Nancy Onyett, FNP-C

Andropause Male 'Menopause'

Andropause also known as male androgen deficiency syndrome is the male equivalent of female menopause.  It results from diminished levels of testosterone in the body and exhibits a similar symptom complex to female menopause.

Testosterone is a hormone secreted by the ovaries, adrenal glands and testes.  It is the primary male sex hormone, responsible for male sexual development and critical in maintaining erectile function, libido, normal energy levels, and mood.  Testosterone also controls a wide range of physiological functions throughout the body systems. 

When a man is in his thirties, the testosterone level starts to decline slowly and when a man reaches eighty it is only 1/5 of what it was in his youth.  In addition to aging, stress plays a role in declining testosterone levels.  While the total testosterone level does not drop drastically the free testosterone, which is the biologically active form, does decline significantly with age.  Men with increased estrogen levels (due to obesity, a high-fat diet, alcohol consumption, and low levels of serum zinc) along with insulin resistance can further reduce free testosterone levels. 

 The number of men in the U.S., between the ages of forty-five and seventy years old, is expected to increase from forty-six million in 1990 to eighty-one million by 2020.  Currently more than five million men in the United States suffer from the effects of hypogonadism or low testosterone levels. 

In men, andropause symptoms appear over a longer period of time due to the gradual decline of testosterone; however, in women  menopausal symptoms occur sooner with the decline in estradiol.  Andropause symptoms present slowly, with a loss of overall energy, thinning bones and muscles, increased body fat, depression, and impaired sexual function.  Testosterone deficiency has also been linked to hypertension, obesity and heart disease.   Men, who have a history of  heart attacks often have lower levels of testosterone and higher levels of estrogen.   A  low free testosterone is an independent predictor for the degree of coronary artery disease in men.  Also, low free testosterone is a common characteristic in men suffering from heart failure.  Testosterone replacement has been shown in the literature to increase cardiac output in some men with congestive heart failure; however, the free testosterone level must be monitored carefully  to prevent problems developing from the hormone.

 One way for both men and women to help maintain and increase the free testosterone level  is by reducing excess body fat through weight-training. Also, lifestyle changes that include avoiding excess alcohol and high-fat diets, high intake of soy products, and caution with drugs that impair liver function, along with stress management helps to raise free testosterone.  Testosterone replacement therapy can dramatically augment the benefits of these lifestyle changes. It is very important to avoid over-the-counter agents promising to improve testosterone levels, such as androstenedione.  Also, over the counter testerosterone products are not effective and can raise liver function tests.  

In general, when testosterone is replaced  for andropausal men it has the potential to prolong the quality-of-life by decreasing the diseases of aging.  Testosterone does protect against cardiovascular disease; it can raise HDL cholesterol, and lower LDL cholesterol levels.  It may decrease blood pressure, excess body fat, and symptoms of arthritis.  Testosterone replacement stimulates the cardiovascular system, the neurologic system, muscles, and bones.  It may protect against Alzheimer’s dementia, type II diabetes, osteoporosis, muscle wasting, loss of libido, erectile dysfunction, inflammatory-related diseases and a range of cardiovascular diseases.

Testosterone replacement consists of a twice daily application with a weight-dosed testosterone cream or by injection every two weeks. I generally, do not use the injection due to the peaks and valleys since it is a two week drug. Also, it does not allow the the cholesterol benefits for cardiac protection and lastly due to the esther it has stimulatory effect on the renin-aldosterone system in the kidney producing more water retention which can be a problem in cardiac patients. Testosterone cream is very effective and gives a consistent free testosterone level if the cream is appropriately applied twice a day.  Serum levels are checked  frequently for hormone optimization with symptom improvement.

The Perils of Medical Marijuana in Arizona

In November 2010 Arizona voters won by a narrow margin for legalizing medical marijuana. Since then Arizona policymakers with assistance of the pain society wrote the statutes for use of marijuana. In Article 2 , R9-17-201 a patient must have one of the following debilitating conditions diagnosed by a physician to qualify for registration to obtain a medical marijuana card.

