HCG AND WEIGHT LOSS as per Dr. Siemons HCG Weight Loss Book

The Real Gonadotrophins
Two hormones known in the female as follicle stimulating hormone (FSH) and corpus luteum stimulating hormone (LSH) are secreted by the anterior lobe of the pituitary gland. These hormones are real gonadotropilins because they directly govern the function of the ovaries. The anterior pituitary is in turn governed by the diencephalon, and so when there is an ovarian deficiency the diencephalic center concerned is hard put to correct matters by increasing the secretion from the anterior pituitary of FSH or LSH, as the case may be. When sexual deficiency is clinically present, this is a sign that the diencephalic center concerned is unable, in spite of maximal exertion, to cope with the demand for anterior pituitary stimulation. When then the administration of hCG increases the functional capacity of the diencephalon, all demands can be fully satisfied and the sex deficiency is corrected.

That this is the true mechanism underlying the presumed gonadotrophic action of hCG is confirmed by the fact that when the pituitary gland of infantile rats is removed before they are given hCG, the latter has no effect on their sex-glands. hCG cannot therefore have a direct sex gland stimulating action like that of the anterior pituitary gonadotrophins, as FSH and LSH are justly called. The latter are entirely different substances from that which can be extracted from pregnancy urine and which, unfortunately, is called chorionic gonadotrophin. It would be no more clumsy, and certainly far more appropriate, if hCG were henceforth called chorionic dienccphalotrophin.

hCG no Sex Hormone
It cannot he sufficiently emphasized that hCG is not sex-hormone, that its action is identical in men, women, children and in those cases in which the sex-glands no longer function owing to old age or their surgical removal. The only sexual change it can bring about after puberty is an improvement of a pre-existing deficiency. But never stimulation beyond the normal.. In an indirect way via the anterior pituitary, hCG regulates menstruation and facilitates conception, but it never virilizes a woman or feminizes a man. It neither makes men grow breasts nor does it interfere with their virility, though where this was deficient it may improve it. It never makes women grow a beard or develop a gruff voice. I have stressed this point only for the sake of my lay readers, because, it is our daily experience that when patients hear the word hormone they immediately jump to the conclusion that this must have something to do with the sex- sphere. They are not accustomed as we are, to think thyroid, insulin, cortisone, adrenalin etc, as hormones.

Importance and Potency of hCG
Owing to the fact that hCG has no direct action on any endocrine gland, its enormous importance in pregnancy has been overlooked and its potency underestimated. Though a pregnant woman can produce as much as one million units per day, we find that the injection of only 125 units per day is ample to reduce weight at the rate of roughly one pound per day, even in a colossus weighing 400 pounds, when associated with a 500-calorie diet. It is no exaggeration to say that the flooding of the female body with hCG is by far the most spectacular hormonal event in pregnancy. It has an enormous protective importance for mother and child, and I even go so far as to say that no woman, and certainly not an obese one, could carry her pregnancy to term without it.

If I can be forgiven for comparing my fellow-endocrinologists with wicked Godmothers, hCG has certainly been their Cinderella, and I can only romantically hope that its extraordinary effect on abnormal fat will prove to be its Fairy Godmother.

hCG has been known for over half a century. It is the substance which Aschheim and Zondek so brilliantly used to diagnose early pregnancy out of the urine. Apart from that, the only thing it did in the experimental laboratory was to produce precocious rats, and that was not particularly stimulating to further research at a time when much more thrilling endocrinological discoveries were pouring in from all sides, sweeping, hCG into the stiller back waters.

Complicating Disorders
Some complicating disorders are often associated with obesity, and these we must briefly discuss. The most important associated disorders and the ones in which obesity seems to play a precipitating or at least an aggravating role are the following: the stable type of diabetes, gout, rheumatism and arthritis, high blood pressure and hardening of the arteries, coronary disease and cerebral hemorrhage.

Apart from the fact that they are often - though not necessarily - associated with obesity, these disorders have two things in common. In all of them, modern research is becoming more and more inclined to believe that diencephalic regulations play a dominant role in their causation. The other common factor is that they either improve or do not occur during pregnancy. In the latter respect they are joined by many other disorders not necessarily associated with obesity. Such disorders are, for instance, colitis, duodenal or gastric ulcers, certain allergies, psoriasis, loss of hair, brittle fingernails, migraine, etc.

If hCG + diet does in the obese bring about those diencephalic changes which are characteristic of pregnancy, one would expect to see an improvement in all these conditions comparable to that seen in real pregnancy. The administration of hCG does in fact do this in a remarkable way.

Diabetes
In an obese patient suffering from a fairly advanced case of stable diabetes of many years duration in which the blood sugar may range from 300-400 mg, it is often possible to stop all anti-diabetes medication after the first few days of treatment. The blood sugar continues to drop from day to day and often reaches normal values in 2-3 weeks. As in pregnancy, this phenomenon is not observed in the brittle type of diabetes, and as some cases that are predominantly stable may have a small brittle factor in their clinical makeup, all obese diabetics have to be kept under a very careful and expert watch.

A brittle case of diabetes is primarily due to the inability of the pancreas to produce sufficient insulin, while in the stable type, diencephalic regulations seem to be of greater importance. That is possibly the reason why the stable form responds so well to the hCG method of treating obesity, whereas the brittle type does not. Obese patients are generally suffering from the stable type, but a stable type may gradually change into a brittle one, which is usually associated with a loss of weight. Thus, when an obese diabetic finds that he is losing weight without diet or treatment, he should at once have his diabetes expertly attended to. There is some evidence to suggest that the change from stable to brittle is more liable to occur in patients who are taking insulin for their stable diabetes.

Rheumatism
All rheumatic pains, even those associated with demonstrable bony lesions, improve subjectively within a few days of treatment, and often require neither cortisone nor salicylates. Again this is a well known phenomenon in pregnancy, and while under treatment with hCG + diet the effect is no less dramatic. As it does not after pregnancy, the pain of deformed joints returns after treatment, but smaller doses of pain-relieving drugs seem able to control it satisfactorily after weight reduction. In any case, the hCG method makes it possible in obese arthritic patients to interrupt prolonged cortisone treatment without a recurrence of pain. This in itself is most welcome, but there is the added advantage that the treatment stimulates the secretion of ACTH in a physiological manner and that this regenerates the adrenal cortex, which is apt to suffer under prolonged cortisone treatment.

Cholesterol
The exact extent to which the blood cholesterol is involved in hardening of the arteries, high blood pressure and coronary disease is not as yet known, but it is now widely admitted that the blood cholesterol level is governed by diencephalic mechanisms. The behavior of circulating cholesterol is therefore of particular interest during the treatment of obesity with hCG. Cholesterol circulates in two forms, which we call free and esterified. Normally these fractions are present in a proportion of about 25% free to 75% esterified cholesterol, and it is the latter fraction which damages the walls of the arteries. In pregnancy this proportion is reversed and it may he taken for granted that arteriosclerosis never gets worse during pregnancy for this very reason.
To my knowledge, the only other condition in which the proportion of free to esterified cholesterol is reversed is during the treatment of obesity with hCG + diet, when exactly the same phenomenon takes place. This seems an important indication of how closely a patient under hCG treatment resembles a pregnant woman in diencephalic behavior.
When the total amount of circulating cholesterol is normal before treatment, this absolute amount is neither significantly increased nor decreased. But when an obese patient with an abnormally high cholesterol and already showing signs of arteriosclerosis is treated with hCG, his blood pressure drops and his coronary circulation seems to improve, and yet his total blood cholesterol may soar to heights never before reached.
At first this greatly alarmed us. But when we saw that the patients came to no harm even if treatment was continued and we found the same in follow-up examinations undertaken some months after treatment was continued as we found in examinations undertaken some months before treatment. As the increase is mostly in the form of the not dangerous form of the free cholesterol, we gradually came to welcome the phenomenon. Today we believe that the rise is entirely due to the liberation of recent cholesterol deposits that have not yet undergone calcification in the arterial wall and is therefore highly beneficial.

Gout
An identical behavior is found in the blood uric acid level of patients suffering from gout. Predictably such patients get an acute and often severe attack after the first few days of hCG treatment but then remain entirely free of pain, in spite of the fact that their blood uric acid often shows a marked increase which may persist for several months after treatment. Those patients who have regained their normal weight remain free of symptoms regardless of what they eat, while those that require a second course of treatment get another attack of gout as soon as the second course is initiated. We do not yet know what dioncephalic mechanisms are involved in gout; possibly emotional factors play a role, and it is worth remembering that the disease does not occur in women of childbearing age. We now give 2 tablets daily of ZYLORIC to all patients who give a history of gout and have a high blood uric acid level. In this way we can completely avoid attacks during treatment.

Blood Pressure
Patients who have brought themselves to the brink of malnutrition by exaggerated dieting, laxatives etc, often have an abnormally low blood pressure. In these cases the blood pressure rises to normal values at the beginning of treatment and then very gradually drops, as it always does in patients with a normal blood pressure. Normal values are always regained a few days after the treatment is over. Of this lowering of the blood pressure during treatment the patients are not aware. When the blood pressure is abnormally high, and provided there are no detectable renal lesions, the pressure drops, as it usually does in pregnancy. The drop is often very rapid, so rapid in fact that it sometimes is advisable to slow down the process with pressure sustaining medication until the circulation has had a few days time to adjust itself to the new situation. On the other hand, among the thousands of cases treated, we have never seen any incident which could be attributed to the rather sudden drop in high blond pressure.
When a woman suffering from high blood pressure becomes pregnant her blood pressure very soon drops, but after her confinement it may gradually rise back to its former level. Similarly, a high blood pressure present before hCG treatment tends to rise again after the treatment is over, though this is not always the case. But the former high levels are rarely reached, and we have gathered the impression that such relapses respond better to orthodox drugs such as Reserpine than before treatment.

Peptic Ulcers
In our cases of obesity with gastric or duodenal ulcers we have noticed a surprising subjective improvement in spite of a diet which would generally be considered most inappropriate for an ulcer patient. Here, too, there is a similarity with pregnancy, in which peptic ulcers hardly ever occur. However we have seen two cases with a previous history of several hemorrhages in which a bleeding occurred within 2 weeks of the end of treatment.

Psoriasis, Fingernails, Hair Varicose Ulcers
As in pregnancy, psoriasis greatly improves during treatment but may relapse when the treatment is over. Most patients spontaneously report a marked improvement in the condition of brittle fingernails. The loss of hair not infrequently associated with obesity is temporarily arrested, though in very rare cases an increased loss of hair has been reported. I remember a case in which a patient developed a patchy baldness - so called alopecia areata - after a severe emotional shock, just before she was about to start an hCG treatment. Our dermatologist diagnosed the case as a particularly severe one, predicting that all the hair would be lost. He counseled against the reducing treatment, but in view of my previous experience and as the patient was very anxious not to postpone reducing, I discussed the matter with the dermatologist and it was agreed that, having fully acquainted the patient with the situation, the treatment should be started. During the treatment, which lasted four weeks, the further development of the bald patches was almost, if not quite, arrested; however, within a week of having finished the course of hCG, all the remaining hair fell out as predicted by the dermatologist. The interesting point is that the treatment was able to postpone this result but not to prevent it. The patient has now grown a new shock of hair of which she is justly proud.

In obese patients with large varicose ulcers we were surprised to find that these ulcers heal rapidly under treatment with hCG. We have since treated non obese patients suffering from varicose ulcers with daily injections of hCG on normal diet with equally good results.

The ?Pregnant" Male
When a male patient hears that he is about to be put into a condition which in some respects resembles pregnancy, he is usually shocked and horrified. The physician must therefore carefully explain that this does not mean that he will be feminized and that hCG in no way interferes with his sex. He must be made to understand that in the interest of the propagation of the species nature provides for a perfect functioning of the regulatory headquarters in the diencephalun during pregnancy and that we are merely using this natural safeguard as a means of correcting the dicncephalic disorder which is responsible for his overweight.



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In treating obesity with the hCG + diet method we are handling what is perhaps the most complex organ in the human body. The diencephalon's functional equilibrium is delicately poised, so that whatever happens in one part has repercussions in others. In obesity this balance is out of kilter and can only be restored if the technique I am about to describe is followed implicitly. Even seemingly insignificant deviations, particularly those that at first sight seem to be an improvement, are very liable to produce most disappointing results and even annul the effect completely. For instance, if the diet is increased from 500 to 600 or 700 Calories, the loss of weight is quite unsatisfactory. If the daily dose of hCG is raised to 200 or more units daily its action often appears to be reversed, possibly because larger doses evoke diencephalic counter-regulations. On the other hand, the diencephalon is an extremely robust organ in spite of its unbelievable intricacy. From an evolutionary point of view it is one of the oldest organs in our body and its evolutionary history dates back more than 500 million years. This has tendered it extraordinarily adaptable to all natural exigencies, and that is one of the main reasons why the human species was able to evolve. What its evolution did not prepare it for were the conditions to which human culture and civilization now expose it.

History taking
When a patient first presents himself for treatment, we take a general history and note the time when the first signs of overweight were observed. We try to establish the highest weight the patient has ever had in his life (obviously excluding pregnancy), when this was, and what measures have hitherto been taken in an effort to reduce.
It has been our experience that those patients who have been taking thyroid preparations for long periods have a slightly lower average loss of weight under treatment with hCG than those who have never taken thyroid. This is even so in those patients who have been taking thyroid because they had an abnormally low basal metabolic rate. In many of these cases the low BMR is not due to any intrinsic deficiency of the thyroid gland, but rather to a lack of diencephalic stimulation of the thyroid gland via the anterior pituitary lobe. We never allow thyroid to be taken during treatment, and yet a BMR which was very low before treatment is usually found to be normal after a week or two of hCG + diet. Needless to say, this does not apply to those cases in which a thyroid deficiency has been produced by the surgical removal of a part of an overactive gland. It is also most important to ascertain whether the patient has taken diuretics (water eliminating pills) as this also decreases the weight loss under the hCG regimen.
Returning to our procedure, we next ask the patient a few questions to which he is held to reply simply with ?yes? or ?no?. These questions are: Do you suffer from headaches? rheumatic pains? menstrual disorders? constipation? breathlessness or exertion? swollen ankles? Do you consider yourself greedy? Do you feel the need to eat snacks between meals?
The patient then strips and is weighed and measured. The normal weight for his height, age, skeletal and muscular build is established from tables of statistical averages, whereby in women it is often necessary to make an allowance for particularly large and heavy breasts. The degree of overweight is then calculated, and from this the duration of treatment can be roughly assessed on the basis of an average loss of weight of a little less than a pound, say 300-400 grams-per injection, per day. It is a particularly interesting feature of the hCG treatment that in reasonably cooperative patients this figure is remarkably constant, regardless of sex, age and degree of overweight.

The Duration of Treatment
Patients who need to lose 15 pounds (7 kg.) or less require 26 days treatment with 23 daily injections or nasal sprays. The extra three days are needed because all patients must continue the 500-calorie diet for three days after the last injection or NASAL SPRAY. This is a very essential part of the treatment, because if they start eating normally as long as there is even a trace of hCG in their body they put on weight alarmingly at the end of the treatment. After three days when all the hCG has been eliminated this does not happen, because the blood is then no longer saturated with food and can thus accommodate an extra influx from the intestines without increasing its volume by retaining water.
We never give a treatment lasting less than 26 days, even in patients needing to lose only 5 pounds. It seems that even in the mildest cases of obesity the diencephalon requires about three weeks rest from the maximal exertion to which it has been previously subjected in order to regain fully its normal fat-banking capacity. Clinically this expresses itself, in the fact that, when in these mild cases, treatment is stopped as soon as the weight is normal, which may be achieved in a week, it is much more easily regained than after a full course of 23 injections or nasal sprays.

As soon as such patients have lost all their abnormal superfluous fat, they at once begin to feel ravenously hungry with continued injections. This is because hCG only puts abnormal fat into circulation and cannot, in the doses used, liberate normal fat deposits; indeed, it seems to prevent their consumption. As soon as their statistically normal weight is reached, these patients are put on 800-1000 calories for the rest of the treatment. The
diet is arranged in such a way that the weight remains perfectly stationary and is thus continued for three days after the 23rd injection or nasal spray. Only then are the patients free to eat anything they please except sugar and starches for the next three weeks.

Such early cases are common among actresses, models, and persons who are tired of obesity, having seen its ravages in other members of their family. Film actresses frequently explain that they must weigh less than normal. With this request we flatly refuse to comply, first, because we undertake to cure a disorder, not to create a new one, and second, because it is in the nature of the hCG method that it is self limiting. It becomes completely ineffective as soon as all abnormal fat is consumed. Actresses with a slight tendency to obesity, having tried all manner of reducing methods, invariably come to the conclusion that their figure is satisfactory only when they are underweight, simply because none of these methods remove their superfluous fat deposits. When they see that under hCG their figure improves out of all proportion to the amount of weight lost, they are nearly always content to remain within their normal weight-range.
When a patient has more than 15 pounds to lose the treatment takes longer but the maximum we give in a single course is 40 injections or nasal spray, nor do we as a rule allow patients to lose more than 34 lbs. (15 Kg.) at a time. The treatment is stopped when either 34 lbs. have been lost or 40 injections or nasal sprays have been given. The only exception we make is in the case of grotesquely obese patients who may be allowed to lose an additional 5-6 lbs. if this occurs before the 40 injections or nasal sprays are up.

