Polycystic Ovarian Syndrome

Acne, weight gain, irregular periods, infertility after years on birth control pills….these are some of the symptoms associated with Polycystic Ovarian Syndrome (PCOS), one of the most common hormonal endocrine disorders in women. It impacts approximately 5 million women in the United States, with symptoms beginning as early as age 11. The cause is unknown, but genetics do play a role. PCOS cannot be cured at this point, but it can be managed. We are currently seeing more patients diagnosed with PCOS and we want to provide a brief overview.

PCOS is primarily a hormone imbalance. In healthy ovaries, there are tiny sacs of fluid called follicles (or cysts). The egg grows and the follicle builds up fluid. When the egg matures, the follicle breaks open and the egg is released and travels through the fallopian tube and into the uterus for fertilization. This process is called ovulation. With PCOS, the egg does not fully mature because the ovary is making too much testosterone. The follicles may start to grow and build up fluid, but since ovulation does not occur, the follicles remain as cysts. And since ovulation does not occur, progesterone is not made and the menstrual cycle is irregular or absent. For women who have been on birth control pills and have underlying PCOS, the condition is masked because it is managed by the hormone regulation of the birth control pills. Many women receive a diagnosis of PCOS after they stop taking birth control pills in order to get pregnant and then have difficulty conceiving. PCOS is the cause of approximately 75% of anovulatory infertility.

The second major hormone issue with PCOS is increased insulin, and this increased insulin can trigger even more male hormone production. The increased insulin exists because the body is not using insulin effectively: a condition known as insulin resistance. This is why weight gain can often be a problem with weight tending to accumulate along the midline. Experts are unsure of the reason for insulin resistance in PCOS, but about 40% of women with diabetes or glucose intolerance will have PCOS.

PCOS can be difficult to recognize because the symptoms can vary so much. Overproduction of testosterone can either spur or disrupt a growth pattern. Patients can be thin or obese, and patients can have increased hair growth on the face, chest, and other areas but thinning hair on the head. There is no specific diagnostic test for PCOS, but women will have one or more of the following: acne, weight gain, multiple small cysts in the ovaries, high testosterone levels, and irregular periods. Diagnosis can then be confirmed with ultrasound to visualize the ovaries and blood tests to measure hormone levels.

If untreated, PCOS can lead to diabetes, high blood pressure, infertility, or cardiovascular disease. This sounds frightening, but PCOS can be managed, and these women can go on to lead healthy lives and have families. The key is diagnosis and lifestyle management.

The first step of treatment is limiting sugar and processed foods and adding more whole grain, fruits, and vegetables into the diet. Exercise is a foundation as this helps with insulin resistance. The prescription drug Metformin has also been used effectively in some patients to improve the response of cells to insulin and it can even lower testosterone levels. Other options include birth control pills or hormone therapy to normalize levels, the prescription drug Aldactone to block male hormones, and managing symptoms with laser hair removal, skin lightening creams and specific vitamins. There are promising studies using magnesium, chromium, vitamin D, calcium and omega 3 fish oil to help with symptoms.

The bottom line is that PCOS can be managed. It starts with exercise and a healthy diet.

Healthy and more informed living with John Hollis Pharmacy! Submitted by Cindy Franklin, Staff Pharmacist

Marijuana: Real and Synthetic

Four states have approved marijuana for both medicinal and recreational use. More states seem poised to follow because of income potential. Colorado posted an extra $70 million in tax revenue for 2014 from combined medicinal and recreational marijuana sales. More states want to share the wealth; therefore, we want our patients and their families informed on the facts.

1. According to the American Chemical Society, the marijuana of today is not the marijuana of the 1970s. The marijuana produced today is much more potent, and the effects on the central nervous system will also be more pronounced.

2. No adolescents should be using marijuana for recreational use ever. Because of the war on drugs decades ago, all research on THC was stopped and we are now trying to catch up. We don’t know as much as we should, but we do know this: Marijuana changes the chemistry of the brain. The brain is composed of fatty tissue. Marijuana is a fat-loving (lipophilic) product. Does it make any sense to insert a lipophilic product into a growing brain? Ever?
3. The Archives of General Psychiatry.(　2011;68(6):555-561) state that marijuana is associated with an earlier onset of psychosis in patients prone to schizophrenia. Schizophrenia often manifests in the late teens or early twenties, and the later it manifests, the better the outcome as patients are old enough to learn coping mechanisms to help manage the condition. Early onset can have devastating results.


