Prepared for second year medical students - a discussion of the medical claims made by popular health trendsetters in the press, why large audiences flock to these 'news' outlets, how this impacts health literacy of the population, and the role of medical practitioner to promote health and health literacy.

1. Northwestern University Feinberg School of Medicine
Adrenal Fatigue and
Bioidentical Hormones
Endocrine Health and Society
Daniel Toft, MD

2. Learning Objectives
1. Review the importance of health literacy for providers,
patients, and systems
2. Review the popular definitions of adrenal fatigue
syndrome and bioidentical hormone replacement
3. Consider the scientific evidence
4. Consider some of the personal and societal factors that
make these topics popular
5. Discuss the role of health care providers in promoting
health literacy of their patients and society

3. Case – 52 year old woman
In May at her gym she had a panel of labs obtained. Found to have very
high E2 levels (412 in follicular phase), saw her gynecologist who
identified an ovarian cyst that was removed in Aug (unilateral
oophorectomy), benign reportedly.
Tired, cold all the time, weight up. Questions about TFTs, cortisol, E2.
No matter how much she sleeps very fatigued; always very cold for years
now. She can get 9 hours and is still not rested. 15# sudden weight gain
several years ago; again 7# up since the ovarian cyst. Was having
periods prior to surgery but irregular; none since. She does not think she
could be pregnant. Having some night sweats but still cold.

4. Case – 52 yo woman
ROS: Awakens to use the rest room. Frozen shoulder pain was also
awakening her. She does not snore. No napping. Boxes, Pilates, 2-
4days/wk working out; used to work out more and felt better when she
did so. No work travel. Carries a heavy bag for work - pharma rep, bag
full of literature. Cooks for herself, higher protein diet, did Atkins years
ago maintaining weight 135 for 10 years. A little depressed - a vicious
cycle, fed by weight gain.
She is worried that she has an endocrine problem contributing to her
fatigue mood and weight gain (“Is it my thyroid? Adrenal fatigue? Just
menopause?”) . She plans to have a colonoscopy. Concerned that her
lipids are not as well controlled now on Lipitor; was on Crestor before.

5. Case – 52 yo woman
No Known Allergies
MED: Lipitor, Advair, Singulair, meloxicam prn shoulder pain
PMH: HL, Allergy induced asthma, Frozen shoulder
PSH: unilateral oophorectomy, chin ganglion cyst removal
FH: F-MI age 57, M-lung cancer, bro-MI age 50, sis-well, no kids
SH: Lives with husband, pharmaceutical sales, no tob

6. Case –52 yo woman
BP 114/72, pulse 80, resp. rate 12, height 5' 5”, weight 161 lb, BMI 26.79
Gen: NAD, A&Ox3, well-nourished, well-developed, full range of affect, tearful
when discussing mood.
Eyes: EOMI, no pallor, anicteric, no lid lag, no proptosis, no xanthoma
ENT: MMM, OP clear
Neck: no LAD or bruit, no acanthosis nigricans
Thyroid: normal size, no nodules
CV: RRR, normal S1S2, no s3/s4/m
Lungs: CTA B no wheeze
Abd: NABS, soft, ND, NT
Ext: no LE edema. pulses 2+ symmetric. no tremor.
reflexes: 2+ without delay
May 2013 thyroid function tests normal, AM cortisol 11, E2 >400, LH/FSH normal,
total chol 210 LDL 120 HDL 88 Tg normal

7. Case – Summary
52 year old woman with
• 3 months of amenorrhea
• 7# weight gain
• Fatigue
• Down mood
• Night sweats
• BMI 26.8 otherwise unremarkable exam
• Endocrine testing normal

8. Case – Diagnosis?
There’s nothing wrong with her
Adrenal fatigue
Hypothyroidism
Perimenopause
Other suggestions?
Mood disorder
Primary sleep disorder

9. Dr. Oz Video on Dealing with
Menopause Symptoms
http://www.oprah.com/health/Learning-to-Deal-with-
Symptoms-of-Menopause-Dr-Oz-Video

10. What messages are you
hearing?
• Quality of life is important
• Women are searching for solutions
• Menopause is a disease
• Shot adrenals are part of menopause and this
can’t be measured
• The normal range is irrelevant

11. #2359 selling book

12. Fam Med 2012
Teaching Health Literacy

13. Health literacy is more than
communicating in plain language
• Plain language is one means to communicate
effectively, but plain language, health
communication, and health literacy are not
synonymous.
• Health literacy encompasses much more than
plain language, reading, writing, numeracy, and
effective communication between health
professionals and the public.
The Calgary Charter on Health Literacy: Rationale and Core Principles for the Development of Health Literacy Curricula. 2009

14. Health literacy defined:
 Health literacy allows the public and personnel working in
all health-related contexts to find, understand, evaluate,
communicate, and use information.
 Health literacy is the use of a wide range of skills that
improve the ability of people to act on information in order to
live healthier lives.
 These skills include reading, writing, listening, speaking,
numeracy, and critical analysis, as well as communication
and interaction skills.
The Calgary Charter on Health Literacy: Rationale and Core Principles for the Development of Health Literacy Curricula. 2009

15. Health literacy applies to all
individuals and to health systems.
 An individual can be health literate by using the skills
needed to find, understand, evaluate, communicate, and use
information.
 Health care professionals can be health literate by
presenting information in ways that improve understanding
and ability of people to act on the information.
 Systems can be health literate by providing equal, easy,
and shame-free access to and delivery of health care and
health information.
The Calgary Charter on Health Literacy: Rationale and Core Principles for the Development of Health Literacy Curricula. 2009