Immunity to hCG
The reason for limiting a course to 40 injections or nasal spray is that by then some patients may begin to show signs of hCG immunity. Though this phenomenon is well known, we cannot as yet define the underlying mechanism. Maybe after a certain length of time the body learns to break down and eliminate hCG very rapidly, or possibly prolonged treatment leads to some sort of counter-regulation which annuls the dencepbahic effect.

After 40 daily injections or nasal sprays it takes about six weeks before this so called immunity is lost and hCG again becomes fully effective. Usually after about 40 injections or nasal spray patients may feel the onset of immunity as hunger which was previously absent. In those comparatively rare cases in which signs of immunity develop before the full course of 40 injections or nasal spray has been completed-say at the 35th injection- treatment must be stopped at once, because if it is continued the patients begin to look weary and drawn, feel weak and hungry and any further loss of weight achieved is then always at the expense of normal fat. This is not only undesirable, but normal fat is also instantly regained as soon as the patient is returned to a free diet.

Patients who need only 23 injections or nasal sprays may be treated daily, including Sundays, as they never develop immunity. In those that take 40 injections or nasal sprays the onset of immunity can be delayed if they are given only six treatments a week, leaving out Sundays or any other day they choose, provided that it is always the same day. On the days on which they do not receive the treatment they usually feel a slight sensation of hunger. At first we thought that this might be purely psychological, but we found that when normal saline is injected without the patient's knowledge the same phenomenon occurs.

Menstruation
During menstruation no treatments are given, but the diet is continued and causes no hardship; yet as soon as the menstruation is over, the patients become extremely hungry unless the treatments are resumed at once. It is very impressive to see the suffering of a woman who has continued her diet for a day or two beyond the end of the period without her treatment and then to hear the next day that all hunger ceased within a few hours after the treatment and to see her once again content, florid and cheerful. While on the question of menstruation it must he added that in teenaged girls the period may in some rare cases be delayed and exceptionally stop altogether. If then later this is artificially induced some weight may be regained.

Further Courses
Patients requiring the loss of more than 34 lbs. must have a second or even more courses. A second course can be started after an interval of not less than six weeks, though the pause can be more than six weeks. When a third, fourth or even fifth course is necessary, the interval between courses should be made progressively longer. Between a second and third course eight weeks should elapse, between a third and fourth course twelve weeks, between a fourth and fifth course twenty weeks and between a fifth and sixth course six months. In this way it is possible to bring about a weight reduction of 100 lbs. and more if required without the least hardship to the patient.

In general, men do slightly better than women and often reach a somewhat higher average daily loss. Very advanced cases do a little better than early ones, but it is a remarkable fact that this difference is only just statistically significant.

It is impressed upon the patient that he will have to follow the prescribed diet to the letter and that after the first three days this will cost him no effort, as he will feel no hunger and may indeed have difficulty in getting down the 500 Calories which he will be given. If these conditions are not acceptable the case is refused, as any compromise or half measure is bound to prove utterly disappointing to patient and physician alike and is a waste of time and energy.

Though a patient can only consider himself really cured when he has been reduced to his stastically normal weight, we do not insist that he commit himself to that extent. Even a partial loss of overweight is highly beneficial, and it is our experience that once a patient has completed a first course he is so enthusiastic about the ease with which the - to him surprising - results are achieved that he almost invariably comes back for more. There certainly can be no doubt that in my clinic more time is spent on damping over-enthusiasm than on insisting that the rules of the treatment be observed.

Examining the patient
Only when agreement is reached on the points so far discussed do we proceed with the examination of the patient. A note is made of the size of the first upper incisor, of a pad of fat on the nape of the neck, at the axilla and on the inside of the knees. The presence of striation, a suprapubic fold, a thoracic fold, angulation of elbow and knee joint, breast-development in men and women, edema of the ankles and the state of genital development in the male are noted.

Wherever this seems indicated we X-ray the sella turcica, as the bony capsule which contains the pituitary gland is called, measure the basal metabolic rate, X-ray the chest and take an electrocardiogram. We do a blood-count and a sedimentation rate and estimate uric acid, cholesterol, iodine and sugar in the fasting blood.

Gain before Loss
Patients whose general condition is low, owing to excessive previous dieting, must eat to capacity for about one week before starting treatment, regardless of how much weight they may gain in the process. One cannot keep a patient comfortably on 500 Calories unless his normal fat reserves are reasonably well stocked. It is for this reason also that every case, even those that are actually gaining must eat to capacity of the most fattening food they can get down until they have had the third injection. It is a fundamental mistake to put a patient on 500 Calories as soon as the treatment are started, as it seems to take about three treatments before abnormally deposited fat begins to circulate and thus become available.
We distinguish between the first three doses, which we call ?non-effective? as far as the loss of weight is concerned, and the subsequent doses given while the patient is dieting, which we call ?effective?. The average loss of weight is calculated on the number of effective doses and from the weight reached on the day of the third injection which may be well above what it was two days earlier when the first injection was given.
Most patients who have been struggling with diets for years and know how rapidly they gain if they let themselves go are very hard to convince of the absolute necessity of gorging for at least two days, and yet this must he insisted upon categorically if the further course of treatment is to run smoothly. Those patients who have to be put on forced feeding for a week before starting the injections usually gain weight rapidly - four to six pounds in 24 hours is not unusual - but after a day or two this rapid gain generally levels off. In any case, the whole gain is usually lost in the first 48 hours of dieting. It is necessary to proceed in this manner because the gain re-stocks the depleted normal reserves, whereas the subsequent loss is from the abnormal deposits only.

Patients in a satisfactory general condition and those who have not just previously restricted their diet start forced feeding on the day of the first injection. Some patents say that they can no longer overeat because their stomach has shrunk after years of restrictions. While we know that no stomach ever shrinks, we compromise by insisting that they eat frequently of highly concentrated foods such as milk chocolate, pastries with whipped cream sugar, fried meats (particularly pork), eggs and bacon, mayonnaise, bread with thick butter and jam, etc. The time and trouble spent on pressing this point upon incredulous or reluctant patients is always amply rewarded afterwards by the complete absence of those difficulties which patients who have disregarded these instructions are liable to experience.
During the two days of forced feeding from the first to the third dose- many patients are surprised that contrary to their previous experience they do not gain weight and some even lose. The explanation is that in these cases there is a compensatory flow of urine, which drains excessive water from the body. To some extent this seems to be a direct action of hCG, but it may also be due to a higher protein intake, as we know that a protein-deficient diet makes the body retain water.

Starting treatment
In menstruating women, the best time to start treatment is immediately after a period. Treatment may also be started later, but it is advisable to have at least ten days in hand before the onset of the next period. Similarly, the end of a course should never be made to coincide with onset of menstruation. If things should happen to work out that way, it is better to give the last injection three days before the expected date of the menses so that a normal diet can he resumed at onset. Alternatively, at least three injections should be given after the period, followed by the usual three days of dieting. This rule need not be observed in such patients who have reached their normal weight before the end of treatment and are already on a higher caloric diet.
Patients who require more than the minimum of 23 injections and who therefore skip one day a week in order to postpone immunity to hCG cannot have their third injections on the day before the interval. Thus if it is decided to skip Sundays, the treatment can be started on any day of the week except Thursdays. Supposing they start on Thursday, they will have their third injection on Saturday, which is also the day on which they start their 500 Calorie diet. They would then base no injection on the second day of dieting, this exposes them to an unnecessary hardship, as without the injection they will feel particularly hungry. Of course, the difficulty can be overcome by exceptionally injecting them on the first Sunday. If this day falls between the first and second or between the second and third injection, we usually prefer to give the patient the extra day of forced feeding, which the majority rapturously enjoy.

The Diet
The 500 calorie diet is explained during the office visit and it is most important that the person who will actually cook is present - the wife, the mother or the cook, as the case may be.

Breakfast: Tea or coffee in any quantity without sugar. Only one tablespoonful of milk allowed in 24 hours. Saccharin or Stevia may be used.

Lunch:
1. 100 grams of veal, beef, chicken breast, fresh white fish, lobster, crab, or shrimp. All visible fat must be carefully removed before cooking, and the meat must be weighed raw. It must be boiled or grilled without additional fat. Salmon, eel, tuna, herring, dried or pickled fish are not allowed. The chicken breast must be removed from the bird.
2. One type of vegetable only to be chosen from the following: spinach, chard, chicory, beet-greens, green salad, tomatoes, celery, fennel, onions, red radishes, cucumbers, asparagus, cabbage.
3. One breadstick (grissino) or one Melba toast.
4. An apple, orange, or a handful of strawberries or one-half grapefruit.

Dinner :
The same four choices as lunch.


The juice of one lemon daily is allowed for all purposes. Salt, pepper, vinegar, mustard powder, garlic, sweet basil, parsley, thyme, majoram, etc., may be used for seasoning, but no oil, butter or dressing.
Tea, coffee, plain water, or mineral water are the only drinks allowed, but they may be taken in any quantity and at all times.

In fact, the patient should drink about 2 liters of these fluids per day. Many patients are afraid to drink so much because they fear that this may make them retain more water. This is a wrong notion as the body is more inclined to store water when the intake falls below its normal requirements.
The fruit or the breadstick may be eaten between meals instead of with lunch or dinner, but not more than than four items listed for lunch and dinner may be eaten at one meal.

No medicines or cosmetics other than lipstick, eyebrow pencil and powder may be used.
Every item in the list is gone over carefully, continually stressing the point that no variations other than those listed may be introduced. All things not listed are forbidden, and the patient is assured that nothing permissible has been left out. The 100 grams of meat must he scrupulously weighed raw after all visible fat has been removed. To do this accurately the patient must have a letter-scale, as kitchen scales are not sufficiently accurate and the butcher should certainly not be relied upon. Those not uncommon patients who feel that even so little food is too much for them, can omit anything they wish.

There is no objection to breaking up the two meals. For instance having a breadstick and an apple for breakfast or before going to bed, provided they are deducted from the regular meals. The whole daily ration of two breadsticks or two fruits may not be eaten at the same time, nor can any item saved from the previous day be added on the following day. In the beginning patients are advised to check every meal against their diet sheet before starting to eat and not to rely on their memory. It is also worth pointing out that any attempt to observe this diet without hCG will lead to trouble in two to three days. We have had cases in which patients have proudly flaunted their dieting powers in front of their friends without mentioning the fact that they are also receiving treatment with hCG. They let their friends try the same diet, and when this proves to be a failure - as it necessarily must - the patient starts raking in unmerited kudos for superhuman willpower.

It should also be mentioned that two small apples weighing as much as one large one never the less have a higher caloric value and are therefore not allowed though there is no restriction on the size of one apple. Some people do not realize that chicken breast does not mean the breast of any other fowl, nor does it mean a wing or drumstick.

The most tiresome patients are those who start counting calories and then come up with all manner of ingenious variations which they compile from their little books. When one has spent years of weary research trying to make a diet as attractive as possible without jeopardizing the loss of weight, culinary geniuses who are out to improve their unhappy lot are hard to take.

Making up the Calories
The diet used in conjunction with hCG must not exceed 500 calories per day, and the way these calories are made up is of utmost importance. For instance, if a patient drops the apple and eats an extra breadstick instead, he will not be getting more calories but he will not lose weight. There are a number of foods, particularly fruits and vegetables, which have the same or even lower caloric values than those listed as permissible, and yet we find that they interfere with the regular loss of weight under hCG, presumably owing to the nature of their composition. Pimiento peppers, okra, artichokes and pears are examples of this.

While this diet works satisfactorily in Italy, certain modifications have to be made in other countries. For instance, American beef has almost double the caloric value of South Italian beef, which is not marbled with fat. This marbling is impossible to remove. In America, therefore, low-grade veal should be used for one meal and fish (excluding all those species such as herring, mackerel, tuna, salmon, eel, etc., which have a high fat content, and all dried, smoked or pickled fish), chicken breast, lobster, crawfish, prawns or shrimp, crabmeat or kidneys for the other meal. Where the Italian breadsticks, the so-called grissini, are not available, one Melba toast may be used instead, though they are psychologically less satisfying. A Melba toast has about the same weight as the very porous grissini which is much more to look at and to chew.

When local conditions or the feeding habits of the population make changes necessary it must be borne in mind that the total daily intake must not exceed 500 calories if the best possible results are to be obtained, that the daily ration should contain 200 grams of fat-free protein and a very small amount of starch.
Just as the daily dose of hCG is the same in all cases, so the same diet proves to be satisfactory for a small elderly lady of leisure or a hard working muscular giant. Under the effect of hCG the obese body is always able to obtain all the calories it needs from the abnormal fat deposits, regardless of whether it uses up 1500 or 4000 per day. It must be made very clear to the patient that he is living to a far greater extent on the fat which he is losing than on what he eats.
Many patients ask why eggs are not allowed. The contents of two good sized eggs are roughly equivalent to 100 grams of meat, but fortunately the yolk contains a large amount of fat, which is undesirable. Very occasionally we allow egg - boiled, poached or raw - to patients who develop an aversion to meat, but in this case they must add the white of three eggs to the one they eat whole. In countries where cottage cheese made from skimmed milk is available 100 grams may occasionally be used instead of the meat, but no other cheeses are allowed.


Vegetarians
Strict vegetarians such as orthodox Hindus present a special problem, because milk and curds are the only animal protein they will eat. To supply them with sufficient protein of animal origin they must drink 500 cc. of skimmed milk per day, though part of this ration can be taken as curds. As far as fruit, vegetables and starch are concerned, their diet is the same as that of non-vegetarians; they cannot be allowed their usual intake of vegetable proteins from leguminous plants such as beans or from wheat or nuts, nor can they have their customary rice. In spite of these severe restrictions, their average loss is about half that of non-vegetarians, presumably owing to the sugar content of the milk.

Faulty Dieting
Few patients will take one's word for it that the slightest deviation from the diet has under hCG disastrous results as far as the weight is concerned. This extreme sensitivity has the advantage that the smallest error is immediately detectable at the daily weighing but most patients have to make the experience before they will believe it.
Persons in high official positions such as embassy personnel, politicians, senior executives, etc., who are obliged to attend social functions to which they cannot bring their meager meal must be told beforehand that an official dinner will cost them the loss of about three days treatment, however careful they are and in spite of a friendly and would-be cooperative host. We generally advise them to avoid all around embarrassment, the almost inevitable turn of conversation to their weight problem and the outpouring of lay counsel from their table partners by not letting it be known that they are under treatment. They should take dainty servings of everything, bide what they can under the cutlery and book the gain which may take three days to get rid of as one of the sacrifices which their profession entails. Allowing three days for their correction, such incidents do not jeopardize the treatment, provided they do not occur all too frequently in which case treatment should be postponed to a socially more peaceful season.

Vitamins and anemia
Sooner or later most patients express a fear that they may be running out of vitamins or that the restricted diet may make them anemic. On this score the physician can confidently relieve their apprehension by explaining that every time they lose a pound of fatty tissue, which they do almost daily, only the actual fat is burned up; all the vitamins, the proteins, the blood, and the minerals which this tissue contains in abundance are fed back into the body. Actually, a low blood count not due to any serious disorder of the blood forming tissues improves during treatment, and we have never encountered a significant protein deficiency nor signs of a lack of vitamins in patients who are dieting regularly.

The First Days of Treatment
On the day of the third injection it is almost routine to hear two remarks. One is: ?You know, Doctor, I'm sure it's only psychological, but I already feel quite different?. So common is this remark, even from very skeptical patients that we hesitate to accept the psychological interpretation. The other typical remark is: ?Now that I have been allowed to eat anything I want, I can't get it down. Since yesterday I feel like a stuffed pig. Food just doesn't seem to interest me any more, and I am longing to get on with your diet?. Many patients notice that they are passing more urine and that the swelling in their ankles is less even before they start dieting.
On the day of the fourth injection most patients declare that they are feeling fine. They have usually lost two pounds or more, some say they feel a bit empty but hasten to explain that this does not amount to hunger. Some complain of a mild headache of which they have been forewarned and for which they have been given permission to take aspirin.
During the second and third day of dieting - that is, the fifth and sixth injection-these minor complaints improve while the weight continues to drop at about double the usually overall average of almost one pound per day, so that a moderately severe case may by the fourth day of dieting have lost as much as 8- 10 lbs.
It is usually at this point that a difference appears between those patients who have literally eaten to capacity during the first two days of treatment and those who have not. The former feel remarkably well; they have no hunger, nor do they feel tempted when others eat normally at the same table. They feel lighter, more clear-headed and notice a desire to move quite contrary to their previous lethargy. Those who have disregarded the advice to eat to capacity continue to have minor discomforts and do not have the same euphoric sense of self-being until about a week later. It seems that their normal fat reserves require that much more time before they are fully stocked.

