"The sound body is the product of the sound mind"
--George Bernard Shaw


What Patients Ask
Q. 
Dear Dr Rinker  I would like to find out more about the anti-aging work you are doing. In the last year I'm finally beginning to feel the effects of aging, and I don't like it. I ache a lot, I see my skin sagging, and I just don't have the same stamina that I used to. Everyone says I don't look my age, but they don't know what it feels like to be in this body.  DV
A.

Dear DV Well, I am very excited about anti-aging medicine, because we teach what we need to learn, and I am very excited about what I am learning, avidly study all the time, and pass on my learning to my patient/clients.  You can read a little about what I specifically do at my website:  http://www.stress-medicine.com/  and in general about anti-aging medicine at the American Academy of Anti-Aging Medicine  http://www.worldhealth.net/   and the Life Extension Foundation  http://www.lef.org/  , both excellent websites.  

In particular, what I do is evaluate a person for physiological decline in several areas:  Hormonal, Cardiovascular, Immune System, Brain-Nervous System, Gastro-Intestinal System,  and Musculo-Skeletal System, and work with them to bring them back to "Prime of Life" function or keep them there if they are functioning well.  I use Bio-Identical hormones when necessary, Natural Supplements, Diet and Exercise Recommendations, and sometimes prescription medications when necessary. My basic concept is that we are still "designed" to be herd animals, and as such, herd survival depends on the older members disappearing from the heard as soon as they pass the age of reproduction and prime hunting age.  That would be us.  So our body is conspiring with Mother Nature to wipe us out by compromising our cellular integrity, our muscular strength, our sleep cycle, our hormonal balance, even our ability to absorb nutrients from food.  We further compromise ourselves by eating a diet that is completely incompatible with our physiology and sets us up for more degenerative disease, because of the extremely high percentage of Omega-6 fats, which are highly inflammatory, and the excessive amount of grains and dairy in our diet which our digestive systems are not designed to absorb or incorporate into our cells. So we too, conspire with Mother Nature in our own demise.  

Most physicians do not address these correctable problems.  They give medicines which help us to compensate temporarily for the symptoms caused by these problems, such as anti-inflammatory drugs because of the high degree of inflammation generated by the toxic diet we consume. It helps for awhile, but our cell membranes throughout our bodies are still being assaulted by free radicals and breaking down and we age faster.  That doesn't mean that anti-inflammatory drugs are wrong, sometimes they are essential.  They are not the cure.  We need to do much more than that if we really want to reverse the process of the degenerative effects of aging.
Q. 
I just started taking thyroid supplementation and I feel more tired, more hair loss, and lower body temperature (average 97.2) . Was this a reverse effect or is this normal? Regards my type of treatment? I have Hashimoto's Thyroiditis.
A. 

One of the things that can happen with thyroid hormone replacement when you are producing antibodies to your own thyroid converting enzymes (thyroid peroxidase) and thyroid carrying protein (thyroglobulin) is that your own thyroid can down regulate, as the body is used to the lower functioning levels after years of your immune system attacking your thyroid hormone, and rendering it ineffective.  That is why we are measuring your temperature BP and pulse on a daily basis, and putting it on a chart.  One, to make sure you don't get too high a pulse and BP and on the other hand to see how your body responds.  It is not uncommon for the body to react by lowering your own hormone.  You were already making an inadequate amount of thyroid and your pituitary was "satisfied" with that, even though you had symptoms of low thyroid function.  That means we have to increase again.  I suggest patients increase the dose according to the specific instructions we discuss, based on symptoms temperature and pulse and less frequently on blood levels.  We are using very small incremental increases in dosage.  Continue to measure your BP. pulse and temp and note the new dose on your chart. If after a week, there is still no improvement in temp, BP pulse or energy (change in hair and skin will take longer) then increase to the next incremental dosage, and stay at that dose, while continuing to chart daily and bring your chart with you when you come for your appointment in two weeks.