1. Cancer

2. HIV

3. Glaucoma

4. AIDS

5. Hepatitis C

6. ALS

7. Crohns disease

8. Alzheimers disease with agitation

9. Cachexia or wasting syndrome from a chronic medical disease

10.Chronic pain from a disease

11. Chronic nausea from a disease

12. Seizures from a chronic disease including those in the form of Epilepsy

13. Severe persistent muscle spasms from a chronic disease characteristic of MS.

14. Lastly, an added disease that is debilitating in ADL's with substantiation that medical marijuana will be of palliative benefit through description of the disease and patient afflictions along with peer reviewed articles for benefit.

The above patient physician relationship must be fully documented with history, physical exam, diagnosis and the reason for medical marijuana in palliative care. At any time, a physician can request a card holder to be revoked from their medical marijuana card based on evidence of diversion, no benefit, and noncompliance.

The irony in medical marijuana; it is still against federal law. Secondly, there are no scientific evidence based medicine guidelines for efficacy in treatment of pain with dosing, effects of marijuana on the pain receptors and benefit vs harm. Therefore, the DEA classifies medical marijuana as a Controlled substance Class I and an illegal substance for medical use based on no scientific evidence. The Federal Prosecutor issued a warning to Arizona State Health Department on May 3,2011 stating cultivators, patients, and caregivers are breaking federal law. http://the420times.com/2011/05/arizona-federal-prosecutor-warns-state-about-medical-marijuana/. In Rhode Island, Maine, Colorado, and California there are documented reports of cultivators and patients prosecuted along with physicians in some states.

The AMA still firmly stands against endorsement for medical marijuana and state regulated marijuana programs. In November 2009, the AMA called for the federal government to ease the restrictions with marijuana for more scientific research. http://www.cbsnews.com/8301-503544_162-5614233-503544.html However, the AMA stands firm in not endorsing it.

The Arizona Pain Society has not endorsed medical marijuana and the Arizona Medical Board policy for Pain Management as endorsed by American Pain Society and the American Academy of Pain Medicine has not endorsed medical marijuana.

How does all the controversy with the boards and laws exist amongst practicing physicians in Arizona. It is easy either they prescribe or they don't. Most of the ones I talked with at the Arizona Pain Society/ Medical Marijuana Conference were against medical marijuana. It is a harm rather than benefit to the public and a drug that can easily be diverted. It will be hard for patients to find a physician in Arizona to prescribe it. Physicians and nurse practitioners adhere to the guidelines with Board of Medicine and the Board of Nursing in prescribing opioids. Those patients who do receive their medical marijuana cards will be reinforced to stay with their physician for pain management due to medical liability with marijuana detection in their urine.

The Medical Marijuana Program is new to Arizona and only passed by a margin of the voters. Most medical professionals and societies for pain management are against it due to the lack of scientific evidence. There isn't a reason to give a patient an addictive substance when pain medications can be manipulated for better pain control. Over the next few years we will watch how the Board of Medicine, and the Arizona Pain Society deals with this issue. I doubt anything will change in policies and guidelines. It is a hard drug to do research for evidenced based medicine.

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Human Growth Hormone

In Age Management medicine, human growth hormone has a place in treatment for conditions of deficiency. In the older adult an IGF1 < 175 accompanied with signs/symptoms of aging are the criteria to treat and improve many of these contitions. In review sign/symptoms of aging include fatigue, decreasing energy, diminishing drive for activity, socialization, memory impairment, poor sleeping, thinning hair, wrinkling, loose skin, centripetal fat deposition, decreasing strength, cardiovascular disease, decreased bone mass, hyperlipidemia, and insulin resistance. Generally, it is the signs and symptoms of aging with age related diseases. The benefits of growth hormone replacement include improved vitality, cardiovascular function, improved lipolysis and helps to reverse the signs/symptoms of aging towards health and vitality.

Growth hormone is titrated in slowly via injection daily for optimal range per blood work. Blood levels fluctuate throughout the day and requires blood work to be done at different times for safety in dosing. This is a critical aspect in compliance on the patient's part to contribute to their health. The blood work is evaluated and dosing adjustments are made for optimal IGF1 ranges. Growth hormone is safe, there is not a study in the literature that negates it; although, it is one of the most feared and under known of hormones. The only contraindication to growth hormone is cancer. One reason why patients are screened with history and physical exam along with blood work and advanced testing for risk factors before being administered growth hormone. Patients must keep up with their current mandatory testing and screening for cancer yearly including, PSA, prostate exam, mammogram, and pap smear. Colonoscopy is a must baseline and as recommended by gastroenterology for frequency in follow up colonoscopies.