Fluctuations in weight loss
After the fourth or fifth day of dieting the daily loss of weight begins to decrease to one pound or somewhat less per clay, and there is a smaller urinary output. Men often continue to lose regularly at that rate, but women are more irregular in spite of faultless dieting. There may be no drop at all for two or three days and then a sudden loss which reestablishes the normal average. These fluctuations are entirely due to variations in the retention and elimination of water, which are more marked in women than in men.
The weight registered by the scale is determined by two processes not necessarily synchronized under the influence of hCG. Fat is being extracted from the cells, in which it is stored in the fatty tissue. When these cells are empty and therefore serve no purpose, the body breaks down the cellular structure and absorbs it, but breaking up of useless cells, connective tissue, blood vessels, etc., may lag behind the process of fat-extraction. When this happens the body appears to replace some of the extracted fat with water which is retained for this purpose. As water is heavier than fat the scales may show no loss of weight, although sufficient fat has actually been consumed to make up for the deficit in the 500-Calorie diet. When such tissue is finally broken down, the water is liberated and there is a sudden flood of urine and a marked loss of weight. This simple interpretation of what is really an extremely complex mechanism is the one we give those patients who want to know why it is that on certain days they do not lose, though they have committed no dietary error.
Patients who have previously regularly used diuretics as a method of reducing, lose fat during the first two or three weeks of treatment which shows in their measurements, but the scale may show little or no loss because they are replacing the normal water content of their body which has been dehydrated. Diuretics should never be used for reducing.

Interruptions of Weight Loss
We distinguish four types of interruption in the regular daily loss. The first is the one that has already been mentioned in which the weight stays stationary for a day or two, and this occurs, particularly towards the end of a course, in almost every case.

The Plateau
The second type of interruption we call a ?plateau?. A plateau lasts 4-6 days and frequently occurs during the second half of a full course, particularly in patients that have been doing well and whose overall average of nearly a pound per effective injection has been maintained. Those who are losing more than the average all have a plateau sooner or later. A plateau always corrects, itself, but many patients who have become accustomed to a regular daily loss get unnecessarily worried. No amount of explanation convinces them that a plateau does not mean that they are no longer responding normally to treatment.
In such cases we consider it permissible, for purely psychological reasons, to break up the plateau. This can be done in two ways. One is a so-called ?apple day?. An apple-day begins at lunch and continues until just before lunch of the following day. The patients are given six large apples and are told to eat one whenever they feel the desire though six apples is the maximum allowed. During an apple-day no other food or liquids except plain water are allowed and of water they may only drink just enough to quench an uncomfortable thirst if eating an apple still leaves them thirsty. Most patients feel no need for water and are quite happy with their six apples. Needless to say, an apple-day may never be given on the day on which there is no injection. The apple-day produces a gratifying loss of weight on the following day, chiefly due to the elimination of water. This water is not regained when the patients resume their normal 500-calorie diet at lunch, and on the following days they continue to lose weight satisfactorily.
The other way to break up a plateau is by giving a non-mercurial diuretic for one day. This is simpler for the patient but we prefer the apple-day as we sometimes find that though the diuretic is very effective on the following day it may take two to three days before the normal daily reduction is resumed, throwing the patient into a new fit of despair. It is useless to give either an apple-day or a diuretic unless the weight has been stationary for at least four days without any dietary error having been committed.

Reaching a Former Level
The third type of interruption in the regular loss of weight may last much longer - ten days to two weeks. Fortunately, it is rare and only occurs in very advanced cases, and then hardly ever during the first course of treatment. It is seen only in those patients who during some period of their lives have maintained a certain fixed degree of obesity for ten years or more and have then at some time rapidly increased beyond that weight. When then in the course of treatment the former level is reached, it may take two weeks of no loss, in spite of hCG and diet, before further reduction is normally resumed.

Menstrual Interruption
The fourth type of interruption is the one which often occurs a few days before and during the menstrual period and in some women at the time of ovulation. It must also be mentioned that when a woman becomes pregnant during treatment - and this is by no means uncommon - she at once ceases to lose weight. An unexplained arrest of reduction has on several occasions raised our suspicion before the first period was missed. If in such cases, menstruation is delayed, we stop injecting and do a precipitation test five days later. No pregnancy test should be carried out earlier than five days after the last injection, as otherwise the hCG may give a false positive result.
Oral contraceptives may be used during treatment.

Dietary Errors
Any interruption of the normal loss of weight which does not fit perfectly into one of those categories is always due to some possibly very minor dietary error. Similarly, any gain of more than 100 grams is invariably the result of some transgression or mistake, unless it happens on or about the day of ovulation or during the three days preceding the onset of menstruation, in which case it is ignored. In all other cases the reason for the gain must be established at once.
The patient who frankly admits that he has stepped out of his regimen when told that something has gone wrong is no problem. He is always surprised at being found out, because unless he has seen this himself he will not believe that a salted almond, a couple of potato chips, a glass of tomato juice or an extra orange will bring about a definite increase in his weight on the following day.
Very often he wants to know why extra food weighing one ounce should increase his weight by six ounces. We explain this in the following way: Under the influence of hCG the blood is saturated with food and the blood volume has adapted itself so that it can only just accommodate the 500 calories which come in from the intestinal tract in the course of the day. Any additional income, however little this may be, cannot be accommodated and the blood is therefore forced to increase its volume sufficiently to hold the extra food, which it can only do in a very diluted form. Thus it is not the weight of what is eaten that plays the determining role but rather the amount of water which the body must retain to accommodate this food.
This can be illustrated by mentioning the case of salt. In order to hold one teaspoonful of salt the body requires one liter of water, as it cannot accommodate salt in any higher concentration. Thus, if a person eats one teaspoonfull of salt his weight will go up by more than two pounds as soon as this salt is absorbed from his intestine.
To this explanation many patients reply: Well, if I put on that much every time I eat a little extra, how can I hold my weight after the treatment? It must therefore be made clear that this only happens as long as they are under hCG. When treatment is over, the blood is no longer saturated and can easily accommodate extra food without having to increase its volume. Here again the professional reader will be aware that this interpretation is a simplification of an extremely intricate physiological process which actually accounts for the phenomenon.

Salt and Reducing
While we are on the subject of salt, I can take this opportunity to explain that we make no restriction in the use of salt and insist that the patients drink large quantities of water throughout the treatment. We are out to reduce abnormal fat and are not in the least interested in such illusory weight losses as can be achieved by depriving the body of salt and by desiccating it. Though we allow the free use of salt, the daily amount taken should be roughly the same, as a sudden increase will of course be followed by a corresponding increase in weight as shown by the scale. An increase in the intake of salt is one of the most common causes for an increase in weight from one day to the next. Such an increase can be ignored, provided it is accounted for, it in no way influences the regular loss of fat.

Water
Patients are usually hard to convince that the amount of water they retain has nothing to do with the amount of water they drink. When the body is forced to retain water, it will do this at all costs. If the fluid intake is insufficient to provide all the water required, the body withholds water from the kidneys and the urine becomes scanty and highly concentrated, imposing a certain strain on the kidneys. If that is insufficient, excessive water will be with-drawn from the intestinal tract, with the result that the feces become hard and dry. On the other hand if a patient drinks more than his body requires, the surplus is promptly and easily eliminated. Trying to prevent the body from retaining water by drinking less is therefore not only futile but even harmful.

Constipation
An excess of water keeps the feces soft, and that is very important in the obese, who commonly suffer from constipation and a spastic colon. While a patient is under treatment we never permit the use of any kind of laxative taken by mouth. We explain that owing to the restricted diet it is perfectly satisfactory and normal to have an evacuation of the bowel only once every three to four days and that, provided plenty of fluids are taken, this never leads to any disturbance. Only in those patients who begin to fret after four days do we allow the use of a suppository. Patients who observe this rule find that after treatment they have a perfectly normal bowel action and this delights many of them almost as much as their loss of weight.

Investigating Dietary Errors
When the reason for a slight gain in weight is not immediately evident, it is necessary to investigate further. A patient who is unaware of having committed an error or is unwilling to admit a mistake protests indignantly when told he has done something he ought not to have done. In that atmosphere no fruitful investigation can be conducted; so we calmly explain that we are not accusing him of anything but that we know for certain from our not inconsiderable experience that something has gone wrong and that we must now sit down quietly together and try and find out what it was. Once the patient realizes that it is in his own interest that he play an active and not merely a passive role in this search, the reason for the setback is almost invariably discovered. Having been through hundreds of such sessions, we are nearly always able to distinguish the deliberate liar from the patient who is merely fooling himself or is really unaware of having erred.

Liars and Fools
When we see obese patients there are generally two of us present in order to speed up routine handling. Thus when we have to investigate a rise in weight, a glance is sufficient to make sure that we agree or disagree. If after a few questions we both feel reasonably sure that the patient is deliberately lying, we tell him that this is our opinion and warn him that unless he comes clean we may refuse further treatment. The way he reacts to this furnishes additional proof whether we are on the right track or not we now very rarely make a mistake.
If the patient breaks down and confesses, we melt and are all forgiveness and treatment proceeds. Yet if such performances have to be repeated more than two or three times, we refuse further treatment. This happens in less than 1% of our cases. If the patient is stubborn and will not admit what he has been up to, we usually give him one more chance and continue even though we have been unable to find the reason for his gain. In many such cases there is no repetition, and frequently the patient does then confess a few days later after he has thought things over.

The patient who is fooling himself is the one who has committed some trifling, offense against the rules but who has been able to convince himself that this is of no importance and cannot possibly account for the gain in weight. Women seem particularly prone to getting themselves entangled in such delusions. On the other hand, it does frequently happen that a patient will in the midst of a conversation unthinkingly spear an olive or forget that he has already eaten his breadstick.

A mother preparing food for the family may out of sheer habit forget that she must not taste the sauce to see whether it needs more salt. Sometimes a rich maiden aunt cannot be offended by refusing a cup of tea into which she has put two teaspoons of sugar, thoughtfully remembering the patient's taste from previous occasions. Such incidents are legion and are usually confessed without hesitation, but some patients seem genuinely able to forget these lapses and remember them with a visible shock only after insistent questioning.

In these cases we go carefully over the day. Sometimes the patient has been invited to a meal or gone to a restaurant, naively believing that the food has actually been prepared exactly according to instructions. They will say: ?Yes, now that I come to think of it the steak did seem a bit bigger than the one I have at home, and it did taste better; maybe there was a little fat on it, though I specially told them to cut it all away?. Sometimes the breadsticks were broken and a few fragments eaten, and ?Maybe they were a little more than one?. It is not uncommon for patients to place too much reliance on their memory of the diet-sheet and start eating carrots, beans or peas and then to seem genuinely surprised when their attention is called to the fact that these are forbidden, as they have not been listed.

Cosmetics
When no dietary error is elicited we turn to cosmetics. Most women find it hard to believe that fats, oils, creams and ointments applied to the skin are absorbed and interfere with weight reduction by hCG just as if they had been eaten. This almost incredible sensitivity to even such very minor increases in nutritional intake is a peculiar feature of the hCG method. For instance, we find that persons who habitually handle organic fats, such as workers in beauty parlors, masseurs, butchers, etc. never show what we consider a satisfactory loss of weight unless they can avoid fat coming into contact with their skin.

The point is so important that I will illustrate it with two cases. A lady who was cooperating perfectly suddenly increased half a pound. Careful questioning brought nothing to light. She had certainly made no dietary error nor had she used any kind of face cream, and she was already in the menopause. As we felt that we could trust her implicitly, we left the question suspended. Yet just as she was about to leave the consulting room she suddenly stopped, turned and snapped her fingers. ?I've got it,? she said. This is what had happened : She had bought herself a new set of make-up pots and bottles and, using her fingers, had transferred her large assortment of cosmetics to the new containers in anticipation of the day she would be able to use them again after her treatment.

The other case concerns a man who impressed us as being very conscientious. He was about 20 lbs. overweight but did not lose satisfactorily from the onset of treatment. Again and again we tried to find the reason but with no success, until one day he said:?I never told you this, but I have a glass eye. In fact, I have a whole set of them. I frequently change them, and every time I do that I put a special ointment in my eyesocket.. Do you think that could have anything to do with it?? As we thought just that, we asked him to stop using this ointment, and from that day on his weight-loss was regular.

We are particularly averse to those modern cosmetics which contain hormones, as any interference with endocrine regulations during treatment must be absolutely avoided. Many women whose skin has in the course of years become adjusted to the use of fat containing cosmetics find that their skin gets dry as soon as they stop using them. In such cases we permit the use of plain mineral oil, which has no nutritional value. On the other hand, mineral oil should not be used in preparing the food, first because of its undesirable laxative quality, and second because it absorbs some fat-soluble vitamins, which are then lost in the stool. We do permit the use of lipstick, powder and such lotions as are entirely free of fatty substances. We also allow brilliantine to be used on the hair but it must not be rubbed into the scalp. Obviously sun-tan oil is prohibited.

Many women are horrified when told that for the duration of treatment they cannot use face creams or have facial massages. They fear that this and the loss of weight will ruin their complexion. They can be fully reassured. Under treatment normal fat is restored to the skin, which rapidly becomes fresh and turgid, making the expression much more youthful. This is a characteristic of the hCG method which is a constant source of wonder to patients who have experienced or seen in others the facial ravages produced by the usual methods of reducing. An obese woman of 70 obviously cannot expect to have her pued face reduced to normal without a wrinkle, but it is remarkable how youthful her face remains in spite of her age.

The Voice
Incidentally, another interesting feature of the hCG method is that it does not ruin a singing voice. The typically obese prima donna usually finds that when she tries to reduce, the timbre of her voice is liable to change, and understandably this terrifies her. Under hCG this does not happen; indeed, in many cases the voice improves and the breathing invariably does. We have had many cases of professional singers very carefully controlled by expert voice teachers, and they have been so enthusiastic that they now frequently send us patients.

Other Reasons for a Gain
Apart from diet and cosmetics there can be a few other reasons for a small rise in weight. Some patients unwittingly take chewing gum, throat pastilles, vitamin pills, cough syrups etc., without realizing that the sugar or fats they contain may interfere with a regular loss of weight. Sex hormones or cortisone in its various modern forms must be avoided,
though oral contraceptives are permitted. In fact the only self-medication we allow is aspirin for a headache, though headaches almost invariably disappear after a week of treatment, particularly if of the migraine type.
Occasionally we allow a sleeping tablet or a tranquilizer, but patients should be told that while under treatment they need and may get less sleep. For instance, here in Italy where it is customary to sleep during the siesta which lasts from one to four in the afternoon most patients find that though they lie down they are unable to sleep.

We encourage swimming and sun bathing during treatment, but it should be remembered that a severe sunburn always produces a temporary rise in weight, evidently due to water retention. The same may be seen when a patient gets a common cold during treatment. Finally, the weight can temporarily increase - paradoxical though this may sound - after an exceptional physical exertion of long duration leading to a feeling of exhaustion. A game of tennis, a vigorous swim, a run, a ride on horseback or a round of golf do not have this effect; but a long trek, a day of skiing, rowing or cycling or dancing into the small hours usually result in a gain of weight on the following day, unless the patient is in perfect training. In patients coming from abroad, where they always use their cars, we often see this effect after a strenuous day of shopping on foot, sightseeing and visits to galleries and museums. Though the extra muscular effort involved does consume some additional calories, this appears to be offset by the retention of water which the tired circulation cannot at once eliminate.

Appetite-reducing Drugs
We hardly ever use amphetamines, the appetite-reducing drugs such as Dexedrin, Dexamil, Preludin, etc., as there seems to be no need for them during the hCG treatment. The only time we find them useful is when a patient is, for impelling and unforeseen reasons, obliged to forego the injections for three to four days and yet wishes to continue the diet so that he need not interrupt the course.

Unforeseen Interruptions of Treatment
If an interruption of treatment lasting more than four days is necessary, the patient must increase his diet to at least 800 calories by adding meat, eggs, cheese, and milk to his diet after the third day, as otherwise he will find himself so hungry and weak that he is unable to go about his usual occupation. If the interval lasts less than two weeks the patient can directly resume treatment and the 500-calorie diet, but if the interruption lasts longer he must again eat normally until he has had his third treatment.

When a patient knows beforehand that he will have to travel and be absent for more than four days, it is always better to stop treatment three days before he is due to leave so that he can have the three days of strict dieting which are necessary after the last injection at home. This saves him from the almost impossible task of having to arrange the 500 calorie diet while en route, and he can thus enjoy a much greater dietary freedom from the day of his departure. Interruptions occurring before 20 effective injections have been given are most undesirable, because with less than that number of injections some weight is liable to be regained. After the 20th injection an unavoidable interruption is merely a loss of time.

Muscular Fatigue
Towards the end of a full course, when a good deal of fat has been rapidly lost, some patients complain that lifting a weight or climbing stairs requires a greater muscular effort than before. They feel neither breathlessness nor exhaustion but simply that their muscles have to work harder. This phenomenon, which disappears soon after the end of the treatment, is caused by the removal of abnormal fat deposited between, in, and around the muscles. The removal of this fat makes the muscles too long, and so in order to achieve a certain skeletal movement - say the bending of an arm - the muscles have to perform greater contraction than before. Within a short while the muscle adjusts itself perfectly to the new situation, but under hCG the loss of fat is so rapid that this adjustment cannot keep up with it. Patients often have to be reassured that this does not mean that they are ?getting weak?. This phenomenon does not occur in patients who regularly take vigorous exercise and continue to do so during treatment.