4. Your teen or young adult may tell you that marijuana is a natural product, so it is much better to use than alcohol. While it is true that alcohol is more of a neurotoxin than marijuana, "natural" does not always mean better. Arsenic is naturally occurring.

5. While there are patients for whom medical marijuana is indicated, we cannot be an advocate of recreational marijuana when more research needs to be done on both acute and chronic effects of marijuana use. For every study that shows benefit, there is another showing detriment. The jury is out, and in that case, caution is advised.

And now there is synthetic marijuana! Also known as K-2, Spice, or Moon Rocks, synthetic marijuana is being sold on line and in convenience stores nationwide as potpourri or incense. A random herb is sprayed with a chemically produced form of marijuana, and the results have been frightening at best with patients presenting in the emergency room with agitation, vomiting, hallucinations, seizure, stroke, psychosis, and death.

While marijuana binds to cannaboid receptors in the brain as a partial agonist (meaning not completely covering the receptor), synthetic marijuana binds as a full agonist meaning that it is much more efficient, so smaller doses produce more dramatic results.

Also, the body does not remove synthetic marijuana from the body easily, and the metabolites can bind to receptors in the brain. Because there is no regulatory agency monitoring production, quality control is non-existent and pesticides can be part of the package.

Talk with your teens about drugs, preferably before they are teens while they are still good listeners. They have friends telling them that smoking once or twice a week can’t hurt them. The truth is that each person responds differently and there is not enough information on safe amounts, especially in an adolescent. The stakes are too high to gamble when dealing with brain function.

Healthy, informed living with John Hollis Pharmacy from Cindy Franklin, staff pharmacist

Allergy Season

Fall allergy season is beginning. If you are prone to autumnal allergies, please do not wait until you are sniffling and sneezing to start an antihistamine! The time to begin is now so that the antihistamine can be in the system when it is needed. Remember histamine is released by the body when it perceives a threat (like pollen or mold). Histamine attaches to receptors on cells and a series of events is triggered, and the result is the swollen nasal membranes, itchy eyes, and mucous production associated with an allergic event. Antihistamines attach to these same receptors on the cells forming a protective barrier to prevent histamine from triggering the allergic response. If the antihistamine is not in the body before pollen or mold hits, then the antihistamine has to work double time to find cell receptors that have not been impacted. An antihistamine is much more effective if it is in the body before pollen comes along.

Also, for those of you who have to use prescription inhalers: there are usually two kinds of inhalers. One is a rescue inhaler which is used to provide immediate relief, and it usually contains some form of albuterol. The other type of inhaler is a steroid inhaler. These stabilize membranes in the body and decrease swelling of membranes. This inhaler can take up to three weeks to work, so it must be used before there is an immediate need. Make sure that you discuss with your doctor or pharmacist the type of inhaler that you have so that it can be used appropriately.

Non-prescription nasal steroid sprays are also very useful as these can decrease swelling of the nasal passages. Because of the minute amount of steroid that is absorbed into the body from nasal sprays or oral inhalers, these may both be used at the same time without harm.

Healthy living (and limited sneezing) with John Hollis Pharmacy by Cindy Franklin, staff pharmacist.

Two More Medicinal Teas!

Continuing our focus on proactive natural healthcare, we are introducing two more medicinal teas!  Remember that our teas have no "filler" items and all ingredients work together to benefit health.  The first is Immuni-tea and it is just in time for the upcoming cold and flu season.  We have used Elderberry as a primary ingredient as this is a Native American plant that is rich in antioxidants and prized for its healing properties, especially in the upper respiratory tract.  It provides a naturally fruity flavor.  To this, we add Echinacea and Goldenseal for the immune system and for inflammation of mucous membranes.  When combined, these two herbs have a synergistic effect.  Cat's Claw and Astragalus are added to boost the immune system, and we finish with Rosehips for vitamin C and Chamomile to soothe the system.  We recommend steeping this tea for 10 minutes to maximize the herbs, and increasing the acidity of the tea with a squeeze of fresh lemon may enhance the beneficial effects.

To support the immune system, we suggest one cup daily in the morning during cold and flu season.  This may be increased to one cup every two hours as needed.

