will reduce the effect of those estradiol. So we will find a number of women come on the 80/20 and say, "Hey bioidentical hormones don't work for me." And no matter, you keeping going up and up on the levels and so now you're getting, you have to give so much more estrogen. So we've found really a 50/50 combination works the best for most patients.

KIRK HAMILTON: So that would be - what would you have then of the estradiol?

DR. KENT HOLTORF: So usually it's - we will do like a 2 mg of estriol, 2 mg estradiol, 0.5 gram a day. So you get 1 mg of each. And we find that works the most so you get more comfort level with the - adding the estriol in there. You know, is there a ton of studies showing that estriol prevents breast cancer? No, it's a lot of smaller studies, physiologic studies. It doesn't seem to have any concern of safety, so putting it in there kind of adds a little insurance policy, but we find too much you're going to reduce the effectiveness.

KIRK HAMILTON: Alright. So let's move to testosterone. How do you use testosterone and do you put it perivaginally, do you put it on the forearm, do you put it behind the knees? What do you do with it?

DR. KENT HOLTORF: Yeah, again, a number of doctors do it differently in our center. Some doctors like the cream and they like it vaginally. You certainly get more absorption, you know, vaginally versus cream on the skin. I typically like sublingual. Often we use higher dose so we will use a 5 mg you know. Some people use 1 to 2.5 mg. Typically don't have a problem with it. I mean occasionally you will, some women get acne, oily skin, then you want to back off. But then again the problem is when you do sublingually that you're getting kind of a peak and then a drop, so how do you test those levels? So it's much easier to test levels if you're doing a cream, but also here's the problem with hormones too. You look at how they work, is that they basically work on nuclear receptors so you're kind of just speeding into the system so peaks and valleys may not make that big a difference. But again it's much harder to test. While a lot of doctors like to do cream, you get more of a steady level, but again you have pluses and minuses of different delivery systems, convenience, as well as what people actually you know physiologic effects.

KIRK HAMILTON: Do you use oral or creams of DHEA or pregnenolone, or do you give those orally, or are those in your armamentaria?

DR. KENT HOLTORF: Yeah, we just do those orally. Let me mention about testosterone. We do find for the same level if you give an injection it seems to, a number of patients just have a better effect. They just feel better with it including women, you give them a little testosterone shot and they're like you know you could have very high levels with creams or sublingual or you give them a shot, they're oh my gosh, I feel so much better. It also depends on you know the levels don't tell the whole story.

KIRK HAMILTON: How often would you give a testosterone shot to a female? Would you do it biweekly, weekly, or -

DR. KENT HOLTORF: Usually we do it every week.

KIRK HAMILTON: Every week, and what would be the dose for a female?

DR. KENT HOLTORF: Probably 20 mg. And you could even do it subcutaneous.

KIRK HAMILTON: Do you utilize those same hormones in pellet insertions?

DR. KENT HOLTORF: You know we don't do a lot of pellets. The problem is you're kind of guessing the dose. You're kind of stuck with it whether it's too low or too high. But it's another option for patients.

KIRK HAMILTON: It still seems like we're treating the symptom because how do you say that for example estrogen, or let's say a bioidentical estrogen will be cardioprotective, bone protective, maybe dementia protective if we're not using these agents long term to find out. See what I'm saying? That's the part that seems, it still seems like we're treating the symptoms with agents that are safer. That's what it seems to me.

DR. KENT HOLTORF: Well yeah, but you look at the studies, of you know preventives studies and Alzheimer's, age-related, you know mental decline, even you know frailty. When you look at what really happens to people as they get older. The decline in their quality of life is they're frail. You know, and they say well they technically die of stroke or heart attack, but they're in the nursing home for 10, 20 years. And that's what we find is people on hormones, they don't have, you know that constant decline and they have much higher quality of life. And yeah, you look at studies and sometimes even the bad estrogens at a certain level, hey it's protective, but also you're getting the negative effects of increased breast cancer and your increase of heart disease because of inflammation. So yeah we have to say well okay, we're not causing the negative effects, but you know studies are showing that protective. And when you look at there's a lot of long-term studies on estradiol and you know getting higher levels of estrogen, all stand up against those illnesses.

KIRK HAMILTON: Tell me about your use of DHEA and pregnenolone and how you use them, and is that in your bioidentical armamentarium.

DR. KENT HOLTORF: Yeah, I think we certainly replace it and to more optimal levels. Is it one of the things that people go "Oh my gosh, I feel so much better?" No, generally not. I mean, it's - some people do feel better with a little DHEA and say it made my memory a little better with pregnenolone. We'll bring it to more optimal levels, but it's not something we will sit there and test every time and adjust it until it's perfect. Some people come in, they're so low, let's bring it to more healthy levels. And are there a lot of great studies on that? No, but in these studies even with stroke now, they're starting to, you know, give high dose progesterone and pregnenolone preventing basically, when someone has a stroke, the neuronal damage. So a lot more exciting stuff is coming out with the hormones as well.