Massage
I never allow any kind of massage during treatment. It is entirely unnecessary and merely disturbs a very delicate process which is going on in the tissues. Few indeed are the masseurs and masseuses who can resist the temptation to knead and hammer abnormal fat deposits. In the course of rapid reduction it is sometimes possible to pick up a fold of skin which has not yet had time to adjust itself, as it always does under hCG, to the changed figure. This fold contains its normal subcutaneous fat and may be almost an inch thick. It is one of the main objects of the hCG treatment to keep that fat there. Patients and their masseurs do not always understand this and give this fat a working-over. I have seen such patients who were as black and blue as if they had received a sound thrashing
.
In my opinion, massage, thumping, rolling, kneading, and shivering undertaken for the purpose of reducing abnormal fat can do nothing but harm. We once had the honor of treating the proprietress of a high class institution that specialized in such antics. She had the audacity to confess that she was taking our treatment to convince her clients of the efficacy of her methods, which she had found useless in her own case.
How anyone in his right mind is able to believe that fatty tissue can be shifted mechanically or be made to vanish by squeezing is beyond my comprehension. The only effect obtained is severe bruising. The torn tissue then forms scars, and these slowly contracts making the fatty tissue even harder and more unyielding.

A lady once consulted us for her most ungainly legs. Large masses of fat bulged over the ankles of her tiny feet, and there were about 40 lbs. too much on her hips and thighs. We assured her that this overweight could be lost and that her ankles would markedly improve in the process. Her treatment progressed most satisfactorily but to our surprise there was no improvement in her ankles. We then discovered that she had for years been taking every kind of mechanical, electric and heat treatment for her legs and that she had made up her mind to resort to plastic surgery if we failed.
Re-examining the fat above her ankles, we found that it was unusually hard. We attributed this to the countless minor injuries inflicted by kneading. These injuries had healed but had left a tough network of connective scar-tissue in which the fat was imprisoned. Ready to try anything, she was put to bed for the remaining three weeks of her first course with her lower legs tightly strapped in unyielding bandages. Every day the pressure was increased. The combination of hCG, diet and strapping brought about a marked improvement in the shape of her ankles. At the end of her first course she returned to her home abroad. Three months later she came back for her second course. She had maintained both her weight and the improvement of her ankles. The same procedure was repeated, and after five weeks she left the hospital with a normal weight and legs that, if not exactly shapely, were at least unobtrusive. Where no such injuries of the tissues have been inflicted by inappropriate methods of treatment, these drastic measures are never necessary.

Blood Sugar
Towards the end of a course or when a patient has nearly reached his normal weight it occasionally happens that the blood sugar drops below normal, and we have even seen this in patients who had an abnormally high blood sugar before treatment. Such an attack of hypoglycemia is almost identical with the one seen in diabetics who have taken too much insulin. The attack comes on suddenly; there is the same feeling of light-headedness, weakness in the knees, trembling, and unmotivated sweating. But under hCG, hypoglycemia does not produce any feeling of hunger. All these symptoms are almost instantly relieved by taking two heaped teaspoons of sugar.
In the course of treatment the possibility of such an attack is explained to those patients who are in a phase in which a drop in blood sugar may occur. They are instructed to keep sugar or glucose sweets handy, particularly when driving a car. They are also told to watch the effect of taking sugar very carefully and report the following day. This is important, because anxious patients to whom such an attack has been explained are apt to take sugar unnecessarily, in which case it inevitably produces a gain in weight and does not dramatically relieve the symptoms for which it was taken, proving that these were not due to hypoglycemia. Some patients mistake the effects of emotional stress for hypoglycemia. When the symptoms are quickly relieved by sugar this is proof that they were indeed due to an abnormal lowering of the blood sugar, and in that case there is no increase in the weight on the following day. We always suggest that sugar be taken if the patient is in doubt.
Once such an attack has been relieved with sugar we have never seen it recur on the immediately subsequent days, and only very rarely does a patient have two such attacks separated by several days during a course of treatment. In patients who have not eaten sufficiently during the first two days of treatment we sometimes give sugar when the minor symptoms usually felt during the first there days of treatment continue beyond that time, and in some cases this has seemed to speed up the euphoria ordinarily associated with the hCG method.

The Ratio of Pounds to Inches
An interesting feature of the hCG method is that, regardless of how fat a patient is, the greatest circumference -- abdomen or hips as the case may be is reduced at a constant rate which is extraordinarily close to 1 cm. per kilogram of weight lost. At the beginning of treatment the change in measurements is somewhat greater than this, but at the end of a course it is almost invariably found that the girth is as many centimeters less as the number of kilograms by which the weight has been reduced. I have never seen this clear cut relationship in patients that try to reduce by dieting only.

Preparing the Solution
Human chorionic gonadotrophin comes on the market as a highly soluble powder which is the pure substance extracted from the urine of pregnant women. Such preparations are carefully standardized, and any brand made by a reliable pharmaceutical company is probably as good as any other. The substance should be extracted from the urine and not from the placenta, and it must of course be of human and not of animal origin. The powder is sealed in ampoules or in rubber-capped bottles in varying amounts which are stated in International Units. In this form hCG is stable; however, only such preparations should be used that have the date of manufacture and the date of expiry clearly stated on the label or package. A suitable solvent is always supplied in a separate ampoule in the same package.

Once hCG is in solution it is far less stable. It may be kept at room-temperature for two to three days, but if the solution must be kept longer it should always be refrigerated. When treating only one or two cases simultaneously, vials containing a small number of units say 1000 I.U. should be used. The 10 cc. of solvent which is supplied by the manufacturer is injected into the rubber- capped bottle containing the hCG, and the powder must dissolve instantly. Of this solution 1 .25 cc. are withdrawn for each injection. One such bottle of 1000 I.U. therefore furnishes 8 injections. When more than one patient is being treated, they should not each have their own bottle but rather all be injected from the same vial and a fresh solution made when this is empty.

As we are usually treating a fair number of patients at the same time, we prefer to use vials containing 5000 units. With these the manufactures also supply 10 cc. of solvent. Of such a solution 0.25 cc. contain the 125 I.U., which is the standard dose for all cases and which should never be exceeded. This small amount is awkward to handle accurately (it requires an insulin syringe) and is wasteful, because there is a loss of solution in the nozzle of the syringe and in the needle. We therefore prefer a higher dilution, which we prepare in the following way: The solvent supplied is injected into the rubbercapped bottle containing the 5000 I.U . As these bottles are too small to hold more solvent, we
withdraw 5 cc., inject it into an empty rubber-capped bottle and add 5 cc. of normal saline to each bottle. This gives us 10 cc. of solution in each bottle, and of this solution 0.5 cc. contains 125 I.U. This amount is convenient to inject with an ordinary syringe.

Injecting
hCG produces little or no tissue-reaction, it is completely painless and in the many thousands of injections we have given we have never seen an inflammatory or suppurative reaction at the site of the injection.
One should avoid leaving a vacuum in the bottle after preparing the solution or after withdrawal of the amount required for the injections as otherwise alcohol used for sterilizing a frequently perforated rubber cap might be drawn into the solution. When sharp needles are used, it sometimes happens that a little bit of rubber is punched out of the rubber cap and can be seen as a small black speck floating in the solution. As these bits of rubber are heavier than the solution they rapidly settle out, and it is thus easy to avoid drawing them into the syringe.
We use very fine needles that are two inches long and inject deep intragluteally in the outer upper quadrant of the buttocks. The injection should if possible not be given into the superficial fat layers, which in very obese patients must be compressed so as to enable the needle to reach the muscle. It is also important that the daily injection should be given at intervals as close to 24 hours as possible. Any attempt to economize in time by giving larger doses at longer intervals is doomed to produce less satisfactory results.
There are hardly any contraindications to the hCG method. Treatment can be continued in the presence of abscesses, suppuration, large infected wounds and major fractures. Surgery and general anesthesia are no reason to stop and we have given treatment during a severe attack of malaria. Acne or boils are no contraindication, the former usually clears up, and furunculosis comes to an end. Thrombophlebitis is no contraindication, and we have treated several obese patients with hCG and the 500-calorie diet while suffering from this condition. Our impression has been that in obese patients the phlebitis does rather better and certainly no worse than under the usual treatment alone. This also applies to patients suffering from varicose ulcers which tend to heal rapidly.

There is also a nasal compound available which is what I prefer to use.

Fibroids
While uterine fibroids seem to be in no way affected by hCG in the doses we use, we have found that very large, externally palpable uterine myomas are apt to give trouble. We are convinced that this is entirely due to the rather sudden disappearance of fat from the pelvic bed upon which they rest and that it is the weight of the tumor pressing on the underlying tissues which accounts for the discomfort or pain which may arise during treatment. While we disregard even fair-sized or multiple myomas, we insist that very large ones be operated before treatment. We have had patients present themselves for reducing fat from their abdomen who showed no signs of obesity, but had a large abdominal tumor.

Gallstones
Small stones in the gall bladder may in patients who have recently had typical colics cause more frequent colics under treatment with hCG. This may be due to the almost complete absence of fat from the diet, which prevents the normal emptying of the gall bladder. Before undertaking treatment we explain to such patients that there is a risk of more frequent and possibly severe symptoms and that it may become necessary to operate. If they are prepared to take this risk and provided they agree to undergo an operation if we consider this imperative, we proceed with treatment, as after weight reduction with hCG the operative risk is considerably reduced in an obese patient. In such cases we always give a drug which stimulates the flow of bile, and in the majority of cases nothing untoward happens. On the other hand, we have looked for and not found any evidence to suggest that the hCG treatment leads to the formation of gallstones as pregnancy sometimes does.

The Heart
Disorders of the heart are not as a rule contraindications. In fact, the removal of abnormal fat - particularly from the heart-muscle and from the surrounding of the coronary arteries - can only be beneficial in cases of myocardial weakness, and many such patients are referred to us by cardiologists. Within the first week of treatment all patients - not only heart cases - remark that they have lost much of their breathlessness

Coronary Occlusion
In obese patients who have recently survived a coronary occlusion, we adopt the following procedure in collaboration with the cardiologist. We wait until no further electrocardiographic changes have occurred for a period of three months. Routine treatment is then started under careful control and it is usual to find a further electrocardiographic improvement of a condition which was previously stationary.
In the thousands of cases we have treated we have not once seen any sort of coronary incident occur during or shortly after treatment. The same applies to cerebral vascular accidents. Nor have we ever seen a case of thrombosis of any sort develop during treatment, even though a high blood pressure is rapidly lowered. In this respect, too, the hCG treatment resembles pregnancy.

Teeth and Vitamins
Patients whose teeth are in poor repair sometimes get more trouble under prolonged treatment, just as may occur in pregnancy. In such cases we do allow calcium and vitamin D, though not in an oily solution. The only other vitamin we permit is vitamin C, which we use in large doses combined with an antihistamine at the onset of a common cold. There is no objection to the use of an antibiotic if this is required, for instance by
the dentist. In cases of broncial asthma and hay fever we have occasionally resorted to cortisone during treatment and find that triamcinolone is the least likely to interfere with the loss of weight, but many asthmatics improve with hCG alone.

Alcohol
Obese heavy drinkers, even those bordering on alcoholism, often do surprisingly well under hCG and it is exceptional for them to take a drink while under treatment. When they do, they find that a relatively small quantity of alcohol produces intoxication. Such patients say that they do not feel the need to drink This may in part be due to the euphoria which the treatment produces and in part to the complete absence of the need for quick sustenance from which most obese patients suffer.

Though we have had a few cases that have continued abstinence long after treatment, others relapse as soon as they are back on a normal diet. We have a few ?regular customers? who, having once been reduced to their normal weight, start to drink again though watching their weight. Then after some months they purposely overeat in order to gain sufficient weight for another course of hCG which temporarily gets them out of their drinking routine. We do not particularly welcome such cases, but we see no reason for refusing their request.

Tuberculosis
It is interesting that obese patients suffering from inactive pulmonary tuberculosis can be safely treated. We have under very careful control treated patients as early as three months after they were pronounced inactive and have never seen a relapse occur during or shortly after treatment. In fact, we only have one case on our records in which active tuberculosis developed in a young man about one year after a treatment which had lasted three weeks. Earlier X-rays showed a calcified spot from a childhood infection which had not produced clinical symptoms. There was a family history of tuberculosis, and his illness started under adverse conditions which certainly had nothing to do with the treatment. Residual calcifications from an early infection are exceedingly common, and we never consider them a contraindication to treatment.

The Painful Heel
In obese patients who have been trying desperately to keep their weight down by severe dieting, a curious symptom sometimes occurs. They complain of an unbearable pain in their heels which they feel only while standing or walking. As soon as they take the weight off their heels the pain ceases. These cases are the bane of the rheumatologists and orthopedic surgeons who have treated them before they come to us. All the usual investigations are entirely negative, and there is not the slightest response to anti- rheumatic medication or physiotherapy. The pain may be so severe that the patients are obliged to give up their occupation, and they are not infrequently labeled as a case of
hysteria. When their heels are carefully examined one finds that the sole is softer than normal and that the heel bone - the calcaneus - can be distinctly felt, which is not the case in a normal foot.
We interpret the condition as a lack of the hard fatty pad on which the calcaneus rests and which protects both the bone and the skin of the sole from pressure. This fat is like a springy cushion which carries the weight of the body. Standing on a heel in which this fat is missing or reduced must obviously be very painful. In their efforts to keep their weight down these patients have consumed this normal structural fat.
Those patients who have a normal or subnormal weight while showing the typically obese fat deposits are made to eat to capacity, often much against their will, for one week. They gain weight rapidly but there is no improvement in the painful heels. They are then started on the routine hCG treatment. Overweight patients are treated immediately. In both cases the pain completely disappears in 10-20 days of dieting, usually around the 15th day of treatment, and so far no case has had a relapse. We have been able to follow up such patients for years.
We are particularly interested in these cases, as they furnish further proof of the contention that hCG + 500 calories not only removes abnormal fat but actually permits normal fat to be replaced, in spite of the deficient food intake. It is certainly not so that the mere loss of weight reduces the pain, because it frequently disappears before the weight the patient had prior to the period of forced feeding is reached.

The Skeptical Patient
Any doctor who starts using the hCG method for the first time will have considerable difficulty, particularly if he himself is not fully convinced, in making patients believe that they will not feel hungry on 500 calories and that their face will not collapse. New patients always anticipate the phenomena they know so well from previous treatments and diets and are incredulous when told that these will not occur. We overcome all this by letting new patients spend a little time in the waiting room with older hands, who can always be relied upon to allay these fears with evangelistic zeal, often demonstrating the finer points on their own body.
A waiting-room filled with obese patients who congregate daily is a sort of group therapy. They compare notes and pop back into the waiting room after the consultation to announce the score of the last 24 hours to an enthralled audience. They cross-check on their diets and sometimes confess sins which they try to hide from us, usually with the result that the patient in whom they have confided palpitatingly tattles the whole disgraceful story to us with a ?But don't let her know I told you.?


Concluding a Course
When the three days of dieting after the last injection are over, the patients are told that they may now eat anything they please, except sugar and starch provided they faithfully observe one simple rule. This rule is that they must have their own portable bathroom-scale always at hand, particularly while traveling. They must without fail weight themselves every morning as they get out of bed, having first emptied their bladder. If they are in the habit of having breakfast in bed, they must weigh before breakfast.
It takes about 3 weeks before the weight reached at the end of the treatment becomes stable, i.e. does not show violent fluctuations after an occasional excess. During this period patients must realize that the so-called carbohydrates, that is sugar, rice, bread, potatoes, pastries etc, are by far the most dangerous. If no carbohydrates whatsoever are eaten, fats can be indulged in somewhat more liberally and even small quantities of alcohol, such as a glass of wine with meals, does no harm, but as soon as fats and starch are combined things are very liable to get out of hand. This has to be observed very carefully during the first 3 weeks after the treatment is ended otherwise disappointments are almost sure to occur.

Skipping a Meal
As long as their weight stays within two pounds of the weight reached on the day of the last injection, patients should take no notice of any increase but the moment the scale goes beyond two pounds, even if this is only a few ounces, they must on that same day entirely skip breakfast and lunch but take plenty to drink. In the evening they must eat a huge steak with only an apple or a raw tomato. Of course this rule applies only to the morning weight. Ex-obese patients should never check their weight during the day, as there may be wide fluctuations and these are merely alarming and confusing.
It is of utmost importance that the meal is skipped on the same day as the scale registers an increase of more than two pounds and that missing the meals is not postponed until the following day. If a meal is skipped on the day in which a gain is registered in the morning this brings about an immediate drop of often over a pound. But if the skipping of the meal - and skipping means literally skipping, not just having a light meal - is postponed the phenomenon does not occur and several days of strict dieting may be necessary to correct the situation.
Most patients hardly ever need to skip a meal. If they have eaten a heavy lunch they feel no desire to eat their dinner, and in this case no increase takes place. If they keep their weight at the point reached at the end of the treatment, even a heavy dinner does not bring about an increase of two pounds on the next morning and does not therefore call for any special measures. Most patients are surprised how small their appetite has become and yet how much they can eat without gaining weight. They no longer suffer from an
abnormal appetite and feel satisfied with much less food than before. In fact, they are usually disappointed that they cannot manage their first normal meal, which they have been planning for weeks.