Anyone over 50 years old who has been on hormone supplementation and still feeling signs/symptoms after six months of therapy are candidates for growth hormone if their IGF1 is < 175 and determined by their health care provider. Growth hormone is a healing hormone often used in burns and trauma. It is elective in age management medicine, because it is not medically necessary therefore insurance does not cover it. If it wasn't so costly, more elderly patients would be using it.

Side effects associated with growth hormone administration include edema, insulin sensitivities, and carpal tunnel syndrome. These side effects are easily corrected with dosing adjustments from the provider. What is important to know is growth hormone does not cause cancer but if someone has a cancer and takes growth hormone then the cancer will grow. Again, that is why careful screening, with history and physical, lab work and advanced testing is critical to health and safety before growth hormone administration. Elderly patients who are interested in growth hormone must see an age management provider.

 

 

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Chronic Disease: Acquired or Genetic

More than one-third of the American population is chronically ill. That doesn’t factor in the idea that you can be 80 percent not well before the first symptoms of disease manifest. Even if you have no outward signs of disease, you may still be heading into a downward spiral that will cause chronic disease later in life. It may take twenty years for enough tumor cells to show up on an x-ray or mammogram. At the time of the diagnosis, you’re at the end stage of a healing crisis, not the beginning. Your arteries could be 90 percent occluded before you experience the first symptoms of angina or some other condition. It might take forty years for an occlusion to get that bad. You’re told it was caught early, when, in actuality, you got it at the end. So, we’ve got possibly another 100 million people walking around who are processing disease that is not yet diagnosed. Then we have another 50 million people who have the early stages of disease. These are our youth.

Most of what we call aging is simply the presence of disease – chronic, seemingly ubiquitous disease that makes us age with such apparent time-dependent consistency that we accept it universally as “simply getting older.” Estimates suggest that up to 90 percent of adult illness is due to the degenerative processes of aging. Despite commonly held beliefs that aging is mostly out of our control, inherited genetics accounts for less than 30 percent of all aging effects, and the importance of genetic inheritance matters less and less the older your calendar age. By the age eighty,behavioral choices account almost entirely for a person’s overall health and longevity.

More than 65 percent of annual American deaths are attributable to heart disease, cancer, and stroke. These three diseases,degenerative diseases of aging, consume more than fifty percent of the U.S.health-care budget. Moreover, health care costs are increasing at double-digit rates each year. The trouble is we have little to show for it. Any improvements in the incidence of heart disease have been because of lifestyle improvements, not medical ones. The same is for cancer.

Prevention is the only vehicle that will account for change. If we really want to make an impact on health care in this country and throughout the world, the focus must be on preventing the degenerative diseases of aging. Instead of micro-managing disease, we should focus on macro-managing wellness. Ninety percent of first heart attacks result from preventable lifestyle choices. The same is true of type II diabetes. The overwhelming majority of cancers are avoidable. These diseases along with many others, such as Alzheimer's disease, are not a component of natural aging. Rather, they are a form of pathological aging that results from a lifetime of unhealthy choices. If we can slow the physiologic processes of aging we can alleviate more than 50 percent of all disease overnight. We can alter this dreadful course by preventing, delaying, or reversing the diseases associated with aging.

Only a small percentage of the American population is truly healthy. And it is no accident that they are healthy. They work at it. So when will you change? You are most likely to change when you lose it all, when you realize one day that you’ve made the wrong choices. Think of how many times you changed because you lost everything. Breaking old habits takes courage. It begins with mindfulness – attention and intention. You can make the mindful decisions to make the changes in your life to grow younger, not older, with each passing day.

[Adapted from Gary Null’s
Ultimate Anti-Aging Program. Gary Null,
PhD. Broadway Books, 1999]

Aging and Hormones

What is aging and the diseases that accompany the aging process? Aging is closely tied to the endocrine system when hormones start to decline  and the internal organs have decreased functioning.  In early states,  the changes include decreased protein synthesis, a decline in immune function, a loss of muscle mass, bone density and an increase in fat mass. The increased fat mass contributes to insulin resistance and cellular oxidation. Slowly, chronic disease states are manifested with diabetes, hypertension,  high LDL, low HDL, dementia, degenerative arthritis, osteoporosis, coronary artery disease, and cancer. The end result is overall declining health and eventually death. 

