SURVIVING HEALTHCARE Robert Yoho, retired cosmetic surgeon

I am now retired, but I spent the last thirty years in private practice performing cosmetic surgery and sometimes assisting with my patients’ medical care. Most of the women I worked with who were over 50 years old suffered from poor sleep, fatigue, hot flashes, muscle wasting, and irritability. They were all looking for a way to feel better and a lot were taking antidepressants. Many thought that I could improve their spirits with surgery, and sometimes they were right. But since they had hormone deficiency symptoms, surgery alone was not the best solution. 
Most plastic surgeons operate on a string of depressed people without considering why they are so miserable. My patients were trusting me, and I wanted to help, so I took training. 
For nearly two decades, I offered appropriate candidates hormone treatment along with their procedures. Those who listened to my advice were usually grateful. Some were not interested, and I respected that as well.
I knew women had doubts about hormone replacement. I also knew that patients never take at least a third of their prescriptions, even vital ones like kidney transplant anti-rejection drugs. Since hormone benefits can take weeks to be felt, I used long-lasting, inexpensive testosterone pellets implanted under the skin. If my patients didn’t like this idea, I offered it as a cream. Testosterone transforms into estrogen, so they received this as well.  
When I saw them a month later, most were thrilled. I then suggested they consider adding progesterone, estrogen, vitamin D, and sometimes thyroid, DHEA, and melatonin. If their finances were tight, I showed them how to inject themselves once a week with testosterone. (Each shot costs only $2 for women and $10 for men.) I followed blood tests, symptoms, and physical exams, and customized therapy based on patient responses.
I saw a few women who felt terrible in their mid-30s. Blood tests showed they were in premature menopause and had estrogen and progesterone levels close to zero. After they began treatment, they felt great again. Many of my patients brought in their friends and husbands, and they responded as well. 
Hormone replacement should be a “feel-good” story. We have overwhelming proof that it is safe and effective. Most hormones are affordable, and tens of millions of people have used them. Thyroid has been available since the late 1800s, and insulin, estrogen, and testosterone for nearly that long. These treat or prevent heart disease, depression, impotence, diabetes, some cancers, and Alzheimer’s disease (AD). 
 But misinformation is everywhere: ✪ Doctors and patients “know” that estrogen causes breast cancer and blood clots, testosterone causes heart disease and prostate cancer, and that human growth hormone (HGH) is practically poison. These ideas are false. ✪ We have been led to believe that insulin’s high price is justifiable. Wrong. ✪ Mainstream medicine says that thyroid disease is relatively uncommon and hazardous to treat. This is also incorrect—it may afflict a third of mature women and is under-treated because of doctors’ economic turf wars rather than unusual risks.

Hormone therapy is a strange opera with many twists and bizarre characters. To navigate it, patients need physician-level knowledge—a tragic situation. I studied this subject for a decade, but you can learn the basics in a few hours with no prior background. Journalists think every issue has two sides. Law and news stories, for example, are rarely black or white. But medical care is right or wrong, and I challenge you to find the truth here.

 I present: ✪ What the science says. ✪ Opinions of independent experts. ✪ The collective physician experien
Support the Show.

To understand this book, you only need to remember a few bio-identical hormone names—estradiol, progesterone, testosterone, and thyroids, which include porcine, T4, and T3. If you read outside sources, you must learn others. Return to this reference chapter as needed. 


Hormones work by attaching to receptor molecules in the human body, and since the natural ones are identical or nearly identical to those made by our glands, they fit like the real thing. Manufactured medicines are foreign substances never found in the body’s ecosystem that are made from animals or chemicals. These do not match as closely as the bio-identicals, do not work as well, and have side effects. They are still useful in a few circumstances but should never be taken long-term. I call them “counterfeit” or “fake” to help you sort out the issues. 
For example, progesterone is bio-identical. In contrast, Provera is a synthetic progesterone imitation. It raises the chances of migraines, weight gain, heart disease, breast cancer, depression, and irregular bleeding. Pregnant women taking it get more miscarriages and their babies have more congenital disabilities. 