Thyroid adjustments take awhile, especially as we started low, and we will work in partnership on this, as you learn to sense how your metabolism works and we both learn how your body responds to thyroid hormone.  I would like to say you will feel great in two weeks but that is not usually how it works.  It usually takes several months to get everything in balance.  The longer you have been living in a low thyroid state and the more organ systems that have been affected by chronic hypothyroidism, the longer it takes your body to recover.

Your body will learn to adjust to having a healthier hormone balance, and we will both learn what the exact right dosage of each hormone is for you. It is an individual balancing act and your body teaches us as I teach you.  It's not a "blind" groping for the right dose, though.  We use your positive response, side effects, blood levels, vital signs and changes over time to assess whether we are on the right track.  The hormones all augment each other and help each other be more effective too, so as time goes on, having better estrogen/progesterone balance will improve your thyroid function and visa versa.  Having better B-12 and folate levels will improve your hormone metabolism.  Having adequate Melatonin levels improves your ability to convert T4 to T3, and having adequate Growth Hormone improves the function of many organs including the pituitary gland and the organs that it affects.

I hope that makes some sense to you.  I will answer any questions you have as we go along, and I definitely want to know if and when you aren't feeling well or if you feel you are having a negative reaction.

So, try the two increases in the Thyroid hormone as I have outlined and contact me if it doesn't feel "right"
Q. 
Do you instruct your patients to use the creams twice per day?  Most of the information I’ve read and pharmacists I’ve spoken to seem to think that’s the best way to go unless you’re using a long-lasting gel (Duragel or something). 
A. 

If a woman is peri-menopausal and has symptoms like migraines and mood swings, she will probably feel better faster if she keeps her hormone levels at a steady state.  Men naturally have testosterone "peaks' twice a day, and dosing testosterone twice a day works well for them.  A woman who has been menopausal for awhile may not require nor respond well to such a quick and steady rise in hormone level and I usually take it more slowly with them. and often dose once a day.

Q. 

Do you ever prescribe progesterone to men?  I read Dr. Uzzi Reiss’s book “Natural Hormone Balance for Women”.  He stated in the book he himself used these hormones (HGH, progesterone, testosterone, melatonin, pregnenolone, DHEA) – all except for estradiol which I know men don’t want too much of as they get older.  My husband used 10 mg of OTC Progestacare for men per day and likes it. 

A. 
I have prescribed progesterone for men in small amounts, as it converts to testosterone,  but it also inhibits the production of DHT, which can irritate the prostate, and yes, I do prescribe all of the other hormones (except estrogen) for men as well as women. Pregnenolone is very important for example in protecting the brain from the damaging effects of prolonged cortisol release, which can happen during prolonged illness and prolonged stress.
Q.  

You asked me to have my blood drawn on day 18-21 of my cycle.  I’ve talked to a couple of other anti-aging physicians (one was Dr. Ron Rothenberg in Encinitas) who have their blood drawn somewhere between days 20 – 23 when progesterone is supposed to be at its peak.  I know you’re an expert, but I just wondered why you look at day 18 rather than later in the cycle?  Also, do you always use testosterone, progesterone, and estrogen in cream form?  If a person doesn’t absorb the progesterone well, do you ever prescribe sublingual or oil-based pills?  Also, what compounding pharmacies do you use?

A. 

Well Ron Rothenberg is an expert too, he is right that progesterone levels will be higher on day 20.  Progesterone is at it's absolute maximum peak, at that point, but on day 18, progesterone is well on it's way to peak, and some women, especially if they have shorter than 28 day cycles may have their peak hormone levels earlier.  Estrogen is just slightly past it's peak and testosterone is at it's peak, so it's the time to get all three hormones at what should be fairly high levels if your ovaries producing well, and if they aren't your FSH should be "complaining" in order to get your ovaries to respond.  If it isn't then you could have a pituitary problem. If FSH is extremely high with poor ovarian response, then menopause is the likely answer.