Losing more Weight
An ex-patient should never gain more than two pounds without immediately correcting this, but it is equally undesirable that more than two lbs. be lost after treatment, because a greater loss is always achieved at the expense of normal fat. Any normal fat that is lost is invariably regained as soon as more food is taken, and it often happens that this rebound overshoots the upper two lbs. limit.

Trouble After Treatment
Two difficulties may be encountered in the immediate post-treatment period. When a patient has consumed all his abnormal fat or, when after a full course, the injection has temporarily lost its efficacy owing to the body having gradually evolved a counter regulation, the patient at once begins to feel much more hungry and even weak. In spite of repeated warnings, some over-enthusiastic patients do not report this. However, in about two days the fact that they are being undernourished becomes visible in their faces, and treatment is then stopped at once. In such cases - and only in such cases - we allow a very slight increase in the diet, such as an extra apple, 150 grams of meat or two or three extra breadsticks during the three days of dieting after the last injection.
When abnormal fat is no longer being put into circulation either because it has been consumed or because immunity has set in, this is always felt by the patient as sudden, intolerable and constant hunger. In this sense, the hCG method is completely self-limiting. With hCG it is impossible to reduce a patient, however enthusiastic, beyond his normal weight. As soon as no more abnormal fat is being issued, the body starts consuming normal fat, and this is always regained as soon as ordinary feeding is resumed. The patient then finds that the 2-3 lbs. he has lost during the last days of treatment are immediately regained. A meal is skipped and maybe a pound is lost. The next day this pound is regained, in spite of a careful watch over the food intake. In a few days a tearful patient is back in the consulting room, convinced that her case is a failure.
All that is happening is that the essential fat lost at the end of the treatment, owing to the patient's reluctance to report a much greater hunger, is being replaced. The weight at which such a patient must stabilize thus lies 2-3 lbs. higher than the weight reached at the end of the treatment. Once this higher basic level is established, further difficulties in controlling the weight at the new point of stabilization hardly arise.

Beware of Over-enthusiasm
The other trouble which is frequently encountered immediately after treatment is again due to over-enthusiasm. Some patients cannot believe that they can eat fairly normally without regaining weight. They disregard the advice to eat anything they please except sugar and starch and want to play safe. They try more or less to continue the 500-calorie diet on which they felt so well during treatment and make only minor variations, such as replacing the meat with an egg, cheese, or a glass of milk. To their horror they find that in spite of this bravura, their weight goes up. So, following instructions, they skip one meager lunch and at night eat only a little salad and drink a pot of unsweetened tea, becoming increasingly hungry and weak. The next morning they find that they have increased yet another pound. They feel terrible, and even the dreaded swelling of their ankles is back. Normally we check our patients one week after they have been eating freely, but these cases return in a few days. Either their eyes are filled with tears or they angrily imply that when we told them to eat normally we were just fooling them.

Protein deficiency
Here too, the explanation is quite simple. During treatment the patient has been only just above the verge of protein deficiency and has had the advantage of protein being fed back into his system from the breakdown of fatty tissue. Once the treatment is over there is no more hCG in the body and this process no longer takes place. Unless an adequate amount of protein is eaten as soon as the treatment is over, protein deficiency is bound to develop, and this inevitably causes the marked retention of water known as hunger- edema.
The treatment is very simple. The patient is told to eat two eggs for breakfast and a huge steak for lunch and dinner followed by a large helping of cheese and to phone through the weight the next morning. When these instructions are followed a stunned voice is heard to report that two lbs. have vanished overnight, that the ankles are normal but that sleep was disturbed, owing to an extraordinary need to pass large quantities of water. The patient having learned this lesson usually has no further trouble.

Relapses
As a general rule one can say that 60%-70% of our cases experience little or no difficulty in holding their weight permanently. Relapses may be due to negligence in the basic rule of daily weighing. Many patients think that this is unnecessary and that they can judge any increase from the fit of their clothes. Some do not carry their scale with them on a journey as it is cumbersome and takes a big bite out of their luggage-allowance when flying. This is a disastrous mistake, because after a course of hCG as much as 10 lbs. can be regained without any noticeable change in the fit of the clothes. The reason for this is that after treatment newly acquired fat is at first evenly distributed and does not show the former preference for certain parts of the body.
Pregnancy or the menopause may annul the effect of a previous treatment. Women who take treatment during the one year after the last menstruation - that is at the onset of the menopause - do just as well as others, but among them the relapse rate is higher until the menopause is fully established. The period of one year after the last menstruation applies only to women who are not being treated with ovarian hormones. If these are taken, the premenopausal period may be indefinitely prolonged.
Late teenage girls who suffer from attacks of compulsive eating have by far the worst record of all as far as relapses are concerned.
Patients who have once taken the treatment never seem to hesitate to come back for another short course as soon as they notice that their weight is once again getting out of hand. They come quite cheerfully and hopefully, assured that they can be helped again. Repeat courses are often even more satisfactory than the first treatment and have the advantage, as do second courses, that the patient already, knows that he will feel comfortable throughout.

Plan of a Normal Course
125 I.U. of hCG daily (except during menstruation) ui injections have been given.
Until 3rd injection forced feeding.
After 3rd injection, 500 calorie diet to be continued until 72 hours after the last injection.
For the following 3 weeks, all foods allowed except starch and sugar in any form (careful with very sweet fruit).
After 3 weeks, very gradually add starch in small quantities, always controlled by morning weighing.

CONCLUSION
The hCG + diet method can bring relief to every case of obesity, but the method is not simple. It is very time consuming and requires perfect cooperation between physician and patient. Each case must be handled individually, and the physician must have time to answer questions, allay fears and remove misunderstandings. He must also check the patient daily. When something goes wrong he must at once investigate until he finds the reason for any gain that may have occurred. In most cases it is useless to hand the patient a diet-sheet and let the nurse give him a "shot."
The method involves a highly complex bodily mechanism, and the physician must make himself some sort of picture of what is actually happening; otherwise he will not be able to deal with such difficulties as may arise during treatment.
I must beg those trying the method for the first time to adhere very strictly to the technique and the interpretations here outlined and thus treat a few hundred cases before embarking on experiments of their own, and until then refrain from introducing innovations, however thrilling they may seem. In a new method, innovations or departures from the original technique can only be usefully evaluated against a substantial background of experience with what is at the moment the orthodox procedure.
I have tried to cover all the problems that come to my mind. Yet a bewildering array of new questions keeps arising, and my interpretations are still fluid. In particular, I have never had an opportunity of conducting the laboratory investigations which are so necessary for a theoretical understanding of clinical observations, and I can only hope that those more fortunately placed will in time be able to fill this gap.
The problems of obesity are perhaps not so dramatic as the problems of cancer, but they often cause life long suffering. How many promising careers have been ruined by excessive fat; how many lives have been shortened. If some way -however cumbersome - can be found to cope effectively with this universal problem of modern civilized man, our world will be a happier place for countless fellow men and women.




Call my office in Wilmington (815) 476-5210 or Lombard (630) 627-3700 to set up an appointment or email me at jones.gretchen@gmail.com

A Standard of Care Approach To Menopause. I Propose The Wiley Protocol

Menopause

WHAT TO EXPECT
Menopause is an individualized experience. Some women notice little difference in their bodies or moods, while others find the change extremely bothersome and disruptive. Estrogen and progesterone affect virtually all tissues in the body, but everyone is influenced by them differently.

Hot Flashes

Hot flashes, or flushes, are the most common symptom of menopause, affecting more than 60 percent of menopausal women in the U.S. A hot flash is a sudden sensation of intense heat in the upper part or all of the body. The face and neck may become flushed, with red blotches appearing on the chest, back, and arms. This is often followed by profuse sweating and then cold shivering as body temperature readjusts. A hot flash can last a few moments or 30 minutes or longer.

Hot flashes occur sporadically and often start several years before other signs of menopause. They gradually decline in frequency and intensity as you age. Eighty percent of all women with hot flashes have them for 2 years or less, while a small percentage have them for more than 5 years. Hot flashes can happen at any time. They can be as mild as a light blush, or severe enough to wake you from a deep sleep. Some women even develop insomnia. Others have experienced that caffeine, alcohol, hot drinks, spicy foods, and stressful or frightening events can sometimes trigger a hot flash. However, avoiding these triggers will not necessarily prevent all episodes.

Hot flashes appear to be a direct result of decreasing estrogen levels. In response to falling estrogen levels, your glands release higher amounts of other hormones that affect the brain's thermostat, causing body temperatures to fluctuate. Hormone therapy relieves the discomfort of hot flashes in most cases.

Some women claim that vitamin E offers minor relief, although there has never been a study to confirm it. Aside from hormone therapy, which is not for everyone, here are some suggestions for coping with hot flashes:
* Dress in layers so you can remove them at the first sign of a flash.
* Drink a glass of cold water or juice at the onset of a flash.
* At night keep a thermos of ice water or an ice pack by your bed.
* Use cotton sheets, lingerie and clothing to let your skin "breathe."

Vaginal/Urinary Tract Changes

With advancing age, the walls of the vagina become thinner, dryer, less elastic and more vulnerable to infection. These changes can make sexual intercourse uncomfortable or painful. Most women find it helpful to lubricate the vagina. Water-soluble lubricants are preferable, as they help reduce the chance of infection. Try to avoid petroleum jelly; many women are allergic, and it damages condoms. Be sure to see your gynecologist if problems persist.

Tissues in the urinary tract also change with age, sometimes leaving women more susceptible to involuntary loss of urine (incontinence), particularly if certain chronic illnesses or urinary infections are also present. Exercise, coughing, laughing, lifting heavy objects or similar movements that put pressure on the bladder may cause small amounts of urine to leak. Lack of regular physical exercise may contribute to this condition. It's important to know, however, that incontinence is not a normal part of aging, to be masked by using adult diapers. Rather, it is usually a treatable condition that warrants medical evaluation. Recent research has shown that bladder training is a simple and effective treatment for most cases of incontinence and is less expensive and safer than medication or surgery.

Within 4 or 5 years after the final menstrual period, there is an increased chance of vaginal and urinary tract infections. If symptoms such as painful or overly frequent urination occur, consult your doctor. Infections are easily treated with antibiotics, but often tend to recur. To help prevent these infections, urinate before and after intercourse, be sure your bladder is not full for long periods, drink plenty of fluids, and keep your genital area clean. Douching is not thought to be effective in preventing infection.

Side View of the Pelvis

The side view of the pelvis and its contents after menopause shows the slight dropping of the uterus, bladder and rectum. Also notice how the vagina becomes shorter and narrower.
Source: W.Utian and R.Jacobowitz, Managing Your Menopause, New York: Prentice Hall Press/Simon & Shuster, 1990, p.29.


Menopause and Mental Health

A popular myth pictures the menopausal woman shifting from raging, angry moods into depressive, doleful slumps with no apparent reason or warning. However, a study by psychologists at the University of Pittsburgh suggests that menopause does not cause unpredictable mood swings, depression, or even stress in most women.

In fact, it may even improve mental health for some. This gives further support to the idea that menopause is not necessarily a negative experience. The Pittsburgh study looked at three different groups of women: menstruating, menopausal with no treatment, and menopausal on hormone therapy. The study showed that the menopausal women suffered no more anxiety, depression, anger, nervousness or feelings of stress than the group of menstruating women in the same age range. In addition, although more hot flashes were reported by the menopausal women not taking hormones, surprisingly they had better overall mental health than the other two groups. The women taking hormones worried more about their bodies and were somewhat more depressed.

However, this could be caused by the hormones themselves. It's also possible that women who voluntarily take hormones tend to be more conscious of their bodies in the first place. The researchers caution that their study includes only healthy women, so results may apply only to them. Other studies show that women already taking hormones who are experiencing mood or behavioral problems sometimes respond well to a change in dosage or type of estrogen.

Studies indicate that women of childbearing age, particularly those with young children at home, tend to report more emotional problems than women of other ages.

The Pittsburgh findings are supported by a New England Research Institute study which found that menopausal women were no more depressed than the general population: about 10 percent are occasionally depressed and 5 percent are persistently depressed. The exception is women who undergo surgical menopause. Their depression rate is reportedly double that of women who have a natural menopause.

Studies also have indicated that many cases of depression relate more to life stresses or "mid-life crises" than to menopause. Such stresses include: an alteration in family roles, as when your children are grown and move out of the house, no longer "needing" mom; a changing social support network, which may happen after a divorce if you no longer socialize with friends you met through your husband; interpersonal losses, as when a parent, spouse or other close relative dies; and your own aging and the beginning of physical illness. People have very different responses to stress and crisis. Your best friend's response may be negative, leaving her open to emotional distress and depression, while yours is positive, resulting in achievement of your goals. For many women, this stage of life can actually be a period of enormous freedom.

What About Sex?

For some women, but by no means all, menopause brings a decrease in sexual activity. Reduced hormone levels cause subtle changes in the genital tissues and are thought to be linked also to a decline in sexual interest. Lower estrogen levels decrease the blood supply to the vagina and the nerves and glands surrounding it. This makes delicate tissues thinner, drier, and less able to produce secretions to comfortably lubricate before and during intercourse. Avoiding sex is not necessary, however. Estrogen creams and oral estrogen can restore secretions and tissue elasticity. Water-soluble lubricants can also help.

While changes in hormone production are cited as the major reason for changes in sexual behavior, many other interpersonal, psychological, and cultural factors can come into play. For instance, a Swedish study found that many women use menopause as an excuse to stop sex completely after years of disinterest. Many physicians, however, question if declining interest is the cause or the result of less frequent intercourse.

Some women actually feel liberated after menopause and report an increased interest in sex. They say they feel relieved that pregnancy is no longer a worry.

For women in perimenopause, birth control is a confusing issue. Doctors advise all women who have menstruated, even if irregularly, within the past year to continue using birth control. Unfortunately, contraceptive options are limited. Hormone-based oral and implantable contraceptives are risky in older women who smoke. Only a few brands of IUD are on the market. The other options are barrier methods--diaphragms, condoms, and sponges--or methods requiring surgery such as tubal ligation.

Is My Partner Still Interested?

Some men go through their own set of doubts in middle age. They, too, often report a decline in sexual activity after age 50. It may take more time to reach ejaculation, or they may not be able to reach it at all. Many fear they will fail sexually as they get older. Remember, at any age sexual problems can arise if there are doubts about performance. If both partners are well informed about normal genital changes, each can be more understanding and make allowances rather than unmeetable demands. Open, candid communication between partners is important to ensure a successful sex life well into your seventies and eighties.

For most women, natural menopause is not a major crisis and does not influence their opinion of their general health.


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LONG-TERM EFFECTS OF ESTROGEN DEFICIENCY
Osteoporosis

One of the most important health issues for middle-aged women is the threat of osteoporosis. It is a condition in which bones become thin, fragile, and highly prone to fracture. Numerous studies over the past 10 years have linked estrogen insufficiency to this gradual, yet debilitating disease. In fact, osteoporosis is more closely related to menopause than to a woman's chronological age.

Bones are not inert. They are made up of healthy, living tissue which continuously performs two processes: breakdown and formation of new bone tissue. The two are closely linked. If breakdown exceeds formation, bone tissue is lost and bones become thin and brittle. Gradually and without discomfort, bone loss leads to a weakened skeleton incapable of supporting normal daily activities.

Each year about 500,000 American women will fracture a vertebrae, the bones that make up the spine, and about 300,000 will fracture a hip. Nationwide, treatment for osteoporotic fractures costs up to $10 billion per year, with hip fractures the most expensive. Vertebral fractures lead to curvature of the spine, loss of height, and pain. A severe hip fracture is painful and recovery may involve a long period of bed rest. Between 12 and 20 percent of those who suffer a hip fracture do not survive the 6 months after the fracture. At least half of those who do survive require help in performing daily living activities, and 15 to 25 percent will need to enter a long-term care facility. Older patients are rarely given the chance for full rehabilitation after a fall. However, with adequate time and care provided in rehabilitation, many people can regain their independence and return to their previous activities.

Healthy bone Osteoporotic bone

Source: Dr. Robert Lindsay, Helen Hayes Hospital, West Haverstraw, N.Y.

For osteoporosis, researchers believe that an ounce of prevention is worth a pound of cure. The condition of an older woman's skeleton depends on two things: the peak amount of bone attained before menopause and the rate of the bone loss thereafter. Hereditary factors are important in determining peak bone mass. For instance, studies show that black women attain a greater spinal mass and therefore have fewer osteoporotic fractures than white women. Other factors that help increase bone mass include adequate intake of dietary calcium and vitamin D, particularly in young children prior to puberty; exposure to sunlight; and physical exercise. These elements also help slow the rate of bone loss. Certain other physiological stresses can quicken bone loss, such as pregnancy, nursing, and immobility. The biggest culprit in the process of bone loss is estrogen deficiency. Bone loss quickens during perimenopause, the transitional phase when estrogen levels drop significantly.

Doctors believe the best strategy for osteoporosis is prevention because currently available treatments only halt bone loss--they don't rebuild the bone. However, researchers are hopeful that in the future, bone loss will be reversible. Building up your reserves of bone before you start to lose it during perimenopause helps bank against future losses. The most effective therapy against osteoporosis available today for postmenopausal women is estrogen (see Managing Menopause). Remarkably, estrogen saves more bone tissue than even very large daily doses of calcium. Estrogen is not a panacea, however. While it is a boon for the bones, it also affects all other tissues and organs in the body, and not always positively. Its impact on the other areas of the body must be considered.