Hormones are produced by the endocrine glands with the decline starting around 35 years old in both men and women. The symptoms can have an insidious onset in each sex. In men,  there are erection problems, low libido, fatigue, low energy, insomnia, depression and male balding pattern. In women symptoms can range from increasing premenstrual syndrome distress, fatigue, irritability, weight gain, insomnia, irregular periods, heat or cold intolerance, increased hair shedding, loss of sexual desire, vaginal dryness, dry wrinkling skin and depression.

In Allopathic Medicine, we are problem oriented to treat the disease state but in Age Management Medicine we focus on prevention of diseases and increase the healthspan to a lifespan in individuals. This is accomplished through restoring all hormones to a 25-30 year old level with blood level monitoring. Natural hormones are prescribed which have identical molecular structure to the human body. These are extracted from yams and soy and compounded to a individualized dosing regimen for Estradiol, Progesterone, and Testosterone. The thyroid is optimized with Armour throid  which is more bioavailable than Synthryoid and Levoxyl. DHEA is replaced and optimized by blood monitoring. Pregnenolone and Melatonin are replaced for sleep and memory but do not require blood monitoring.

American College of Gynecology guidelines for hormone replacement therapy have unfortunately confined its use to short-term symptom treatment only, using the lowest dose possible. A better understanding of the conflicting evidence in hormone therapy suggests that hormone replacement  provides significant health benefits and disease protection for many women if begun early in menopause. The PEPI trial in 1990 with 875 postmenopausal women proved the safety and efficacy of natural micronized progesterone combined with estrogen for the best cardiovascular protection. Other health benefits from this trial were less weight gain with women taking hormones after menopause, an increase in the HDL  and protection against endometrial cancer. Later studies with natural Estradiol and natural micronized Progresterone have shown protection against cardiovascular disease, osteoporosis, alzheimers disease, urogenital atrophy, colon cancer, endometrial cancer and hypercholoesterolemia. Also, hormone therapy helps to prevent depression, fatigue, incontinence, weight gain and the loss of feminity.

When hormones are started and titrated to acceptable levels withing the parameters of a 25-30 year old range there is no need to stop; unless, there is a new cancer development. If hormones are stopped it is psychologically deteriorating and it induces symptoms of menopause and andropause. Also stopping hormones  reverses  the aging process with risk for adult onset disease states.  When providers practice under evidenced based guidelines for Age Management Medicine they are providing improved health for their patients.

 

 

"The Fighter" , An Athlete's Perspective

After reading many critic reviews, I knew there would be more drama in "The Fighter" but I didn't expect it to be a slow paced melodramatic noncompetitive, monotonous flick!  The four of us competitors decided to see the movie thinking we would gain some competitive aspirations.  After the first fifteen minutes, we were looking at each other realizing the star was Christian Bale, who captivated our attention in his crack head role as Dicky, a useless trainer to his brother, a Welterweight champion, Micky Ward.  I must say, as competitors we were disappointed in Mark Wahlberg’s passive submissive role to his useless family and his lack of internal drive with a competitive focus.  He was a wimp, a follower!

However, I realized after leaving the movie there were some take home messages. The most profound message was negative emotion (a loss of spirit) which Mark Wahlberg did portray accurately in his Micky Ward role. In reality, overwhelming emotion that is not channeled appropriately can cause a competitive athlete to suffer despair, confusion, and a true loss of spirit physically, mentally, and emotionally.  I quickly related these messages to our world of competitive bodybuilding.  A very important aspect in our lives as competitors is harmony and consistency; although, at times there are harsh life circumstances that we can't avoid. Too often families take a back seat because they are the biggest distraction in a bodybuilder’s life and one that has to be put into perspective in order to succeed. We saw that in Micky Ward’s egomaniac power controlling family and his loser crack head brother but unfortunately Mickey couldn’t recognize the failure till losses in the ring and then felt like he had to quit.  He was a loser less of a boxer let alone a man!

Micky Ward did accomplish a positive support person in his life after a series of failed fights. We saw this role in his girlfriend who was a feisty spirited woman. She was not about to put up with Micky's trailer-park, trash talking, power controlling family. Charlene, played by Amy Adams quickly turned Micky around in his fighter role pointing him in the right directions with a good manager and a trainer to enhance his boxing career. In our competitive, role we have positive relationships to enhance us or quickly the relationships are dissolved otherwise there is failure all around with physique, training, correct dieting and a strong focus to the fight on stage in posing.