For women I prescribe a natural plant based facial cream base for my   biestrogen and progesterone most often, but I also use sublingual, oral and vaginal preparations. It’s very individualized.  The biestrogen is great on the face as it has a wonderful anti-aging anti-wrinkle effect. Progesterone can be applied to the breasts, belly and thighs and has an anti-diuretic effect ( helps decrease water retention) and reduces cysts in the breasts.  I do also prescribe progesterone as a sublingual or an oral form too, which can help get levels higher and more consistent for some women. 
Q. 

What form do you usually prescribe the testosterone in men (gels, creams, pellets, sublinguals, etc).

A. 

Typically as an alcohol based topical gel. but sometimes as in Subcutaneous injection when men cannot properly absorb it topically.  I can prescribe SL, and sometimes do for women who need it to reduce SHBG levels.

Regarding the use of pellets.  I have considered the use of pellets and have decided not to use that form of treatment, as it just didn't seem flexible enough...Once it's implanted, it's a hassle to remove if you are having side effects or problems with the dosage.  That's just my impression, and physicians who do this treatment may disagree with me, but I chose not to because I find that I am often fine tuning the dosages based on blood levels and patient response to treatment.
Q.

After the initial blood work, how often does the blood work usually need to be repeated?  Does every test have to be repeated or just the hormone panel?

A. 

It depends on the person, and their treatment program, but I do not repeat the entire profile except for yearly check-ups.  I follow-up with hormone checks to make sure we are in the right range and are not producing too many cancer-causing metabolites a few months after starting hormone replacement and every 3 to 6 months to make adjustments.  I do that with Lipids and cardiovascular inflammatory factors too.

Q. 

Do you ever prescribe testosterone patches for men?  You mentioned you prescribe testosterone sublingually sometimes for women, how about for men?  Do you prescribe estradiol patches for women?  Do you ever prescribe a testosterone thick gel for women to put directly on their labia? 

A.

I am not opposed to prescribing testosterone patches for men, but most men don't like them.  Changing  a patch every day can get to be a nuisance for a guy who has to find a new spot for the patch (without hair) every day!   I do provide estridiol patches for women, which can be changed 1-2x per week but also add estriol cream to balance them, since the patch only has estradiol.  Yes there is a testosterone available for the labia, but I recommend only a small portion of a woman's dose go on the labia, since it converts readily to DHT when applied to genital skin in men and women.  However, using a small portion of the testosterone  dose on the labia and clitoris up to 2 hours before sex can greatly enhance both orgasm and the sexual experience.

If we have some troubles with a certain prescription, can we e-mail or call you to change it (possibly to a different form, stronger/weaker titration, etc.)  From what I’ve read and people I’ve talked to, it sounds as though sometimes there’s a bit of trial and error involved.  It would be great to be able to communicate with you sometimes if any minor changes needed to be made.    

I agree that fine tuning of hormones is often necessary.  That is why I give each hormone separately and educate my clients about what each hormone is likely to cause in the way of benefits and negative side effects, and I encourage communication to get the best response with the least side effects.  I also do follow up blood tests after a few months to make sure that there aren't negative side effects that are not usually perceived by the senses, such as a build up of end stage metabolites of hormones, like Estrone and Dihydrotestosterone which can increase the negative aspects of hormone therapy and cancer risk.  Vitamins and supplements can reduce this build up of metabolites.

Q. 

What other conditions do you treat? I understand you treat other kinds of conditions.

A. 

I treat people who have multi-system complaints, which can be hormonal in nature, or infections, such as virus and Lyme disease. I also treat people using the Wilson Temperature Syndrome protocol, and treat Chronic Fatigue Syndrome and Fibromyalgia.

Q. 

I was recently diagnosed with Multiple Sclerosis by a neurologist, who told me I don’t have all of the “typical” symptoms of MS and he wants to do a spinal tap. I also tested positive at your office for Lyme disease, and infections with Bartonella and Babesia.  I don’t know what I should do. I am afraid to have a spinal tap, and already have had a MRI and a CT scan of my brain, which were “atypical” but not certain as to what is wrong with my brain. What should I do?

A.