16. Situations in which health literacy is critically
important for individual users, health care
professionals, and health systems include:
• health system reform efforts
• understanding health issues
• preventing poor health
• communicating complexity
• culturally appropriate communication
• behavior change efforts
• health promotion
• navigation of health systems
The Calgary Charter on Health Literacy: Rationale and Core Principles for the Development of Health Literacy Curricula. 2009

17. Case – Diagnosis?
There’s nothing wrong with her
Adrenal fatigue
Hypothyroidism
Perimenopause

18. Case – JC Diagnosis?
There’s nothing wrong with her
Adrenal fatigue
Hypothyroidism
Perimenopause

19. Why Does Your Energy
Level Fluctuate?
http://www.oprah.com/health/Dr-Oz-Reveals-
Common-Energy-Problems-Video

20. Low energy is caused by
• Insulin resistance
• Viruses
• Sleep deficit
• Hormone imbalance – “slow functioning adrenal
and thyroid glands” manifested by high cortisol
levels caused by stress

21. #2124 selling book

22. #266,511 in books

26. Adrenal Fatigue
Causes:
• Long-term mental, emotional, or physical stress
Symptoms:
• Tiredness
• Trouble falling asleep or waking up
• Salt and sugar craving
• Needing stimulants like caffeine to get through the day
Etiology:
• In the setting of long-term stress, the adrenal glands
cannot keep up with the body’s need for stress hormones

27. Adrenal Fatigue
Diagnosis:
• Symptoms
• Serum or salivary cortisol levels
Treatments:
• Sleep
• Exercise
• Avoidance of tobacco/alcohol
• Vitamins and supplements
• Adrenal/pituitary/hypothalamic “extracts”
• Corticosteroids

28. Adrenal Fatigue – Myth vs. Fact
• “Adrenal fatigue” is not a real medical condition. There are no
scientific facts to support the theory that long-term mental, emotional,
or physical stress drains the adrenal glands and causes many
common symptoms.
• Adrenal insufficiency is a real disease diagnosed through blood tests.
• There is no test that can detect adrenal fatigue.
• Supplements and vitamins made to “treat” adrenal fatigue may not be
safe. Taking these supplements when you don’t need them can cause
your adrenal glands to stop working and may put your life in danger.
• The symptoms attributed to AFS deserve thoughtful consideration and
may be manifestations of adrenal insufficiency, depression,
obstructive sleep apnea, or other health problems.
http://www.hormone.org/hormones-and-health/myth-vs-fact/adrenal-fatigue

29. Case – Diagnosis?
Adrenal fatigue
Hypothyroidism
Perimenopause

30. Hypothalamic-Pituitary-Ovarian Regulation
Hypothalamus
- +
GnRH
Pituitary
Ovary
+
-
LH FSH -
Estrogen
Progesterone
Folliculogenesis
Inhibin (Activin, Follistatin)
Activin ↑
Follistatin ↓
Inhibin
+
Estrogen
Progesterone
Estrogen
Stress
-

31. Menses Follicular phase Luteal phase Menses

32. Menopause
• Permanent cessation of menstrual periods,
defined as no cycles for 12 months
• Average age is 51
• Low estrogen and high FSH biochemically
• Perimenopause refers to the time around
menopause – typically starts 4 years before
cessation of menses

33. Perimenopausal symptoms
• Irregular menstrual cycles
• Marked hormonal fluctuations
• Hot flashes
• Sleep disturbances
• Mood symptoms
• Vaginal dryness – can cause dyspareunia
• Joint pain

34. How to treat menopausal
symptoms
http://www.oprah.com/health/Dr-Oz-Talks-with-Dr-
Prudence-Hall-About-Bioidenticals

35. What what?
• Menopause is a disease
• Progesterone prevents cancer
• Estrogen and testosterone are necessary for libido
• 35 yo hormone levels are the goal
• Bioidentical hormones decrease death; synthetic
hormones cause death

36. What are bioidentical hormones?
Identical in molecular structure to endogenous hormones:
• 17-beta Estradiol (E2), estrone (E1), Estriol (E3)
• Progesterone
• Testosterone
However, all are synthesized chemically.
• Molecularly identical hormones typically start with
chemicals extracted from soy and yams
• “Synthetic” hormones typically come from animals

37. Bioidentical hormone therapy: clarifying the misconceptions. Cleve Clin J Med. 2011

38. Compounding
Bioidentical hormone therapy: clarifying the misconceptions. Cleve Clin J Med. 2011

39. Bioidenticals – key points
• Hormone therapy is indicated for relief of menopausal symptoms;
claims of reversal of the aging process are unsubstantiated.
• Products that are custom-compounded are not regulated by the US
Food and Drug Administration and therefore carry no assurance of
purity, safety, or efficacy.
• Transdermal progesterone creams may not achieve high enough
serum levels to protect the endometrium.
• Hormone therapy is titrated on the basis of symptom response.
Measuring hormone levels in saliva is not called for and is probably
not reliable.
Bioidentical hormone therapy: clarifying the misconceptions. Cleve Clin J Med. 2011

40. Case – JC
Adrenal fatigue
Hypothyroidism
Perimenopause!

41. Case – JC
Plan:
• Open discussion of her lab results
• Discussed perimenopausal symptoms and changes
• Discussed the potential risks and benefits of combined
estrogen and progesterone replacement
• Encouraged continued regular exercise

42. Final thoughts
Health literacy includes an awareness of and ability to
navigate differences between the cultures of the health
system and the public. It also includes an awareness of and
ability to minimize the power imbalances between the health
system and the public.
Health literate health professionals and systems are those
that allow and encourage patients to feel welcome and
empowered to ask questions, that deliver information in
ways that people can use, and that proactively take the
steps to prevent ill health and provide treatment to all people
in need.