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A Case of a 68 Year Old "Healthy" Man
Complaining of Fatigue, Low Libido and Depression
Bill is a 68 year old retired business consultant, happily married and a proud grandfather whose primary concern when he first came to me was fatigue. He also mentioned his low libido and tendency to depression and wondered were his symptoms related to exhausted adrenal glands or to a low growth hormone level. He had done some reading which suggested these types of hormone imbalances or even nutritional deficiencies could relate to his less than optimal level of well being.
DEFICIENCIES OF MODERN MEDICINE
His primary care doctor, cardiologist, and rheumatologist all told him he is quite healthy and his complaints are normal for a 68 year old man, and that testing for adrenal and growth hormones was not indicated. He had had physical exams, all the standard blood tests, echo cardiogram, colonoscopy, and more, and everything was normal. I was very much in agreement with Bill that the lack of disease does not necessarily equate with optimal health. When he asked if there could be some imbalances or deficiencies that a strictly conventional medical approach might miss, I said, "Absolutely YES, I see it everyday." As powerful and effective as modern medicine can be, when it comes to such areas as nutritional deficiencies, heavy metal toxicity (such as mercury or lead), or certain kinds of hormone imbalances, conventional medicine has a poor track record.
Bill had had a minor heart attack years past which he was told did not damage his heart, and if he kept his LDL cholesterol level low enough, he should have no more cardiac issues. (I told Bill that there was a lot more to preventing heart attacks than keeping cholesterol levels down, and we would address this at another visit.) His only prescription medication was the simvastatin for his cholesterol level, and a prescription anti-inflammatory (Celebrex) for his back. With the help of this medication, he could play golf with little to no pain.
He came to me thinking there had to be a better answer for his fatigue and low libido and depression. One of my first questions was, "well how do you sleep?" Good sleep could be the cure for all his complaints. He related that he gets to sleep fine and sleeps deeply, but he awakens after being asleep three or four hours. He gets back to sleep easy enough but feels that his sleep the rest of the night is really not that good. He awakens not very refreshed, but after a shower and breakfast, he doesn't feel too bad and can go out and play a round of golf and feel quite fine really. But by mid afternoon, he is "worthless, dragging, no zip, ill-humored, and needs to nap". He says he never really can pull himself back up to any decent level, even with a nap or snack. He has dinner and goes to bed by 8:30 PM.
IMBALANCED ADRENAL AND THYROID HORMONES
I am thinking well yes, he may have low Growth Hormone levels certainly, but perhaps his nighttime Cortisol levels are too high, interfering not only with the depth of his sleep, but contributing to his depression and as well to a low level of Growth Hormone (elevated nighttime cortisol levels suppress growth hormone secretion). And if his daytime Cortisol levels are low, this could be a large contributor to his fatigue and low libido. Hypoglycemia could also be a factor here, but he said he eats protein three times a day and avoids sweets and soda pop. So, I ordered a salivary adrenal function test on him. I also measured his thyroid levels (Free T-3, Free T-4, TSH, Reverse T-3 and Thyroid antibody profile. (All he had had previously for his thyroid was a TSH and total T-4.)
DEFICIENCY OF VITAMIN B-12
I also wanted to measure his vitamin B-12 levels, the most difficult vitamin to absorb. The older we get, the less we are able to absorb vitamin B-12 from our gastrointestinal tracts. Low vitamin B-12 could explain his fatigue and tendency to depression (as well as his forgetfulness). Vitamin B-12 levels can be normal in the blood while very deficient inside the cells where it counts. Physicians who pronounce to their patients that their B-12 blood levels are normal and do not need extra B-12 supplementation may be missing a very critical deficiency. It’s much harder to measure intracellular B-12.
If the vitamin B-12 blood level is low, we can believe that, but if the B-12 level is normal, an individual could still be deficient. In this event I obtain a methylmalonic acid level, a functional test for vitamin B-12 deficiency (a deficiency of vitamin B-12 will cause a high normal or an excess of methylmalonic acid). Or in some cases I will give a patient an intramuscular injection of vitamin B-12, and if he or she reports within a day or two a significant boost in energy, mood, or memory, this tells me they need extra vitamin B-12 and often by injection. (Certain behavioral and neurological issues my require weeks or months of B-12 injections before results are evident.)
Broadening our view, Bill's fatigue, depression, low libido, and the muscle weakness that he also described could be caused by low testosterone levels. I explained to Bill, that the heart muscle also contains testosterone receptors, and low testosterone levels could also weaken his heart. So I also ordered Free and Total testosterone and Estradiol levels. (One reason for men's low testosterone levels is the fact that as men age they often convert testosterone to estrogen. Although Bill did not have the abdominal fat accumulation, breast development and prostate problems that men get with low testosterone and high estradiol levels, he certainly had some of the other characteristic low testosterone symptoms.