Cardiovascular Disease

Most people picture an older, overweight man when they think of a likely candidate for cardiovascular disease (CVD). But men are only half the story. Heart disease is the number one killer of American women and is responsible for half of all the deaths of women over age 50. Ironically, in past years women were rarely included in clinical heart studies, but finally physicians have realized that it is as much a woman's disease as a man's.

Influences on Bone Development
Increases bone formation Speeds bone loss
Dietary calcium Estrogen deficiency
Vitamin D Pregnancy
Exposure to sunlight Nursing
Exercise Lack of exercise

CVDs are disorders of the heart and circulatory system. They include thickening of the arteries (atherosclerosis) that serve the heart and limbs, high blood pressure, angina, and stroke. For reasons unknown, estrogen helps protect women against CVD during the childbearing years. This is true even when they have the same risk factors as men, including smoking, high blood cholesterol levels, and a family history of heart disease. But the protection is temporary. After menopause, the incidence of CVD increases, with each passing year posing a greater risk. The good news, though, is that CVD can be prevented or at least reduced by early recognition, lifestyle changes and, many physicians believe, hormone replacement therapy.

Menopause brings changes in the level of fats in a woman's blood. These fats, called lipids, are used as a source of fuel for all cells. The amount of lipids per unit of blood determines a person's cholesterol count. There are two components of cholesterol: high density lipoprotein (HDL) cholesterol, which is associated with a beneficial, cleansing effect in the bloodstream, and low density lipoprotein (LDL) cholesterol, which encourages fat to accumulate on the walls of arteries and eventually clog them. To remember the difference, think of the H in HDL as the healthy cholesterol, and the L in LDL as lethal. LDL cholesterol appears to increase while HDL decreases in postmenopausal women as a direct result of estrogen deficiency. Elevated LDL and total cholesterol can lead to stroke, heart attack, and death.

Percentage of Deaths from Specific Conditions

Menopause

MANAGING MENOPAUSE
Hormone Replacement Therapy

To combat the symptoms associated with falling estrogen levels, doctors have turned to hormone replacement therapy (HRT). HRT is the administration of the female hormones estrogen and progesterone. Estrogen replacement therapy (ERT) refers to administration of estrogen alone. The hormones are usually given in pill form, though sometimes skin patches and vaginal creams (just estrogen) are used. ERT is thought to help prevent the devastating effects of heart disease and osteoporosis, conditions that are often difficult and expensive to treat once they appear. The cardiovascular effects of progesterone, however, are still unknown. Hormone treatment for menopause is still quite controversial. Its long-term safety and efficacy remain matters of great concern. There is not enough existing data for physicians to suggest that HRT is the right choice for all women. Several large studies are currently attempting to resolve the questions, though it will take several more years to reach any definitive answers.

In the 1940's when estrogen was first offered to menopausal women, it was given alone and in high doses. Today, after 50 years of trial and error, it is well known that estrogen stimulates growth of the inner lining of the uterus (endometrium) that sheds during menstruation. This growth may continue uncontrollably, resulting in cancer. Today, doctors typically prescribe a lower dose of estrogen. However, few doctors still prescribe estrogen alone to women who have a uterus. Most now prefer to add a synthetic form of progesterone called progestin to counteract estrogen's dangerous effect on the uterus. Progestin reduces the risk of cancer by causing monthly shedding of the endometrium. The obvious drawback to this approach is that menopausal women resume monthly bleeding. Once menopause arrives, most women enjoy the freedom of life without a period. Many are reluctant to begin their cycles again. In addition, there are other unpleasant side effects of progestin which often discourage women from continuing HRT. These include breast tenderness, bloating, abdominal cramping, anxiety, irritability, and depression.

Only about 15 percent of women who are eligible for hormone replacement therapy are now receiving it. This leaves 85 percent who either do not want or need it, or do not know about it.

The good news is that researchers are evaluating different schedules of low-dose estrogen and progestin to completely eliminate monthly bleeding. Currently most women receive what is called cyclic HRT. They may take estrogen continually and progestin for the first 12 days of each month. The use of a continuous combined dose, where estrogen and smaller amounts of progestin are taken every day, is also being studied. In theory, this use of progestin stems endometrial growth so no bleeding will occur. Unfortunately, it may take 6 months or more until bleeding finally stops. In many cases, monthly bleeding has been replaced by more bothersome irregular bleeding patterns. Obviously, further research is needed to evaluate and perfect this treatment. Various types of progestins in different dosages, preparations, and schedules are being studied in hopes of reducing its other unpleasant side effects while retaining the known advantages of estrogen.

Estrogen and Your Bones

HRT and ERT are successful methods of combatting osteoporosis. As previously discussed, estrogen halts bone loss but cannot necessarily rebuild bone. Long-term estrogen use (10 or more years) may be required to prevent postmenopausal bone loss. Why estrogen helps protect the skeleton is still unclear. We do know that estrogen helps bones absorb the calcium they need to stay strong. It also helps conserve the calcium stored in the bones by encouraging other cells to use dietary calcium more efficiently. For instance, muscles require calcium to contract. If there is not enough calcium circulating in the blood for muscles to use, calcium is "borrowed" from the bone. Calcium is also needed for blood clotting, sending nerve impulses, and secreting various hormones. Prolonged borrowing from bone calcium for these processes speeds bone loss. That's why it's important to consume adequate amounts of calcium in your diet (see "Keeping Healthy").

Estrogen's Effect on Your Heart

The majority of past clinical studies have shown that women who use estrogen substantially reduce their risk of developing and dying from heart disease. One or two studies demonstrate conflicting evidence, but they are far outnumbered by the positive reports. Results from a 1991 study showed that after 15 years of estrogen replacement, risk of death by CVD was reduced by almost 50 percent and overall deaths were reduced by 40 percent. Some researchers credit this reduction to oral estrogen's ability to maintain HDL and LDL at their healthier, premenopausal levels, through its interaction with proteins in the liver. Others believe it is estrogen's direct effect on the blood vessels themselves (through receptors on the vessel walls) which creates this benefit. In the latter case, both oral estrogen and the skin patch would be effective. Studies are underway to determine which mechanism contributes most to a healthy heart.

Many doctors now believe that estrogen replacement benefits women at risk for heart disease (but not those with blood clots--see "Cautions to Estrogen Use"). Risk factors for heart disease include a strong family history of CVD, high blood pressure, obesity, and smoking.

At any time of life, women who smoke are much more likely to develop heart disease or have a stroke than women who do not smoke. But after menopause, a smoker's risk climbs dramatically. Low estrogen levels and smoking are separate risk factors for CVD. When the two are combined, the risk is much higher than either one alone. Smoking also raises your risks for some types of cancer and for chronic lung disease, such as emphysema. Fortunately, quitting smoking--at any age--can cut the risk of disease almost immediately. Studies have shown that when older people quit, they increase their life expectancy. Their risk of heart disease goes down, their lungs function better, and blood circulation improves. So quitting smoking, whether before, during or after menopause, can have a definite impact on both the length and quality of your life.

Many women who have quit smoking say they found support in group counseling sessions. Local chapters of the American Cancer Society and the American Heart Association are good places to start looking for a smoking cessation group. Nicotine gum and nicotine patches prescribed by a doctor may also help.

While we know that estrogen users have a decreased risk of CVD, women with certain preexisting heart conditions are usually advised not to take HRT or ERT. These conditions include blood clots and recent heart attacks. Researchers hope to further investigate nonhormonal methods of preventing heart disease such as weight reduction or control, exercise, smoking cessation, and dietary modification. According to a 5-year study reported in 1988, weight gain (a common occurrence among many menopausal women) significantly raises blood pressure, total and LDL cholesterol, and fat levels. Together, these make up a dangerous recipe for heart disease. Several other studies also noted that having about one drink per day had a protective effect on the heart.

Physicians advise caution in this area, however, as excess alcohol can increase risks for other serious problems.

While cardiovascular benefits associated with oral estrogen are fairly well-known, there is surprisingly little information on the cardiovascular effects of progestin combined with estrogen. Some studies suggest that progestins counteract the favorable effects of estrogen alone, while other studies show no such effect. This remains just one more gray area where questions outnumber reliable answers.


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Cautions to Estrogen Use
Serious risk Relative risk Subjective Complaints
Stroke
Recent heart attack
Breast cancer (current or family history)
Uterine cancer
Acute liver disease
Gall bladder disease
Pancreatic disease
Recent blood clot
Undiagnosed vaginal bleeding Cigarette smoking
Hypertension
Benign breast disease
Benign uterine disease
Endometriosis
Pancreatitis
Epilepsy
Migraine headaches Nausea
Headaches
Breakthrough bleeding
Depression
Fluid retention
Source: R.L. Young, N.S. Kumar, and J.W. Goldzieher, Management of Menopause When Estrogen Cannot Be Used, Drugs, 40(2):220-230,1990

Drawbacks of HRT: The Cancer Risk

A major issue surrounding HRT and ERT is the influence of estrogen on breast cancer. Researchers believe that the longer your lifetime exposure to naturally occurring estrogen, the greater your risk of breast cancer. It has not been proven, however, that estrogen administered at menopause has the same effect. There is disagreement on the many trials conducted to date because of wide variations in the populations studied and the doses, timing, and types of estrogen used. A recent analysis of previous studies suggests that low-dose estrogen taken on a short-term basis (10 years or less) does not pose increased risk of breast cancer. Long-term use (more than 10 years) at a high dose may significantly increase the risk. By how much is still a matter of heated debate. At the very most, researchers think long-term use could possibly increase the risk of getting breast cancer by 30 percent. This means that incidence would rise from 10 women per 10,000 each year to 13 women per 10,000 each year. To reach any consensus, however, more women need to be monitored for an extended period of time. The fear of cancer is one of the most common reasons that women are unwilling to use HRT. Interestingly, actual death rates for breast cancer have not risen at all. This may be because estrogen users have more frequent medical visits and obtain more preventive care including yearly mammograms.

While no one can determine who will eventually develop breast cancer, there are certain risk factors you should be aware of when considering HRT. A family history of breast cancer (sister or mother) is probably the most important risk factor of all. You may also be at an increased risk if: you menstruated before age 12; delayed motherhood until later in life; or have a late menopause (after age 50). Also, the older you are, the higher the risk. Most doctors believe that if you are not in a high-risk category for breast or endometrial cancer, the benefits of HRT far outweigh the risks. However, for some women, the side effects of therapy make it impossible to use. This is a personal decision to be made by each woman with help from her doctor.

Other Risks

Physicians usually caution women not to use HRT if they are already at high risk for developing blood clots. Obesity, severe vericose veins, smoking, and a history of blood clots put you in this category. A history of gall bladder disease could also be cause to avoid HRT, as women taking estrogen may have a greater chance of developing gallstones.

Hormonal Therapy
Here is what scientists can say so far about the advantages and disadvantages of hormone replacement therapy (HRT--estrogen and progesterone) and estrogen replacement therapy (ERT--estrogen alone). More research is underway.
Pro Con
HRT and ERT reduce the risk of osteoporosis.
HRT and ERT relieve hot flashes.

HRT and ERT reduce the risk of heart disease.

HRT and ERT may improve mood and psychological well-being.
ERT increases the risk of cancer of the uterus (endometrial cancer).
HRT can have unpleasant side effects, such as bloating or irritability.

HRT and ERT may increase risk of breast cancer; long-term use may pose the greatest risk.

In women with blood clots, HRT and ERT may be dangerous.

Menopause

KEEPING HEALTHY
Good nutrition and regular physical exercise are thought to improve overall health. Some doctors feel these factors can also affect menopause. Although these areas have not been well studied in women, anecdotal evidence is strongly in favor of eating well and exercising to help lower risks for CVD and osteoporosis.

There is no consensus within the medical community about the risks and benefits associated with hormone therapy. There is no agreement on normal hormonal changes associated with aging.

Nutrition

While everyone agrees that a well-balanced diet is important for good health, there is still much to be learned about what constitutes "well-balanced." We do know that variety in the diet helps ensure a better mix of essential nutrients.

Nutritional requirements vary from person to person and change with age. A healthy premenopausal woman should have about 1,000 mgs of calcium per day. A 1994 Consensus Conference at the National Institutes of Health recommended that women after menopause consume 1,500 mgs per day if they are not using hormonal replacement or 1,000 mgs per day in conjunction with hormonal replacement. Foods high in calcium include milk, yogurt, cheese and other dairy products; oysters, sardines and canned salmon with bones; and dark-green leafy vegetables like spinach and broccoli. In calcium tablets, calcium carbonate is most easily absorbed by the body. If you are lactose intolerant, acidophilus milk is more digestible. Vitamin D is also very important for calcium absorption and bone formation. A 1992 study showed that women with postmenopausal osteoporosis who took vitamin D for 3 years significantly reduced the occurrence of new spinal fractures. However, the issue is still controversial. High doses of vitamin D can cause kidney stones, constipation, or abdominal pain, particularly in women with existing kidney problems. Other nutritional guidelines by the National Research Council include:

Choose foods low in fat, saturated fat, and cholesterol. Fats contain more calories (9 calories per gram) than either carbohydrates or protein (each have only 4 calories per gram). Fat intake should be less than 30 percent of daily calories.
Eat fruits, vegetables, and whole grain cereal products, especially those high in vitamin C and carotene. These include oranges, grapefruit, carrots, winter squash, tomatoes, broccoli, cauliflower, and green leafy vegetables. These foods are good sources of vitamins and minerals and the major sources of dietary fiber. Fiber helps maintain bowel mobility and may reduce the risk of colon cancer. Young and older people alike are encouraged to consume 20 to 30 grams of fiber per day.
Eat very little salt-cured and smoked foods such as sausages, smoked fish and ham, bacon, bologna, and hot dogs. High blood pressure, which may become more serious with heavy salt intake, is more of a risk as you age.
Avoid food and drinks containing processed sugar. Sugar contains empty calories which may substitute for nutritious food and can add excess body weight.
For people who can't eat an adequate diet, supplements may be necessary. A dietician should tailor these to meet your individual nutritional needs. Using supplements without supervision can be risky because large doses of some vitamins may have serious side effects. Vitamins A and D in large doses can be particularly dangerous.

As you age, your body requires less energy because of a decline in physical activity and a loss of lean body mass. Raising your activity level will increase your need for energy and help you avoid gaining weight. Weight gain often occurs in menopausal women, possibly due in part to declining estrogen. In animal studies, scientists found that estrogen is important in regulating weight gain. Animals with their ovaries surgically removed gained weight, even if they were fed the same diet as the animals with intact ovaries. They also found that progesterone counteracts the effect of estrogen. The higher their progesterone levels, the more the animals ate.

Exercise

Exercise is extremely important throughout a woman's lifetime and particularly as she gets older. Regular exercise benefits the heart and bones, helps regulate weight, and contributes to a sense of overall well-being and improvement in mood. If you are physically inactive you are far more prone to coronary heart disease, obesity, high blood pressure, diabetes, and osteoporosis. Sedentary women may also suffer more from chronic back pain, stiffness, insomnia, and irregularity. They often have poor circulation, weak muscles, shortness of breath, and loss of bone mass. Depression can also be a problem. Women who regularly walk, jog, swim, bike, dance, or perform some other aerobic activity can more easily circumvent these problems and also achieve higher HDL cholesterol levels. Studies show that women performing aerobic activity or muscle-strength training reduced mortality from CVD and cancer.

Just like muscles, bones adhere to the "use it or lose it" rule; they diminish in size and strength with disuse. It has been known for more than 100 years that weight-bearing exercise (walking, running) will help increase bone mass. Exercise stimulates the cells responsible for generating new bone to work overtime. In the past 20 years, studies have shown that bone tissue lost from lack of use can be rebuilt with weight-bearing activity. Studies of athletes show they have greater bone mass compared to nonathletes at the sites related to their sport. In postmenopausal women, moderate exercise preserves bone mass in the spine, helping reduce the risk of fractures.

Exercise is also thought to have a positive effect on mood. During exercise, hormones called endorphins are released in the brain. They are "feel good" hormones involved in the body's positive response to stress. The mood-heightening effect can last for several hours, according to some endocrinologists. Consult your doctor before starting a rigorous exercise program. He or she will help you decide which types of exercises are best for you. An exercise program should start slowly and build up to more strenuous activities. Women who already have osteoporosis of the spine should be careful about exercise that jolts or puts weight on the back, as it could cause a fracture.


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ONGOING/FUTURE RESEARCH

To gather more data to help women make a well-informed decision regarding hormone therapy, researchers at the National Institutes of Health (NIH) launched the Postmenopausal Estrogen/Progestin Interventions Trial (PEPI) in 1989. With 127 women enrolled at each of seven medical centers, PEPI will address the short-term safety and efficacy of various methods of HRT. The study will compare women who take estrogen by itself to those who take it with different types of progestin. It will also examine the effects of both cyclical and continuous progestin on cardiovascular risk factors, blood clotting factors, metabolism, uterine changes, bone mass, and general quality of life.