Lastly, “never give up” no matter how difficult a road is to competitive success. We saw that in Micky's rocky road till his champion Welterweight fight that won him the title. Yes, that was a win title for his championship but long overdue.  The fight was less than life discretely staged with choreography in cinema.

One more comment, Christian Bale was the star in this film deeply submerged as a crack head failure in life after a former boxing career knocking out Sugar Ray. He internalized the character allowing his sensitivity to project a true drug addict and criminal with explicit drug withdrawal. His all-star performance should win him an Oscar in a supporting role. It was impossible to separate character from actor in Dicky.

 

Increase Breast Size with Upper Pec Training.

A dream for every woman is to have fuller breasts; which, stand up anid give the chest a developed look to it. The hard way to accomplish this is through upper chest training but once accomplished; it is permanent as long as it is maintained. Once the upper pecs get developed the chest gives an illusion of fuller perky breasts . I perform upper pec training for competition so that when I am on stage flexing a side chest pose the upper pecs are flexed and blends in with the breasts giving a much larger chest development. Here is what my training session looked like for Wednesday night. Notice it doesn't take a lot of weight only moderate weight but with each exercise the upper pecs have to be squeezed tightly. This muscle group is small and very easy to exhaust quickly.

Incline dumbbell presses

20  x 10,  30 x 10, 40 x  8, 40 x 8.

Incline fly presses

20 x 10, 30 x 10, 35 x 10 40 x 8.

Flat fly presses

20 x 10, 30 x 10, 35 x 10  35 x 10.

Cable fly presses

30 x 15, 35 x 15, 40 x 10, 45 x 10.

Standing close grip bicep curls

45 x 10, 60 x 10, 65 x 10, 70 x 8.

Sitting db curls

15 x 10, 20 x 10, 25 x 8  25 x 8

Standing cable curls drop sets of 4;  85, 55, 35.

85 x 6, 55 x 8, 35 x 15 x 4 sets

A smaller volume of exercises with longer rest periods between sets. This session took explosive energy to manage the upper body moderate weight. At the end of this session I posed for 15 minutes with full focus on upper pecs. The side chest posing gave the true depth and volume of my chest development giving the illusion of another cup size larger than what I already am; which, is so surprising to see with just a short amount of explosive chest work.

Shapely Beautiful Legs

Training legs is not only exhaustive and painful but the results are amazing over time with constant change in exercises performed. Slowly, leg definition develops that gives a flowing physique and tight hips. At present, my training emphasis is all compound moves upper and lower body throughout the winter until spring. Light weight does nothing for shaping or fitness in women; a concept that many women refuse to believe.

 Slowly, my weight in squats has been climbing each week  to achieve my goals of improved outer sweep in the quadriceps along with improved hamstring/glute tie-in with definition. So far I have been keeping my weight at 151 by clean food intake and alternating days of cardio. I found that I can squat the same amount of weight at 151 as I did at 185 so there is no need to be bulky with added weight to lose in the spring for contest preparation.

Last night's session :

Leg extensions set of 4 x 15

40, 60, 80, 100

Leg curls set of 4 x 15

40, 60, 80, 90

After warmup squats were alternated with wide stance and narrow stance squatting below parallel.

 135 x 8 x 2 sets

145 x 8 x 2 sets

155 x 8 x 2 sets

165 x 8 x 2 sets

175 x8 x 2 sets

Glute kickbacks 4 sets of 10

80, 90, 110, 120

I am happy with this training session as I increased my squat weight by 10# this week. Training is a triangle of balance to achieve with the right trainer.

Happy Days!

Tight Glutes to Sexy Legs.

Over the years as a bodybuilder I have trained many people who just want to change their physique to be more attractive. What doesn't surprise me is the responses of women "oh, I can't lift heavy weights", "I will get hair on my face", or "no, I can't do those squats". Men are let's do what I have to do to change the way I look. I find men easier to work with partly due to their male drive and their open-minded thinking for weight lifting.