Drugmakers invent sexy copyrighted brand names for their profitable patented compounds. This allows patients to harass doctors by saying, “I saw an ad for…” Pharma also creates chemical names that are hard to pronounce and remember. The brand Celebrex, for example, is the chemical celecoxib—try saying that one. The advantage for the manufacturer is that when medications go off-patent and are sold as generics, the chemical is more difficult to recall than the recognizable brand. 
The drugmakers use the names to confuse. Progestin, progestogen, and Provera, the artificial ones, sound like natural progesterone. And Premarin, the horse-urine estrogen (this name was from PRegnant MAre’s uRINe), gets mixed up with Provera, the synthetic progesterone. These strategies work, so the doctors are just as bewildered as you are:
✪ Many journal articles make no distinction between bio-identical progesterone and progestins/progestogens such as Provera. They call both of these progesterone, which implies there is little difference. 
✪ Likewise, medical articles call many related substances estrogens, which is accurate but fools both doctors and patients into thinking that they are all alike. Technically, estrogens include bio-identical estradiol, the counterfeits such as Premarin, and the other relatively weak human estrogens, estrone and estriol. These last two are bio-identical but are almost inactive and cause some health issues. 
✪ Hormone replacement therapy (HRT) sometimes refers to treatment with bio-identicals and sometimes to treatment with the counterfeits!


Support the Show.

Menopause information is everywhere—some good, some bad, and all of it confusing. Many authorities call this unpleasant syndrome “natural” and recommend ignoring it. But hormones greatly improve women’s health and menopause symptoms. 
June is 49: She started estradiol, progesterone, and testosterone eight weeks ago: Hey, doing well on my hormones. About two months in now. My energy is up, as is my sex drive and my enjoyment of it. My muscle tone and skin look great, and some old friends I gathered with on the East coast last week accused me of having an aging painting of myself in a closet somewhere. I’m still having hot flashes at night and wonder if I should adjust my estrogen up some? My reply was: Increase your estradiol to two mg each morning. We may decide to increase your progesterone and will check your levels on your next office visit.
How the female reproductive system works: Young women start with hundreds of ova or eggs. Each cycle, the uterus is prepared for a potential baby and one ovum is used. As women mature, usually in their mid-40s, the eggs run low and periods become irregular. After the eggs are gone, the cycles stop but some hormone production persists as long as the ovaries are not cut out.
This is the “change of life.” Progesterone levels typically fall and estrogen production continues. Some women get depression, anxiety, irritability, and sleep disturbance. Other symptoms include bloating, acne, breast tenderness, and heavy, irregular menstrual periods. 
At about age 50, women “fall off a hormonal cliff.” As all their hormones decline, full menopause develops. Many are miserable and have intense hot flashes. After a few last irregular periods, they are in complete menopause, defined as a year without a menstrual cycle. Their symptoms are usually more dramatic and unpleasant than men’s at the same age and often more severe than any pre-menstrual syndrome (PMS) they had earlier in their lives.
For the first several years, most women need only progesterone. As menstrual periods slow and stop, estrogen and the other hormones should be added. Estradiol has the strongest effect on hot flashes. Testosterone improves strength, alertness, sexuality, and helps with bladder and vaginal symptoms. Since it transforms into estrogen, it protects the heart in both sexes. Patients who want simplicity or are on a tight budget sometimes use it as the sole therapy.
Janice, 64, watched her husband die of lung cancer two years ago after a three-year illness and has been “out of gas” ever since. She said she was “done with men,” so she flew to Los Angeles to have her breast implants taken out. Because Janice had fatigue, depression, anxiety, and no interest in sex, I discussed menopause therapy with her. She agreed to try. So I wrote a prescription for estradiol and progesterone and placed a testosterone pellet. Janice called four months later—she had a new boyfriend and felt great. She is returning to have her implants replaced. 
Hormone supplementation slows and may prevent: 
✪ Alzheimer’s disease (AD).
✪ Heart disease
✪ Fatigue, depression, sleep disturbance, anxiety, and irritability.   
✪ Bone loss, osteoporosis, and increased chance of fractures. 
✪ Skin problems including thinning, wrinkling, itching, sagging, easy injury, and loss of elasticity. 
✪ Thinning of joint cartilage. Tooth loss and gum disease. 
✪ Vaginal area difficulties: dry, thin, and inelastic. 
✪ Spontaneous urination during coughing or lifting. 
✪ Sexual decline including painful sex. 
Linda is a 63-year-old registered nurse: Testosterone makes me feel sexy and gives me an overall feeling of well-being. My strength and muscle tone improve, e
Support the Show.