And then there was Bill's persistent diarrhea. This was a symptom he did not bring up during my history taking, but which showed up on the new patient questionnaire he filled out for his first appointment. Bill said that he had mentioned this on several occasions to his primary care doctor who, upon learning that Bill had not traveled out the country, dismissed the need for any parasite testing and said not to worry about it and to adjust his diet and fiber intake. I told Bill that intestinal parasite infections are extremely common whether one has traveled or not. I ordered a stool and saliva test looking for parasites, worms, pathogenic bacteria and yeast. The screen also included a test for gluten sensitivity. Intestinal infections and/or gluten sensitivity can cause loss of electrolytes and poor absorption of nutrients leading to depletion and fatigue. (Gluten sensitivity can lead to far more problems). And I obtained a urinary Growth Hormone level and a serum IGF-1 level (also known as Insulin like Growth Factor-1).
BILL'S LAB TEST RESULTS:
Low day time Cortisol levels and elevated midnight Cortisol level (adrenal imbalance)
Low normal Free T-3 level (thyroid imbalance)
Normal Vitamin B-12 level with high normal methylmalonic level
Low Free Testosterone and low-normal Total Testosterone levels
Presence in the stool of Blastocystis Hominis (intestinal parasite)
Elevated IgA gliadin antibodies (gluten intolerance)
Low normal IGF-1 level and low urinary Growth Hormone level
BILL'S TREATMENT PROGRAM
For treatment, I felt that number one was to balance his adrenal hormones. He required low doses of Hydrocortisone (subphysiologic doses) initially, an adaptogenic herbal formula and DHEA. In several months I discontinued the hydrocortisone adding licorice root extract instead. (This treatment plan is just a summary highlighting the most relevant components.) In several weeks I also prescribed for him a low dose of T-3 (liothyronine) and then a formula to enhance the conversion of T-4 to T-3. Several months later he was able to discontinue the prescription T-3 (and his blood levels of free T-3 remained improved. I taught him how to administer intramuscular vitamin B-12 injections (to be done twice a week). He needed the hydroxycobalamin form (and not the cyanocobalamin or methylcobalamin form). It was the kinesiology evaluation that told me this.
I prescribed an anti parasitic antibiotic (Alinia) to treat his Blastocystis Hominis (along with a probiotic to protect his intestinal flora) and gave him instructions on how to follow a gluten free diet. I told him that I thought the gluten intolerance was triggered by the intestinal parasite infection and that in time with the healing of his intestinal mucosal inflammation, he might be well able to tolerate gluten again. (It is not everyone for whom gluten avoidance will be only temporary. Some need to avoid it lifelong.) I also recommended a L-glutamine formula to help facilitate healing of his intestinal mucosa.
That seems like a lot of treatment, but for Bill, this was not a challenge. He was ready to take on anything and everything to feel better again. After six weeks of implementing all the initial treatments, Bill returned with a smile on his face, reporting that he was maybe 50% back to where he needed to be, but emphasized that he had 50% yet to go. I explained that he may need 6 or 8 more weeks to give his treatments a chance to work more deeply. After all, how many years had he been feeling so depleted and now he expects a complete turnaround in just six weeks?
GROWTH HORMONE DEFICIENCY
He reluctantly agreed, but after 3 more weeks of treatment, he phoned to say that his improvement was on a plateau and that he believed that 4 to 5 more weeks of the same treatment was not going to bring him that much higher. Somehow, I trusted his assessment and agreed to step up his program which first would be to boost his Growth Hormone levels. Initially, I had the impression that he was not the kind of patient who had a serious and pathologic Growth Hormone deficiency related to a significant pituitary stalk injury, and one who requires daily Growth Hormone injections. I suspected that he had a less severe age-related growth hormone deficiency. For this reason I decided to rely on his IGF-1 level and his urinary Growth Hormone level and to forego the "gold standard", the Growth Hormone Stimulation Test for measuring Growth Hormone. This test involves the intravenous administration of Arginine and L DOPA and drawing blood samples just prior this administration and again at 30, 60, 90, and 120 minutes (five samples total). Bill was happy to forego this test.
His IGF-1 was normal according to the conventional range, but according to some pituitary specialists who utilize a more strict reference range, his level was clearly low—which suggested a low Growth Hormone level. (And he did not follow all the required avoidance of specific foods and supplements for one week prior to this blood draw, so his numbers were likely a bit falsely elevated. If he had followed all the requirements, his level would have likely been lower.) Although not the gold standard, his urinary Growth Hormone level was very low—which was consistent with the "low" IGF-1.