KIRK HAMILTON: Tell me about lifestyle in your hormone replacement regimen. Does it get so busy trying to replace the hormones and all the other things, that lifestyle gets put the wayside, not intentionally, just you know people have so much to do, or you really hammer lifestyle in these people?

DR. KENT HOLTORF: Right. I think we're the former. I think lifestyle is very important, but you know we spend an hour with patients talking about the hormones. Typically they've gone through the lifestyle, they've gone through the diet, and as soon as you bring it up, they're like "Don't even go there!" I've already - it's not what they're coming to us for, and so we're there to help them with the hormones and all of a sudden hey now they feel better, they can do those other things. And when you find that someone, they're dieting and exercising, they don't lose weight and they're like forget it. Why even do it? So you optimize their, especially their thyroid or their hormones and they're like, "Oh my gosh, it's actually doing something now," so now they're motivated to do those other things.

KIRK HAMILTON: Well I'd like to close with the discussion on thyroid. I saw that you have a nonprofit institute for thyroid education. Can you describe that a little bit? And then I want to ask you a few questions on thyroid.

DR. KENT HOLTORF: Yeah, so it's the National Academy of Hypothyroidism. So it's a nonprofit site at NAHypothyroidism.org. And what I really wanted to do with this. There's so many sites that are, that have good information, it's like hey standard blood tests aren't reliable. But they're not well referenced and you get, you know they go to their endocrinologist. They know your TSH is fine, your thyroid. You don't need thyroid, and you look at the studies. The studies show that they will miss 80% of people with low thyroid, especially if they have diabetes, insulin resistance, if they're dieting, any chronic illness, inflammation, and but that just gets the people - the studies are there but no one refers to them. So we wanted to do an extensive review and have it here so people can - the patient can say look at. You know, walk into the doctor textbook symptoms of low thyroid, the doctor says no it's not your thyroid, you need to diet more and eat less and exercise more. But no, you need to look deeper at their thyroid. So we wanted to put a well referenced scientific site, you know nonprofit, so we're just there to give the information for patients and I think it's just the way we're treating thyroid in this country is just very poor. So that was the goal of the - strictly education for that site.

KIRK HAMILTON: Well let's jump into that then. Do you consider a thyroid a bioidentical hormone? In other words, do you use a desiccated version or do you use a combination of synthetic T3 and T4 or what do you use?

DR. KENT HOLTORF: That's a good question. What again does natural mean? What does that mean? Does it mean pig, does it mean human? And just like bioidentical hormones, I mean there's synthesized in the lab, so T4 and T3, we'll typically use - we don't use a lot of Armour. We will use it. We use it, because we use a lot of straight T3. Most, you know, standard physicians will give T4, which is inactive thyroid, and we're finding that the low thyroid problems really aren't a problem with the thyroid gland. The problem's with the local cellular control of the thyroid. So the body, with any stress, if it's with depression, insulin resistance, the body will basically up-regulate enzymes that will reduce T4 to T3 conversion, so now the T4 doesn't work very well. But you know the most important aspect that's rarely talked about, and there will be a big article on this next week, is transport, thyroid transport. And it may get a bit technical, but I think it's very important. We used to think, we were taught in medical school that you have T4 and T3 in the serum, those diffuse into the cell. Then so whatever's in the serum is in the cell. Shown totally not to be the case. Totally inaccurate. There's active transporters. So what is found is T4 and T3 have different transporters. And the T4 is much more energy dependent. With any low cellular energy states including fibromyalgia, chronic fatigue syndrome, insulin resistance, any inflammation, that gets dysfunctional. So now T4 doesn't get into the cell very well and that's you know get lower levels, intracellular thyroid levels. But also, but the pituitary has completely different transporters. It doesn't get affected. So with any of these conditions, the TSH - the pituitary sees the thyroid, so TSH goes down, T4 goes up because it's not getting into the cell. People go, "Oh you're high thyroid." Actually it's low thyroid. And the classic case of this is depression. You look at the studies on depression. They have low normal TSH, high normal T4 and even the studies go oh they're kind of hyperthyroid. No, we wonder why T3 is a, you know, the STAR*D Report, largest study on depression. It's a better treatment than antidepressants because you're low thyroid. And so we need to look deeper at the test and look at, hey what's the best marker for cellular levels of thyroid.

KIRK HAMILTON: For the regular clinician, then, are you measuring free T4, T3 and TSH levels?

DR. KENT HOLTORF: Yeah, we do everything.

KIRK HAMILTON: Reverse T3 as well, all the time.

DR. KENT HOLTORF: Currently I think if you look at the data, what is the - we want to know what is going on in the cell when we have our blood tests. Now the pituitary is what we use to measure the rest of the body, but it's probably the worst tissue to use because it's completely different than every cell in the body. The data is showing that probably the best marker for cellular levels of thyroid is the free T3, reverse T3 ratio.

KIRK HAMILTON: Okay, and what are you trying to drive that to?