Estradiol has the most dramatic effects of any hormone. Its benefits include:
✪ Helps the heart more than other hormones. 
✪ Decreases the risks of cataracts, vaginal atrophy, and macular degeneration of the retina. 
✪ Reduces the chances of stroke, diabetes, colon cancer, Alzheimer’s, memory problems, and osteoporosis.  
✪ Cures hot flashes and improves sexuality. 
From the Los Angeles Times, 1999: I could live without my husband, children, or cats. But I could never live without my beloved estrogen. 
Who should use estrogen and how much? Menopausal women and sometimes men transitioning to women are prescribed estrogen. Men with prostate cancer are also occasionally treated with it. Women in menopause should start at 1.5 milligrams in the morning, then increase to 2 to 2.5 milligrams. This brings blood levels up to about 70 pg/ml, which protects the heart and other organs. We believe this is safe because young, healthy women have estrogen levels in the hundreds during parts of their cycle. 
Premarin, the horse estrogen, was the first treatment for menopause. It has many beneficial effects, but it causes a slight increase in blood clotting. This makes it obsolete for long-term use. Estradiol, the primary bio-identical type, is safer. Every study on it—KEEPS, EPAT, WEST, CORA, DANISH, and ELITE (those academics love acronyms)—found no increase in blood clotting. 
Although the estradiol transdermal patch may provide the best relief of hot flashes and does not cause blood clots, it does not protect against heart disease. In contrast, both types of oral estrogen protect the heart. This was proven in many studies, including the CORA, ELITE, WEST, and DANISH. 
Since many medical authorities think that oral estradiol and oral Premarin are the same thing with the same risks, they often recommend using the patch if there are concerns about blood clotting. Doctors should instead prescribe brand name, generic, or compounded oral estradiol. These are safe and protect against heart disease and stroke. 
Doctors are usually hesitant to prescribe oral estrogens for sick patients or those with heart risk factors such as smoking, obesity, or a family history. They use the patch for them if they recommend hormones at all. However, as I describe in the Be Careful Whom You Trust chapter, these are precisely the patients who need cardiac protection the most. In nearly every situation, their risk to reward ratio favors the oral type. We should accept the minor hazard of blood clotting to protect their hearts. Dr. Rouzier describes these issues in a well-referenced article.
Surgeons and anesthesiologists have many responsibilities, and they rarely read the confusing estrogen studies closely. Since blood clots after surgery are such a hazard, most of them tell their patients to stop all replacement before surgery. Some gynecologists are adamant about this. 
Estradiol is available as generic, compounded, or patented varieties. Hormone doctors mostly recommend a compounding pharmacy's product because generics are less predictable and the patent type is too expensive if not paid for by insurance. Brand names from foreign sources made by major manufacturers are often affordable and of excellent quality. 
Estradiol patches such as Vivelle Dot (twice a week) or Climara (once a week) may relieve menopause symptoms better than the oral forms. The higher dose of .1 mg a day works best. To help the transdermal patch stick, patients scrub the area with alcohol before they apply it. The device sometimes causes skin irrita
Support the Show.