Basically, it is not sex specific as to the work needed to be done to shape the legs and glutes. Often, I see these trainers in upscale gyms with their clients doing light weights or machines while they are texting or looking around the gym. Forget it, as a customer you will never benefits from that type of training. Training your glutes, hamstrings and quads requires trust, open-mindedness, and willingness to take that extra step to change by doing the work and maintaining a clean diet.

Glutes, quads, and hamstrings reguire basic exercises such as deep below parallel squats with working weight gradually adding more weight to get the effectiveness from the exercise. Glutes should be narrow, tight, and slightly humped so when one turns sideways there is that perfect concave glute looking flexed. The hamstring development when achieved is tied in at the gluteus muscle and extends in the back of the leg so when the person starts to sit there is a perfection in appearance of the hamstring. Quads should have an outer sweep as they travel up the leg with splitting for the three vastus muscle groups and lastly the teardrop muscle that sits on inside of the leg connecting to the vastus group should be separated.

The only way to achieve development in these muscle groups is to incorporate conditioning for heavy compound moves such as variances in deep squats with leg stances and dead lifts. See my blogs under Dead Lifts, Glutes Hamstrings Training, and Beautiful Shapely Legs.

 

The Role of Glycogen Metabolism in Competitive Bodybuilding

In competitive bodybuilding we start a contest preparation 12-16 weeks out from the competition.  This consists of a structured meal plan and a change in training intensity that includes a six day routine. The meal plan is continually altered over the time period to burn fat and deplete interstitial water through carbohydrate lowering. The last four weeks  a competitor is focused on selection of a song to pose to, a routine that is choreographed, cardio, and lastly continued weight training. As a competitor, the overwhelmed feeling sinks in and pure chaos with a scattered brain takes over. 

Why and what is the chemistry behind the mental, physical and emotional exhaustion that the body is going through  until the end? This crucial time period is when the carbohydrates are dropping weekly along with changes in protein for the body to burn quickly. The last four weeks of dietary changes dial a physique into a tight sculpted body with deep definition enhanced by continued cardio and weight training. Usually the protein is dropped from chicken or turkey to Ahi Tuna then lastly to Tilapia (a white very low fat fish). This is when competitors develop problems due to drastic dietary cuts with the intense training along with their daily life. The "dead in the head" or "deer in headlights" feeling is prevalent.

The biochemistry involves gluconeogenesis in breaking down protein and the very small amount of carbohydrates for energy. This occurs in the liver where glycogen is stored.  A competitor develops a negative balance quickly as protein is the main molecule active in the cycle and a small amount of carbohydrate. When the glycoen stores are exhausted in the liver the symptoms of hypoglycemia are prevalent and a competitor needs to be in a situation to rest and restore through a protein drink or their next meal  but not to add anymore carbohydrates to the diet. Muscle glycogen stores become depleted as well which promotes the overwhelming fatigue and weakness.  At this point a competitor's body fat is very low without much reserve to burn. A difficult time  to think and stay awake all day long.  

Most competitors have very easy jobs or make arrangements to take off work the last four weeks before a competition due to these biochemical processes in the liver and muscles depleting the body further of interstitial water and fat content. Depending  how a competitor looks the last two weeks and especially the last week the diet is stripped of the protein drinks and the quanity of green vegetables with Tilapia is lowered with each meal. Usually this is the roughest period and competitors do not work. At the time of competition women are 7-10% body fat and men are 4-5% body fat.

What I have learned as a competitor myself is do it right or don't do it at all. The judges are looking at parameters of development, symmetry, body fat, presentation and lastly the overall package. The overall package captures the judges eyes as the competitor artisically displays their physique  on stage. I have been on stage over the last 15 years and sometimes I am just off in a body part lagging or I feel so miserable I can't display the artistic presence.  When I am at my best I can artisically display muscle groups through the mandatory poses. Competitive bodybuilding is a difficult sport and one that is demanding and scientifically intricate to mold that physique for stage presence. Competitors sacrifice social engagements, friends, food, and sometimes their families to achieve their goal.

Bodybuilding is a sport that I love and will continue to do the rest of my life.  I was two weeks out from the Western Regional Bodybuilding, Fitness, and Figure Competition when hypoglycemia was overtaking me to either stop working or postpone competing. I am in a position as a health care provider in my own practice and I could not take off work; therefore, I will plan carefully for the next show so this will not happen again.

All of now, please leave a comment if you wish.