I absolutely understand your desire to be sure you are doing the right thing for your brain, health and future. It is so unfair that patients like you are caught up in this heated and confusing debate about Lyme, Bartonella, Babesia. There is strong debate over testing interpretation and/or treatment. I will recommend a Neuro-radiologist who is “Lyme aware” to give you a second opinion on the studies you’ve already had. There is huge controversy over the labs too.  I prefer to use IgeneX  Laboratory, because they are a private lab can ignore the CDC recommendation to delete kDa bands 31 and 34 from the western blot,( two of the most specific bands for Borrelia burgdorferi ) as there was a vaccine many years ago on the market that used those two bands, It was pulled from the market when many of the patients receiving the vaccine developed Lyme symptoms.  Labcorp and Quest will also NOT do the western blot if a "screening test" IFA or ELISA is negative, even if ordered.  There is no reliable screening test. (Reliable means that the test picks up 98+% of patients with illness and even has some false positives.  ELISA or IFA do not even come close to that.  (More like only 35-40% of patients with Lyme have a positive Elisa or IFA.

There are 18-27 species of Babesia that have been found in humans so far, but tests are only available for 2: B Duncani and B Microti.  Many if not most of Babesia IgM is negative or very low, even in patients with exposure and symptoms.  Lyme literate doctors often call the Bartonella infections that accompany Lyme as "Bartonella-like Organisms" (BLO) because it is not exactly like Bartonella Henselae in most patients developing symptoms after a tick bite. Very hard to get high titres on them.  The IDSA Guidelines do not recognize co-infections nor the diagnostic problems in testing for them. They don't acknowledge chronic Lyme unless you have "proof" in biopsy or lab tests and even then are skeptical that chronic Lyme disease should be treated. Looking only for high IgM titres for Bartonella and Babesia as proof  that you have an infection is going to very likely end up with the neurologist saying you definitely don't have those infections.  One method that may prove helpful is to submit blood to Fry Labs, where they use special staining on slides and a medical technologist scans the slides for 2 hours looking for physical evidence of the organisms.  That is not proof positive that you don’t have these infections if it comes back negative. It just says that it was not found in that blood sample.  The benefit is that it could pick up species of Bartonella and Babesia that we don’t have antibody tests for.


On the other hand, maybe it is MS. The antibiotics as ILADS recommends it are expensive and take many months to help, and have side effects of their own. The treatments for MS are expensive and have a lot of side effects too, and don't always help.  It's a painful dilemma, and I can't tell you what you should do or who you should believe.  I can only tell you what I beleive based on my experience and training and observation of many patients over the years with MS (a few) with Lyme and co-infections (many) My training was through ILADS.  I've been to 3 conferences sponsored by ILADS, where neurologists, internists, microbiology researchers, infectious disease specialists and even a physician (orthopedic) who was diagnosed with late Stage ALS (Lou Gherig's Disease) and was almost at the respirator stage when he began IV treatment for Lyme. Nine moths after treatment he was able to stand up and give a 45 min lecture on his experience. It was very persuasive.  People don't recover from late stage ALS.

You may want to look at Brian Fallon PhD's research from Columbia University on CNS manifestations of Lyme and Co infections and treatment trials he has published.  They don't show a "cure" in many patients because the studies were not long enough, they certainly show improvement and persistence of infection after 90 days of IV treatment (in one study). Alan Mc Donald MD has published several articles on Lyme and Dementia they are online too.

What to do?  Follow your gut. Ask questions. Have a friend with you as an advocate in case you become bewildered or frightened and don't get all of what's said to you. Record meetings with everyone you have an appointment with, including me, so you can be sure you got what they said.  Talk to people, including others with Lyme disease, friends etc. Get second opinions, and weigh the pros and cons of their recommendations.
Read some books. (Cure Unknown) (Lyme Disease Solution) (Renegade Patient by yours truly) (Stephen Buhner, Treatment of Lyme disease and Co infections)

And do what you think is best, what feels right for you.

With care

Dr.Tedde Rinker