Estradiol has the most dramatic effects of any hormone. Its benefits include:
✪ Helps the heart more than other hormones. 
✪ Decreases the risks of cataracts, vaginal atrophy, and macular degeneration of the retina. 
✪ Reduces the chances of stroke, diabetes, colon cancer, Alzheimer’s, memory problems, and osteoporosis.  
✪ Cures hot flashes and improves sexuality. 
From the Los Angeles Times, 1999: I could live without my husband, children, or cats. But I could never live without my beloved estrogen. 
Who should use estrogen and how much? Menopausal women and sometimes men transitioning to women are prescribed estrogen. Men with prostate cancer are also occasionally treated with it. Women in menopause should start at 1.5 milligrams in the morning, then increase to 2 to 2.5 milligrams. This brings blood levels up to about 70 pg/ml, which protects the heart and other organs. We believe this is safe because young, healthy women have estrogen levels in the hundreds during parts of their cycle. 
Premarin, the horse estrogen, was the first treatment for menopause. It has many beneficial effects, but it causes a slight increase in blood clotting. This makes it obsolete for long-term use. Estradiol, the primary bio-identical type, is safer. Every study on it—KEEPS, EPAT, WEST, CORA, DANISH, and ELITE (those academics love acronyms)—found no increase in blood clotting. 
Although the estradiol transdermal patch may provide the best relief of hot flashes and does not cause blood clots, it does not protect against heart disease. In contrast, both types of oral estrogen protect the heart. This was proven in many studies, including the CORA, ELITE, WEST, and DANISH. 
Since many medical authorities think that oral estradiol and oral Premarin are the same things with the same risks, they often recommend using the patch if there are concerns about blood clotting. Doctors should instead prescribe brand name, generic, or compounded oral estradiol. These are safe and protect against heart disease and stroke. 
Doctors are usually hesitant to prescribe oral estrogens for sick patients or those with heart risk factors such as smoking, obesity, or a family history. They use the patch for them if they recommend hormones at all. However, as I describe in the Be Careful Whom You Trust chapter, these are precisely the patients who need cardiac protection the most. In nearly every situation, their risk to reward ratio favors the oral type. We should accept the minor hazard of blood clotting to protect their hearts. Dr. Rouzier describes these issues in a well-referenced article.
Surgeons and anesthesiologists have many responsibilities, and they rarely read the confusing estrogen studies closely. Since blood clots after surgery are such a hazard, most of them tell their patients to stop all replacement before surgery. Some gynecologists are adamant about this. 
Estradiol is available as generic, compounded, or patented varieties. Hormone doctors mostly recommend a compounding pharmacy's product because generics are less predictable and the patent type is too expensive if not paid for by insurance. Brand names from foreign sources made by major manufacturers are often affordable and of excellent quality. 
Estradiol patches such as Vivelle Dot (twice a week) or Climara (once a week) may relieve menopause symptoms better than the oral forms. The higher dose of .1 mg a day works best. To help the transdermal patch stick, patients scrub the area with alcohol before they apply it. The device sometimes causes skin irrit
Support the Show.

Men need testosterone. The benefits are enormous and the risks almost nonexistent. To learn how the bad press was contrived, read the Killing Testosterone With Fake News chapter later. 
Steven is an 82-year-old retired CEO of a major media company: I had lost all strength, and I was sitting in a wheelchair in a Palm Springs nursing home. The staff had to lift me in and out of bed. I was inches from being snuffed out. Then my doctor started coming in every week and giving me testosterone shots. In six weeks, I stood up and walked out of there, back into my life. (Note: this can also work for women.)
Men’s symptoms: Starting around thirty years old, testosterone blood levels fall about a percent a year. Muscular strength, sexuality, and energy levels slowly decrease. Recovery from exercise gets slower, and some men notice reduced intellectual capabilities. Bone density falls, but fractures are less common in men than women since men start higher. Atrial fibrillation and stroke are more common with low testosterone levels. Skin problems, heart disease, hot flashes, dental issues, and irritability increase as testosterone declines. Some of these disorders must be treated early or they are irreversible. 
Sam is a beloved 83-year-old physician: I was about to give up. I just had a knee replacement, and I have osteoporosis. The author sent me some cream testosterone as a gift, and now I think I'm going to live fifteen more years! I can't thank him enough, and I'm indebted to him forever for his kindness. I’m doing well, much better than I ever expected.
Testosterone has many benefits. Using it gradually improves health over at least a decade. Testosterone supplementation has the following effects:
✪ Strength increases, cholesterol falls, and weight loss is progressive. 
✪ Sexuality improves—morning erections return, for example. 
✪ Heart disease risks decline. 
✪ Diabetes and migraine headaches get better and are sometimes cured. 
✪ Testosterone supplementation decreases anxiety and improves mood.
Testosterone levels also relate to health:
✪ Older men with higher testosterone levels had better results on intellectual testing.
✪ Lower levels were associated with earlier death in men. They correlated also with coronary disease.
Testosterone transforms into estrogen in both men and women. This “female” hormone helps sexuality in either sex and protects the heart better than any other hormone. Sometimes estrogen blood levels do not rise to those of younger men even with aggressive testosterone supplementation. So a few physicians are starting to prescribe estradiol for men. This will vastly improve cholesterol numbers.
Testosterone has a few side effects. Hair loss and hair growth can happen but are of no consequence compared to the benefits. Acne is rarely a significant
Support the Show.