Several new studies are looking at normal body changes as women move from pre- to postmenopause. Up to now, the lack of such data has been one problem in assessing the value of HRT. Without knowing what "normal" is, scientists have difficulty judging the effect of a particular treatment. Another problem with past studies is the "healthy user effect." In many trials preceding PEPI, the HRT users studied had freely chosen to begin treatment, with advice from their doctors. In general, most physicians discourage women with a preexisting illness or long family history of breast cancer from taking HRT. This factor could skew study results to appear that nonusers became ill or died more frequently simply because they failed to take estrogen. Only by randomly assigning study participants to the treatment can this bias be overcome. Until more random trials are completed, the jury is still out on HRT.

Many women feel that their physicians do not listen to their concerns. Nor do they give them enough information to make an educated decision about hormone therapy.

Another NIH study is the Women's Health Initiative, a multicenter trial involving 70,000 postmenopausal women ages 50 to 79. The study will assess the long-term benefits and risk of hormone therapy as it relates to cardiovascular disease, osteoporosis, and breast and uterine cancer. It will also help determine the effects of calcium supplementation, dietary changes, and exercise on women in this age group. Some of the specific questions to be addressed by the Women's Health Initiative include:

* How long is estrogen effective for each system of the body (skeletal, cardiovascular, nervous, endocrine)?
* What is the best dose and route of administration of estrogen and progestin to prevent side effects yet maintain efficacy?
* How long is estrogen safe to take?
* Does estrogen act the same way in older women as in younger women?
* Are there effective alternatives to HRT?
Clearly, no one has all the answers about menopause. Medical research is beginning to give us more accurate information, but some myths and negative attitudes persist. Women are challenging old stereotypes, learning about what's happening in their bodies, and taking responsibility for their health. The important thing to remember as you go through menopause is to be good to yourself. Take time to pursue your hobbies, be they gardening, painting or socializing with friends. Have a positive attitude toward life. Sharing concerns with friends, a spouse, relatives or a support group can help. Don't fight your body--allow the changes that are happening to become a part of you, a part that is natural and that you accept.






Call my office in Wilmington (815) 476-5210 or Lombard (630) 627-3700 to set up an appointment or email me at jones.gretchen@gmail.com

VITAMIN D. YOU MAY BE DEFICIENT!

Numerous studies and the epidemiological trends over recent years support the theory that people need significantly more vitamin D than has been commonly accepted. A University of Toronto study involving 796 women between the ages of 18 and 35 showed that the generally recommended amounts of vitamin D for women are too low to offer any benefit. According to Reinhold Vieth and his colleagues, any amount of daily vitamin D intake under 800 IU wasn’t enough to prevent a vitamin D deficiency.
Despite this information and more, the US Food and Nutrition board for osteoporosis-related matters still recommends only 400 IU per day for women under the age of 50.
I’ve written in past issues about the seriousness of decreasing levels of vitamin D, and the problem seems to just keep getting worse. The evidence continues to grow, but, for some reason, it also continues to be ignored. You already know the important role it plays in building and maintaining a strong immune system, and vitamin D levels also are linked to more than just proper bone growth and strength. Some of the most common health ailments today can be directly linked to inadequate vitamin D levels:
Heart Disease and Diabetes
Heart disease continues to reign as the number-one killer in this country. Although dozens of factors are involved in developing heart disease, excess sugar consumption and the inability to regulate blood sugar levels properly are undoubtedly two of the major contributing factors. Studies have now shown that low vitamin D levels decrease insulin levels and increase insulin resistance, both of which are associated with diabetes and subsequent cardiovascular problems.

Cancer
Numerous studies have found a direct association between low vitamin D levels and cancers of the breast, prostate, colon, and the skin.
Arthritis
Studies have now shown that a lower-than-optimal level of vitamin D contributes to degenerative arthritis (the “wear and tear” form of arthritis) in the hip and the knee.
Since you know adequate levels of vitamin D are also essential for proper immune system response, it shouldn’t come as any surprise that vitamin D deficiencies are also associated with such diseases as rheumatoid arthritis and even multiple sclerosis.
Depression
Sunlight exposure is a necessary requirement for vitamin D production in the body, and is also necessary for proper mood health. However, with the fear of skin cancer and wrinkling, tanning or even getting sun exposure has become taboo. The result is that depression is becoming more and more commonplace.
The problem is that, even under normal circumstances, it would be difficult for many people to get enough sun exposure to avoid depression in most of the Northern and Northeastern US cities. Only during a few summer months are there enough UV-B rays reaching those areas to allow for proper vitamin D production. (The three main forms of UV, or ultraviolet, radiation from the sun are UV-A, UV-B, and UV-C. UV-B rays are the ones we need to produce vitamin D naturally, but they are also the ones that can produce sunburn and tanning.)
Even when UV-B rays are adequate, most people now either slather on the sunscreen or avoid the sun altogether. Any sunscreen with a protective factor of 8 or more will block almost all of the UV-B rays from reaching the skin.
The ironic thing about all of this is that the incidence of skin cancer has more to do with consuming the wrong fats (too many omega-6 fatty acids and not enough omega-3s) than it does with exposure to the sun. Until the general public understands this fact, skin cancer problems will continue to increase, which will in turn cause even more fear of sunlight exposure and more depression. This whole situation has gotten way out of control. Because of the fats we’re now eating and our fear of sunlight, it’s becoming necessary to supplement our diets with vitamin D. But in the natural scheme of things, our bodies can manufacture enough vitamin D when given regular exposure of the entire body to sunlight for 20-30 minutes daily.
Obesity
Decreased vitamin D levels result in less production and secretion of the hormone leptin. Leptin is one of the primary hormones involved in fat storage and weight loss. Millions of dollars are now being spent on trying to duplicate these effects by artificially increasing levels of leptin in the body or turning it into a weight-loss drug. The simple answer, of course, is to ensure you’re producing and/or receiving adequate amounts of vitamin D.
On a very interesting, related note, researchers appear to have found a connection between bulimic dieting behavior, binge-eating, and light. Individuals with these characteristics apparently prefer to eat in dim or more subdued light compared to individuals without such problems.
Obviously, this information is still being researched and analyzed, but, based on what we know about vitamin D and leptin levels, it certainly may be more than just a simple coincidence. If you’re concerned about losing weight or have the above problems, there would certainly be no harm in opening the shades and turning up the lights at mealtime.

The connection between light, our body’s biological clock (or circadian rhythm), and our health is one that has always been a big interest of mine. Our relationship with light may seem primitive, but it is one of our most basic connections to our environment. Vitamin D is only one of the links in this connection. The other link is our biological hormones Estradiol and Progesterone and Testosterone.
You Don’t Need the Government’s Permission to Increase Your Vitamin D
When you look at the increasing incidence of heart disease, diabetes, cancer, et cetera, it becomes obvious that most government agencies and health organizations are far too slow in changing or modifying their recommendations. I think much of the problem stems from bureaucracy and, oftentimes, politics.
For example, there’s now a huge market for drugs to treat osteoporosis, and I seriously doubt that anyone developing or selling these drugs would really want the problem to be solved through diet. Even though osteoporosis and associated hip fractures have become a major problem in this country, the regulating authorities continue to recommend a daily dose of 400 IU of vitamin D. The same regulating authorities are also not approving bioidentical hormone replacement at biological levels needed to prevent bone loss through the use of estrogen and progesterone. They are way behind the times. Just don’t let your supplement be behind the times. Make sure you’re getting 2,000 to 5,000 IU of cholecalciferol (Vitamin D3) a day – not cod liver oil due to it competing for the receptor site of Vitamin D due to it’s abundance of Vitamin A. Don’t get worried about that much causing an overdose. Although various foods do contain vitamin D, unless you’re taking something like cod-liver oil, you won’t be getting much vitamin D. Milk is fortified with 10 micrograms per quart, which works out to about 400 IU per quart or 100 IU per each eight-ounce glass.
Make a point to get outside regularly and enjoy the sunshine, without the sunscreen. There’s no need to overdo it and get sunburned. Once your skin turns red, vitamin D production will stop anyway. Twenty minutes a day is all someone with fair skin needs to get enough vitamin D during the summertime. If your skin is darker, you’ll need more sunlight exposure to produce the same amount of vitamin D. And always keep in mind that, in addition to helping produce vitamin D, sunlight exposure can help regulate your biological clock, fight depression, and possibly even help you to control your appetite and lose weight. As time goes on, we’ll undoubtedly learn dozens more reasons why people weren’t made to live underground, in a cave, or in a dark house or office.
Numerous studies and the epidemiological trends over recent years support the theory that people need significantly more vitamin D than has been commonly accepted. A University of Toronto study involving 796 women between the ages of 18 and 35 showed that the generally recommended amounts of vitamin D for women are too low to offer any benefit. According to Reinhold Vieth and his colleagues, any amount of daily vitamin D intake under 800 IU wasn’t enough to prevent a vitamin D deficiency.
Despite this information and more, the US Food and Nutrition board for osteoporosis-related matters still recommends only 400 IU per day for women under the age of 50. That isn’t enough! And the FDA also allows Vitamin D2 to be sold. Make sure the label says D3 and is cholecalciferol not cod liver oil.



Call my office in Wilmington (815) 476-5210 or Lombard (630) 627-3700 to set up an appointment or email me at jones.gretchen@gmail.com

Understand How Hormones Change Stem Cells

Cancer Researchers Link Ovarian Hormone to Breast Stem Cells Growth
ScienceDaily (May 7, 2010) — Cancer researchers at Princess Margaret Hospital (PMH) have discovered that the ovarian hormone progesterone plays a pivotal role in altering breast stem cells, a finding that has important implications for breast cancer risk.

The findings, published online in Nature, are significant because reproductive history is among the strongest risk factors for breast cancer, says principal investigator Rama Khokha, a molecular biologist at Ontario Cancer Institute and the Campbell Family Cancer Research Institute, PMH. Other major known risk factors are age, genetics and breast density.

"Our study shows how and when hormones affect breast stem cells during the natural reproductive cycle. There are well accepted links between ovarian hormones and breast cancer, and there is mounting evidence that stem cells are seeds for breast cancer. We now show a direct connection between hormones and breast stem cells. "

Lead author Purna Joshi adds: "Our research demonstrates that when progesterone peaks during the second half of the menstrual cycle, it starts a cross-talk between stem cells and neighbouring cells that propels normal breast stem cells to expand in number, and may trigger an environment where cancer can begin."

Until now, breast stem cells were thought to be generally inactive in the adult female breast, says Dr. Khokha, whose speciality is modelling human cancer in the laboratory. In this study, the research team replicated the human natural reproductive cycle in mice to determine the impact of hormones on breast stem cells.

How hormones change these stem cells opens a new pathway to understanding the cell growth that begins breast cancer, and, with further research, will open new ways of targeting stem cells.

"It is the first evidence, to our knowledge, for progesterone-driven dynamic shifts in the mammary stem cell pool. This activation provides an opportunity to start the process of cell transformation leading to breast cancer."

The research was also supported by the Canadian Cancer Society Research Institute and the Canadian Breast Cancer Foundation.



Call my office in Wilmington (815) 476-5210 or Lombard (630) 627-3700 to set up an appointment or email me at jones.gretchen@gmail.com

400 reasons you need Estrogen

You need to think about starting natural estrogen bioidentical hormone replacement therapy when approaching menopause in your late 40’s and early 50’s. Why? Well, for relief of symptoms like hot flashes, night sweats, vaginal dryness, and low libido among others, nothing works better than estrogen. Long term benefits of estrogen bioidentical replacement therapy include prevention of memory loss, maintenance of heart health, prevention of heart disease, bone production (prevention of osteoporosis), prevention of Alzheimer’s disease, prevention of cataracts and macular degeneration, maintenance of mood and prevention of depression, and quality and youthfulness of your genital tissues and skin. Vitamins and herbs cannot do all these things (although they may temporarily improve some symptoms like hot flashes). Quite simply, estrogen keeps women’s cells healthy. Only estrogen in women can prevent disease and improve quality of life…and only bioidentical transdermal estrogen!
What is natural bioidentical hormone replacement? It means using hormones that are biologically identical to what your body makes. In other words, the hormones are the same chemical structure as the ones that your body makes. Customized natural hormonal therapy is the only way to replace hormones safely. One size does not fit all.
Studies have shown that women who use hormone replacement live longer than those who do not. To be effective in preventing disease, estrogen must be started in women in their 50’s. For example, you need 10 years of estrogen replacement to help prevent Alzheimer’s disease.
Estrogen has 400 functions in your body. It increases your metabolic rate, enhances energy, improves insulin sensitivity, and regulates body temperature. It prevents muscle damage and helps maintain muscle.
In the cardiovascular arena, it helps maintain the elasticity of your arteries, dilates your small arteries, increases blood flow, inhibits platelet stickiness, decreases the accumulation of plaque on your arteries, decreases blood pressure, decreases LDL (bad cholesterol) and prevents its oxidation, acts as a natural calcium channel blocker to keep your arteries open (pharmaceutical companies make alien molecules to do this in patients with heart disease), decreases lipoprotein A ( a bad fat that is a risk factor for heart disease), reduces homocysteine (another risk factor for heart disease), increases HDL (good cholesterol) by 10 to 15%, and reduces the overall risk of heart disease by 40 to 50%.
Estrogen has many benefits for your brain and nervous system. It helps maintain your memory, increases reasoning and new ideas, helps with fine motor skills, enhances the production of nerve-growth factor, improves your mood, increases concentration, helps prevent Alzheimer‘s disease, improves your mood, aids in the formation of neurotransmitters in your brain such as serotonin which decreases depression, irritability, anxiety, and pain sensitivity.
For eye health, it protects against macular degeneration and helps prevent cataracts.
For beauty, it maintains the amount of collagen in your skin increases the water content of your skin and is responsible for its thickness and softness, improves breast firmness, maintains the moisture and thickness of the genital tissues, and decreases facial wrinkles.
For bones, it maintains bone density and helps prevent tooth loss.
It increases sexual interest and decreases your risk of colon cancer
Your body has receptor sites for estrogen everywhere: in your brain, muscles, bone, bladder, gut, uterus, ovaries, vagina, breast, eyes, heart, lungs, and blood vessels, so it is needed for health is all these areas.
So with decreased estrogen you get thinner skin, more wrinkles/aging skin, decrease in breast size, stress incontinence, oily skin, acne, decreased sex drive, decreased dexterity, increase in insulin resistance and possible diabetes, vaginal dryness, decreased memory, osteoporosis, urinary tract infections, and increased cholesterol.
Perimenopause and menopause occurs in our 40’s and 50’s. Most women of that age group can expect to live to be a mean age of 83. You may spend 30-40 years without the benefits of estrogen and experience resultant and inexorable disease and decline from loss of estrogen.
With a safe and effective way of replacing estrogen with bio-identical hormones, women no longer need to bear the disease and decline of estrogen deficiency.
A few things to remember:
1. Estrogen must be balanced with progesterone (not progestins or medroxyprogesterone which are piosons), even if you had a hysterectomy. Estrogen without progesterone or not enough progesterone equals 10 pounds. Besides, progesterone also has many benefits of itself.
2. Never take any type of oral estrogen, even bioidentical. It can cause or make cardiovascular heart disease worse due to a protein that is made in the liver when a great deal of estrogen hits the liver when absorbed from the gut. Transdermal estrogen doesn’t do that because it is absorbed more evenly.
3. Take only bioidentical estrogen that has estradiol (your main estrogen) and estriol (a weaker estrogen with cancer and heart protective effects). This compound is generally called Biest (bi-estrogen). Another bioidentical estrogen compound called Triest is now considered to be outdated since it contains estrone, another one of our week estrogens. We need a little estrone for bone health, but we do not need to replace it especially since estrone can be metabolized in the body into cancer causing metabolites.


Call my office in Wilmington (815) 476-5210 or Lombard (630) 627-3700 to set up an appointment or email me at jones.gretchen@gmail.com

Testosterone For Men

Testosterone in Men byCandice Lane, M.D.
Filed under For Men

There has been a lot of buzz about women’s hormones, but you hear very little about men. To make it worse, men do not seek or share this information as women do. How many men do you know who go out for coffee with their buddies and talk about their hormones? Few people appreciate the pervasive effects of testosterone on men’s general health.



The fact is that as men age, they lose their testosterone. The loss of youthful levels of testosterone with the onset of its associated symptoms is sometimes called andropause. It is the natural diminution (or pause) in production of male hormone (an androgen) as men age.



Testosterone loss in men is a gradual process. Testosterone decline starts around age 30, and may drop 1% to 3 % per year depending on genetics and lifestyle. That means that men can sustain a 20% drop in testosterone by age 50, and a 50% drop by age 80. Each man may experience the symptoms of a decline in testosterone differently depending on what his normal was at his hormonal peak. Often the symptoms are ignored or rationalized away until the resultant decreased functioning becomes a way of life.



The most obvious and disturbing changes for men are those of sexual function, but equally troubling symptoms of low testosterone may manifest as a decline in mental functions, musculoskeletal conditions, and metabolic or physical diseases.



Changes in mental functioning may manifest as spells of mental fatigue and inability to concentrate, feeling burned out, low energy, tiredness or sleepiness in the afternoon or evening, decrease in mental sharpness, attention, and wit, or a change in creativity like getting spontaneous new ideas. There may be a decrease in desire to start new projects, or a decreased interest in past hobbies or new work-related activities. Competitiveness may diminish and irritability increase. Memory functions may become impaired with increased forgetfulness. Men can experience a sense of depression with a sense that work, marriage, or recreational activities have lost their significance.