DR. KENT HOLTORF: Really it depends on the units, but we want that to be above 2.

KIRK HAMILTON: T3 over - okay. Free T3 over the reverse T3. Then if let's say you have a serum T3 level, let's say the upper range is 420, let's say. And you drive it to 4 or 500. Does that bother you, or are you trying to stay at the upper range of the normal?

DR. KENT HOLTORF: No, again the big problem is what's going on in the cell. And if you get with any of these you know chronic inflammation, chronic illness, insulin-resistant diabetes, they don't have transporters into the cell. So you may need much higher levels. Now also a normal level is when you have, let's say you're not getting any thyroid, your thyroid basically secretes mostly T4, goes into the cell a little bit, diffuses out back into the serum. But now you're giving T3, it's going to go high in the serum and then into the cells. So you're really not even checking the same thing. Those normal ranges don't apply.

KIRK HAMILTON: Alright. So does it matter - so when you do your T3 and reverse T3 measurement to get the ratio, are they not taking their thyroid that morning, or are they taking that?

DR. KENT HOLTORF: Correct.

KIRK HAMILTON: They're not.

DR. KENT HOLTORF: And that's the problem. If you take T3 and you check it within you know eight hours so it's going to be higher, it's, "Oh my gosh they're hyperthyroid," and they're like well no, their pulse is you know 54, and they're freezing cold and then all of a sudden they're low thyroid. So that's the problem with serum tests. They're a piece of information, but when you just use those and rely on those, but it certainly doesn't mean ignore them.

KIRK HAMILTON: Do you give a sustained release T3 in a set q12 hour regimen or how do you do it?

DR. KENT HOLTORF: Here's the big problem. And if you look at a lot of sites, they say time-release T3 doesn't work. And they're somewhat right because the standard formula for thyroid, it just doesn't absorb very well. The formula, they'll use PCCA, the service that gives a lot of good formulas, but their thyroid formula is not very good, and about you know a number of, a significant amount of patients won't absorb it. And they need very high doses and it just doesn't work. And I've worked on that for a number of years. We've found a much better formula, and I got it to a certain point. I worked with a pharmacist until we eliminated the binders in there that were really reducing it, and I really think we were able to improve the time released T3 preparation.

KIRK HAMILTON: So do you give it once a day then?

DR. KENT HOLTORF: Yeah. So all we need is once a day and we worked with American Integrative Pharmacy.

KIRK HAMILTON: And what's your kind of therapeutic dose range, just a ballpark with the T3?

DR. KENT HOLTORF: It depends. Some people, you know, 10, 25 to 200.

KIRK HAMILTON: And then you used ratio to determine -

DR. KENT HOLTORF: Yeah. For instance, you look at the you know studies by Lowe on fibromyalgia. He found the average thyroid dose to relieve symptoms was about 100 over 100 mcg.

KIRK HAMILTON: You're not having any "hearts jumping" out of the chest, huh?

DR. KENT HOLTORF: That's the thing. You can't just put people on that. And another problem you have is that you get thyroid resistance, but the heart gets less resistant. So you have to be careful as that all of a sudden the heart, you get the pulse too high. You know, the heart's seen the thyroid, but the rest of the body is not, then what do you do? So, that comes into the part where hey if you can relieve all of their other illnesses, the thyroid would be fine. So that's why typically thyroid's a great treatment but you know often times just by itself, it's certainly has limitations.

KIRK HAMILTON: Well let me close by your comments on iodine. Do you use iodine or do you do the combination iodide/iodine?

DR. KENT HOLTORF: Yeah, we use the combination.

KIRK HAMILTON: And are you doing a challenge test or do you just kind of give it as a standard dose, let's say 6.5 to 50. I mean there's a range there that people can --

DR. KENT HOLTORF: Right. Yeah, well we typically do a urine test for iodine. I don't typically use a challenge test. They could just - you know, I think there's all different ways and it's a matter how much is, the hassle factor, logistics. We'll do urine test and then give iodine to supplement. I think you need to be careful of you know Hashimoto's. It can flare it initially so you want to be careful with that and go slow.

KIRK HAMILTON: Okay. Any last things you'd like to comment on?

DR. KENT HOLTORF: No, I think we got through a lot of information.

KIRK HAMILTON: I was going to ask you about the adrenal, but we'll save that for another time.

Okay, Dr. Holtorf, thank you so much for coming on the show today, and thanks for taking the time to explain it. It's a complex topic and it evolves.

DR. KENT HOLTORF: It is. It really is. And I think you know the more we get doctors looking at this information, the better. We'll get better care in this country.

KIRK HAMILTON: Okay. Thank you so much.

DR. KENT HOLTORF: Thanks so much.

KIRK HAMILTON: And I want to thank you the audience for listening to this edition of Staying Healthy Today Radio. And until next time, Stay and Be Well.

No part of this interview may be copied or reprinted in any form, electronic or print, without written permission from Prescription 2000, Inc.