I prescribed for Bill a topical cream (formulated by a compounding pharmacy) containing specific amino acids and other nutrients that absorb through the skin and into the bloodstream, and eventually reach the brain and stimulate the pituitary gland to secrete more Growth Hormone. (We call such treatment agents secretagogues—substances that nourish and stimulate a gland to secrete its hormone, and to a level that is no more than the gland can naturally produce. They can help a marginally underfunctioning gland step up hormone production. They do not work for a gland that is no longer able to produce its hormone. I am not aware of secretagogues over-stimulating the pituitary. Therefore, they are considered quite safe.)
25 YEARS YOUNGER
Using a specific on and off protocol with this cream, Bill reported that from this single measure, he experienced as much and possibly more improvement than all the other measures combined. And this improvement did not fade after his initial excitement. It has stayed with him and enabled him to feel and function as if he were "twenty years younger". He also reported somewhat better sleep. Although he still awoke too early, he could get back to sleep a bit easier. It was not that much improvement with his sleep, yet his energy and stamina, nonetheless, continued to be excellent. Follow up urine testing showed mid range normal Growth Hormone levels.
His testosterone levels did not come up using the Growth Hormone enhancing cream and so I prescribe for him a topical bio-identical testosterone cream from a compounding pharmacy. It is common that when Growth Hormone levels rise, many of the other hormone deficiencies self-correct. (This did not happen with Bill's testosterone levels.) Bill could observe another increment of improvement using the testosterone cream, though not as big an increment as the growth hormone enhancing cream provided. (I have far more patients for whom the testosterone cream has made the biggest difference.)
A COMBINATION APPROACH IS THE TICKET
In summary, what helped Bill was a combination of balancing and optimizing adrenal hormones, thyroid hormone, testosterone, and growth hormone levels as well as vitamin B-12 injections, intestinal parasite treatment and a gluten free diet.
WORKING TOWARD WELL-BEING
Bill's story is very characteristic of many patients I see who have "nothing wrong" (according to a strictly standard medical approach) but who are living life at level far below what they consider acceptable. They often have hormone and nutrient deficiencies and imbalances, toxicities such as heavy metals, diminished detoxification capacity, and chronic infections. The sad fact is that many physicians talk their patients into believing that they should accept their less than optimal state of health and well being. But fortunately, more and more patients are wising up to the limitations of conventional medicine. And just as fortunately (but not as commonly) more and more conventional physicians are expanding their definition of health to include more than just the lack of illness, but rather a state of well being.
In a patient with as many complaints as Bill had, I am hoping to uncover a core disturbance, a condition that is responsible for many symptoms. By finding and treating this condition, multiple benefits will ensue. For example, by balancing the adrenal glands, we can successfully address: fatigue, poor sleep, poor coping tolerance, anxiety, low libido, low immune function, and more. And by treating one condition we can sometimes achieve more success with another treatment that is needed. For example, by diagnosing and treating an underlying infection, much stress is taken off the adrenal glands, and therefore the adrenal balancing measures I prescribe will work more quickly and effectively.
On the other hand, there may be several intermingled causes for any one symptom. For example, Bill's fatigue may not be adequately addressed from balancing his adrenals. He may feel that just 40% of his energy is back from getting his adrenal hormones straight. Contributing to his fatigue might also be low thyroid function, intestinal parasites, gluten sensitivity, low B-12 status, and low Growth Hormone levels.
How do I know what to pursue and in what order? This is where the art of medicine and experience comes to play. It is like detective work actually. From all the clues I gather about a patient, from the details of the history, the nature, intensity, chronicity and variety of the complaints, the patients age and gender, and sometimes from physical examination, I will decide to test (or treat) what strikes me as the most likely disorders of all those I am considering. Kinesiology testing can often help in prioritizing what should be addressed first. The more years I have been incorporating this modality, the more valuable it has become.
It makes more sense to find the deepest issues and treat those rather than to chase each and every surface symptom. In Bill's case the deep issues were hormonal imbalances and deficiencies, nutrient deficiencies, and a chronic infection. If his gluten sensitivity persists, this could also fall into this "deep" category. However, I am not a purist. If, for example, someone has a serious sleep issue, I am not going to await the results of adrenal testing and treatment before offering a direct sleep treatment. If sleep is seriously hurting, I will treat it with a sleeping pill or natural alternative, and when we find an underlying cause of the sleep disturbance, then we can hopefully eliminate the sleeping pills. We achieve the best outcomes (and end up with less prescription medications) by focusing on treatments that correct core disturbances.
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, Ralph Golan MD
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