Musculoskeletal symptoms may appear as sore-body syndrome with aches and joint and muscle pains. A decline in flexibility and mobility may be noticed with increased stiffness. Muscle size, tone, and strength may decrease. Physical stamina and athletic performance may decline. Some men experience back pain, neck pain, or a tendency to pull muscles or get leg cramps. Some develop osteoporosis or inflammatory arthritis.



Low testosterone levels correlate with more risk factors of heart disease than any other individual factor in the male body. Cardiovascular risk factors increase in men as testosterone decreases. Cholesterol and triglyceride levels increase, coronary and major arteries constrict leading to a greater risk of cardiac events, and blood pressure rises. Insulin resistance increases with obesity, adult diabetes, and increased cortisol levels. There is increased central abdominal fat with increased waist to hip ratio. Estrogen levels associated with higher stroke and heart attack rates (and increased fat in the breast and hip area) increase. Another increase associated with decreased testosterone is in lipoprotein A and fibrinogen, which correlate with cardiac events. Also, human growth hormone output decreases leading to a decline in energy, strength, stamina, and heart muscle mass and output. Low testosterone levels are associated with increased incidence of death even after researchers adjust for age, medical problems, and variables.



Although not all signs and symptoms of aging are due to hormonal decline, many correlate well with a decline in hormones and can be alleviated by hormone adjustment.



Treatment of low testosterone should be administered by a doctor trained in hormone therapy after a full history, examination, and laboratory testing. Regular follow-up is important to control symptoms, prevent side effects, and to make sure hormone levels are optimal.



Call my office in Wilmington (815) 476-5210 or Lombard (630) 627-3700 to set up an appointment or email me at jones.gretchen@gmail.com

Women To Women - Not Hormones, Only Vitamins.

When you search Google for “bioidentical hormones”, what’s the first site to come up? It’s Women to Women. I find this astounding because Women to Women has nothing to do with bioidentical hormones.

“Women to Women” is a vitamin sales website that proclaims it’s devoted to women’s health. They say they use phytotherapy to achieve natural hormone balance. So what is phytotherapy? It’s vitamins and herbs. On Women to Women, they are basically saying you can rebalance your hormones with vitamins.

Hormones decline in women because our ovaries shut down with age. There is no vitamin in the universe that will bring back ovarian function or hormones once in the process of menopause. Some vitamins may improve your symptoms and improve health, but no vitamin can replace the beneficial functions of estradiol, progesterone, or testosterone. As far as balancing your hormones, eventually they will all be balanced by being gone, and no vitamin will prevent that!

Don’t get me wrong. I am a devoted believer in using vitamins to help treat many problems including adrenal fatigue, adrenal stress, thyroid problems, hypertension, high cholesterol, osteoporosis and a number of other disorders. Vitamins and herbs can overall improve our general health. But without hormones to direct your cells functioning, vitamins are limited in what they can do. The fact is that you need both hormones and vitamins, and the way you get hormones just like with vitamins, is with replacement! Hormones can totally relieve your symptoms and keep you healthy. Vitamins, even with diet and exercise, cannot do this.
Women to Women has an extensive library of many legitimate disorders and there is a lot of good information there. However, most every conclusion is that there is no good hormonal treatment and the best treatment is to use their vitamins. Admittedly, those writing the articles are very skillful in coming round to this conclusion, but be aware that the people writing the articles are nurses without any specialized hormone training, not doctors with bioidentical hormone training.

The fact is Women to Women is basically a site dedicated to making money by selling vitamins to women who are suffering from menopause. Granted vitamins may mildly and usually temporarily improve some symptoms of menopause like hot flashes, but they falsely claim that women can “rebalance women’s hormones without the use of drugs”. O.K. I agree with balancing your hormone without the use of drugs; that is, without the use of pharmaceutical drugs like the synthetic hormones Premarin and Provera (HRT), but bioidentical hormones (BHRT) are not drugs. They are natural hormones with the exact same molecular structure as in the human body.

Women to Women goes on to say “We have found that about 85% can find relief through an approach that combines medical-grade nutritional supplements, gentle endocrine support, and dietary and lifestyle changes.” Relief of what and for how long? This is a fundamental misunderstanding or misrepresentation of menopause and hormone imbalance.

Menopause is a hormone deficiency of estrogen and progesterone caused by ovarian failure and cessation of ovulation that is genetically dictated by our life cycle. How can you balance hormones that are not there? Vitamins will not put back your hormones or keep you ovulating until you are 90. The symptoms, aging, and decline of menopause are due to losing your hormones. As you become deficient, the only remedy is to replace your hormones.

Estrogen is the woman’s hormone for health. It has 400 functions in the human female body. It is responsible for heart health, eye health, brain health, and bone health. When estrogen is started early (at least in your 50’s) the medical literature has shown it can help prevent heart disease, osteoporosis, cataracts, macular degeneration (blindness), Alzheimer’s disease, depression, colon cancer, wasting of our genital tissues, urinary leakage, cholesterol problems, loss of sexual desire, loss of skin beauty, loss of memory and other things. (Estrogen-Natural Bioidentical Hormone Replacement) The current medical literature has shown that bioidentical hormones are safe. They do not cause breast cancer. To prevent disease, bioidentical hormones need to be used on a long terms basis. At least 10 years use is needed to prevent Alzheimer’s. Current bioidentical experts recommend lifelong use to stay healthy and vital.

Women to Women has said bioidentical hormones are not the fountain of youth. Well that may be. None of us will get younger with hormones (except maybe with growth hormone), but we don’t have to experience the disorders of aging either that are more likely to occur without our sex hormones. Progesterone has its very own functions (Progesterone Deficiency) and is necessary to balance estrogen.

Women to Women staff comes from a sect of alternative medicine that believes in aging naturally by allowing your hormones to decline and only alleviating, if necessary, the symptoms (hot flashes, night sweats, etc.) of this slow and painful decline. But what about the diseases that occur due to hormone loss like Alzheimer’s, osteoporosis, and colon cancer? Why not try to prevent these diseases by replacing our hormones?

Women to Women recommends using vitamins first to treat the symptoms of menopause (remember vitamins don’t put hormone back). Why? Well maybe because they sell vitamins…that’s their business. They do not recommend bioidentical hormones. Why? Well, because they can’t sell a pharmacy product online with the click of a button and a charge of the card, and that would put their vitamin business out of business. Their articles minimize Suzanne Somers’s writings and claim that she is in the minority of women needing replacement. Why? Maybe because she writes about bioidentical hormones as the basis of health, and again, they can’t sell hormones online.

Let the buyer beware. The formula used by Women to Women is not anything special and can be easily duplicated at a lower cost. Their lifestyle coaching might prove beneficial if personal support is your goal
What’s my problem with all this? The vitamins won’t hurt, right? Wrong. It shakes confidence in real medical treatment, deters seeking treatment, and is a financial drain. I have had several patients that have come to me after trying Women to Women’s program which did not work. They spent a large amount of money with Women to Women without relief (of course you have to do the 3 month program). This financial loss discouraged and inhibited them from seeking medical advice from doctors trained in hormone replacement therapy. For about the same price of their premium plan you can get bioidentical hormones for replacement from a pharmacy.

So how does Women to Women get to the top of Google search for bioidentical hormones? They spend huge amounts of money on advertising with Google Adwords for one thing. In addition they have a large amount of content on their website which pushes them up in the page rankings.

There is a way to actually balance and replace your hormones that really works and has immediate and long term benefits – and that is natural bioidentical hormone replacement



Call my office in Wilmington (815) 476-5210 or Lombard (630) 627-3700 to set up an appointment or email me at jones.gretchen@gmail.com

Bioidentical Hormones are Safe Bioidentical Hormones are Safe

by Candice Lane, M.D.

There is no doubt that there is improvement in the symptoms of menopause by using hormone replacement therapy. It includes elimination of symptoms such as hot flashes and night sweats, reversal of bone loss leading to osteoporosis, improved sleep, emotional stability, libido and quality of life.But extreme confusion revolves about the safety of taking hormones.

Some doctors are telling patients to get off all hormones. Some are prescribing Premarin and Provera, while others are prescribing “bio-identical hormones”. Still others are switching back and forth between the two.

Hormone replacement therapy or HRT is a broad category. Some people use this term to refer to all hormone replacement therapy. When you hear this term in the media, they are generally referring to Premarin and Provera which are not natural to the human body. These drugs are referred to as synthetic hormones because they are synthesized with molecules that do not occur in the human body in nature.

Premarin is a type of estrogen obtained from horse’s urine. Although it is natural to horses, it is a different molecule than occurs in the human body. It is a very potent estrogen that can alleviate many symptoms but has negative effects as well.

Provera is a progestin used to prevent tissue from building up in the uterine lining while taking Premarin. A progestin is NOT progesterone. It is a different molecule. Progestins actually inhibit production of progesterone by the human body and have dangerous effects on the human body.

The new classification of hormone replacement therapy is called bio-identical hormone replacement therapy or BHRT. This therapy includes estrogens and progesterone that are made from soy and wild yams obtaining a compound that has the exact same molecular structure as these substances in the human body… therefore, bio-identical.

The dangers of Synthetic HRT (Premarin and Provera) were discovered in the Women’s Health Initiative Study in 2002.

This study analyzed the outcome of women taking Premarin (conjugated equine estrogen or horse estrogen from pregnant mare’s urine) and Provera (medroxyprogesterone acetate or synthetic progesterone) and found increased rates of breast cancer and cardiovascular disease. Since the drugs used were not bio-identical hormones the results only apply to Premarin and Provera, not BHRT.

Premarin is taken orally. Any oral estrogen can be a problem for heart health. It can activate coagulation and inflammation. Descenci in Circulation in 2005, found that transdermal estrogen does not have this effect.

The main breast cancer problem is the synthetic Provera (medroxyprogesterone). When the Women’s Health Initiative patients who received only Premarin without Provera were analyzed the rate of breast cancer was not increased. (Anderson, JAMA, 2004). This indicated that it was the Provera that caused an increased incidence of breast cancer.

BHRT (bio-identical hormone therapy) does not increase the chance of breast cancer. The main danger of synthetic HRT is the non-bio-identical progestin (Provera).

In the Fournier et al. study in the International Journal of Cancer, 2005 studied 54,000 women who were taking bio-identical estrogen and either bio-identical progesterone or synthetic progestin. The women taking the bio-identical progesterone had a 10% decrease in risk of breast cancer and the women taking artificial progestin had a 40% increase in the risk of breast cancer.

The De Lignieres study from Climacteric 2002 could not show an increased risk of breast cancer with use of bio-identical hormones but showed an increased risk with the use of synthetic progestin (Provera/medroxyprogesterone). In fact, they could not justify stopping BHRT(bio-identical), which is beneficial for quality of life, prevention of bone loss and cardiovascular risk profile without activating coagulation and inflammatory protein synthesis as in users of oral estrogens.

The real problem with synthetic HRT is the synthetic progestin(Provera). In contrast, several studies document that higher progesterone levels during pre-menopausal years or during pregnancy are protective against breast cancer. (Campanoli, Journal of Steroid Biochemistry and Molecular Biology, 2005).

In any case, estrogen should not be taken without progesterone which counters the proliferative tissue effect of estrogen on breast and uterine lining.

Bio-identical hormone therapy, which is different from Premarin and Provera, is safe, effective, and proven beyond any reasonable medical and scientific doubt



Call my office in Wilmington (815) 476-5210 or Lombard (630) 627-3700 to set up an appointment or email me at jones.gretchen@gmail.com

Breast Thermography is Now Available in Illinois

Breast thermography is a 15 minute non invasive test of physiology. It is a valuable procedure for alerting your doctor to changes that can indicate early stage breast disease.

The benefit of breast thermography is that it offers the opportunity of earlier detection of breast disease than has been possible through breast self examination, doctor examination or mammography alone.


Thermography can detect the subtle physiologic changes that accompany breast pathology, whether it is cancer, fibrocystic disease, an infection or a vascular disease. Your doctor can then plan accordingly and lay out a careful program to further diagnose and /or MONITOR you during and after any treatment.

Normal




Good thermal symmetry with no suspicious vascular patterns or significant thermal findings.


Fibrocystic Changes



The very significant vascular activity in the left breast justified clinical correlation and close monitoring which returned an opinion of fibrocystic changes taking place. These changes can be monitored thermographically at regular intervals until a stable baseline is established and is reliable enough for annual comparison.

Early Stage Malignant tumor




This is the specific area of a small DCIS. We can see the vascular feed and the discreet area of hypothermia that is displacing the surrounding hyperthermia.


Thermography is a painless, non invasive, state of the art clinical test without any exposure to radiation and is used as part of an early detection program which gives women of all ages the opportunity to increase their chances of detecting breast disease at an early stage. It is particularly useful for women under 50 where mammography is less effective.

Thermography's role in breast cancer and other breast disorders is to help in early detection and monitoring of abnormal physiology and the establishment of risk factors for the development or existence of cancer. When used with other procedures the best possible evaluation of breast health is made.

This test is designed to improve chances for detecting fast-growing, active tumors in the intervals between mammographic screenings or when mammography is not indicated by screening guidelines for women under 50 years of age.

All patients thermograms (breast images) are kept on record and form a baseline for all future routine evaluations.

This patient's thermograms have remained stable for two years. These patterns are like a thermal fingerprint which will only change if pathology develops.

Baseline

3 Month Follow-up


First Annual

Second Annual



With the new ultra-sensitive, high resolution digital infrared cameras available today a technology that has been developing over the past 20 years is now becoming more accessible.

Thermography as a physiologic test, demonstrates heat patterns that are strongly indicative of breast abnormality, the test can detect subtle changes in breast temperature that indicate a variety of breast diseases and abnormalities and once abnormal heat patterns are detected in the breast, follow-up procedures including mammography are necessary to rule out or properly diagnose cancer and a host of other breast diseases such as fibrocystic syndrome, Pagets disease, etc.

Canadian researchers recently found that infrared imaging of breast cancers could detect minute temperature variations related to blood flow and demonstrate abnormal patterns associated with the progression of tumors. These images or thermograms of the breast were positive for 83% of breast cancers compared to 61% for clinical breast examination alone and 84% for mammography.

By performing thermography years before conventional mammography, a selected patient population at risk can be monitored more carefully, and then by accurately utilize mammography or ultrasound as soon as is possible to detect the actual lesion - (once it has grown large enough and dense enough to be seen on mammographic film), can increase the patients treatment options and ultimately improve the outcome.

It is in this role that thermography provides its most practical benefit to the general public and to the medical profession. It is certainly an adjunct to the appropriate usage of mammography and not a competitor. In fact, thermography has the ability to identify patients at the highest risk and actually increase the effective usage of mammographic imaging procedures.

Until such time as a cure has been found for this terrible disease, progress must be made in the fields of early detection and risk evaluation coupled with sound clinical decision making.

Thermography, with its non-radiation, non-contact and low-cost basis has been clearly demonstrated to be a valuable and safe early risk marker of breast pathology, and an excellent case management tool for the ongoing monitoring and treatment of breast disease when used under carefully controlled clinical protocols.



Call my office in Wilmington (815) 476-5210 or Lombard (630) 627-3700 to set up an appointment or email me at jones.gretchen@gmail.com

Development, Structure, and Function of the Ovary

The gonads in utero exist in an undifferentiated state until the seventh week of fetal life, at which time the primitive ovary can be differentiated from the testis. Estrogen formation in the ovary begins between weeks 8 and 10, and by 10 to 11 weeks of gestation, some oognia in the developing ovarian cortex begin developing into primary oocytes.

The ovary contains a finite number of germ cells. The maximal number of about 7 million oogonia being reached by the fifth to sixth month of gestation. Afterward, the germ cells decrease in number through a process of atresia such that only 1 million remain at birth, 400,000 are present at the time of menarche, and only a few remain at menopause. Two X chromosomes are required for normal development of the ovary. In individuals with a 45,X karyotype, ovarian development occurs, but the rate of atresia (ovarian dealth) is accelerated so that only a fibrous streak remains at the time of birth.

Final maturation of ovarian follicles commences during puberty. The two major hormones that regulate follicular development are the pituitary gonadotropins - follicle stimulating hormone (FSH) and luteinizing hormone (LH).

As the time of puberty nears, a decrease in the sensitivity of the hypothalamic-pituitary system allows for increased secretion of FSH and LH, possibly secondary to increased episodic or pulsatile secretion of luteinizing hormone releasing hormone (LHRH) by the hypothalamus. An increase in estrogen secretion subsequently exerts a positive feedback which leads to an exaggeration of the pulsatile release of LH and eventually to ovulation and the menarch, after which average plasma gonadotropin concentrations reach adult values in which day and night levels are similar.

The culmination of puberty is the onset of predictable, cyclic menses. The average time between the beginning of breast development and the onset of menses is 2 years. During the first few years after menarche, menstrual cycles are often irregular and unpredictable due to anovulation (similar to perimenopause). The age of menarch is variable and is determined in part by socioeconomic and genetic factors as well as general health. The mean age in the United States has decreased at a rate of 3 to 4 months per decade over the last 100 years and is now around 13 years old.


Call my office in Wilmington (815) 476-5210 or Lombard (630) 627-3700 to set up an appointment or email me at jones.gretchen@gmail.com