We have also added ZZZ-tea to our collection.  This was a fun but difficult tea to finish as we had to be careful not to conduct our testing in late afternoon...we did not want any drowsy drivers!  ZZZ-tea has a non-caffeinated rooibos base that acts as a potent anti-oxidant to help promote the natural recuperation that occurs during sleep.  Chamomile has a featured role as it is the superstar of night time teas for soothing and calming, and then we add lavender and lemon balm to promote relaxation and hops to help with anxiety and sleeplessness.  Each individual has a unique response to herbal blends, so we suggest not using alcohol or sleep aids in addition with ZZZ-tea.  ZZZ-tea is best enjoyed one hour before bedtime.

We have these available now as the weather is cooling and perfect for hot tea.

Healthy living with John Hollis Pharmacy from Cindy Franklin, staff pharmacist.

Toothpaste and Gum Disease

It is time for true confessions. In January of this year, I was diagnosed with gingivitis, commonly known as gum disease. It is rather embarrassing to admit, but my dentist graciously assured me that genetics play a major role. We discussed treatment options, and I had recently listened to a lecture on alternative and natural remedies. Gum disease was one of the topics as gum disease is a marker for cardiovascular health (and not in a good way). Not opposed to being a lab rat, I asked my dentist if we could try a Co-Enzyme Q 10 toothpaste, and we discussed the recent continuing education program. My dentist is very progressive and agreed to a trial. I returned at the end of June for my 6 month visit, and the hygienist viewed my record and gazed at my gums. She looked back at my record….and once again in my mouth. She called the dentist. I had gone from a mouthful of "5" (on a 1 to 5 scaled with 5 being BAD) to a normal mouth with only one small spot of disease. My dentist was delighted and asked if I had switched to an electric toothbrush. I explained that because I was doing a controlled experiment, the only thing that I did was use the toothpaste. I did not change my type of toothbrush, I had stopped using a mouth rinse, and I even stopped flossing as I wanted to see exactly what the toothpaste would do. We were all extremely pleased with the results, and I am so happy to be able to floss again.

Now for the toothpaste….there are CoQ10 toothpaste formulations on the market, but I wanted to make sure to get 1% active ingredient, and the currently marketed formulations did not list the strength of CoQ10 so this made me suspicious, especially as CoQ10 is an expensive raw ingredient. I knew that we had a great, clean toothpaste formulation and that we had raw CoQ10 in the pharmacy, so John went to work, and we now have CoQ10 1% Toothpaste under the Local Economy label. CoQ10 is a bright yellow-orange, and the toothpaste is a lovely golden color. The toothpaste is available at John Hollis Pharmacy or through Lis Bradley, DDS, in Brentwood. She really was impressed with the results.

Healthy living with John Hollis Pharmacy from Cindy Franklin, staff pharmacist!

Toothpaste and Snoring

My life changed six months ago. John had been working on toothpaste formulations and gave me a sample to try. That night, my husband David and I both used it. I woke up the next morning completely refreshed, and I quickly checked to make sure that David was still breathing. You see, for years, David has jarred the house with bone-rattling snoring. I am sure you think that you have heard snoring before, but his truly would shake the rafters and wake the house. The sounds would hit a crescendo around 3 to 4 a.m. and I was never able to sleep much after this, so you can understand my concern when there was no noise. At first, I hesitated to believe that toothpaste could make that much difference. The next night, I made David try his regular toothpaste, and once again, he roared.

John and I discussed the potential culprit in the regular paste. Sodium lauryl sulfate (SLS) is an inexpensive and very effective foaming agent found in most toothpaste formulations. I then began a collection of SLS-free toothpaste. Most were unpleasant, but David no longer snored. We had found the enemy. SLS allergy has been reported in the literature, but I could find little information on an association with snoring. For David, his allergy was severe enough to cause some kind of mucosal swelling that interfered with his breathing. By simply switching to SLS-free toothpaste, the topical exposure to SLS ended and he was able to breathe at night, resulting in a snore-free sleep. Both of us are now well rested!

We began to question the other ingredients in toothpaste, especially as it is something used twice daily at minimum. Toothpaste usually has silica, aluminum or calcium as the base and this is often sourced from China. This was also a cause for concern. John continued to pursue his toothpaste formulation, and I continued to taste test the terrible options that were already available on the market. After much research, the new toothpaste formulation is complete. We use xylitol (Non-GMO) in a concentration high enough to promote dental health. We were able to find a pure calcium base that was actually mined in the United States which we flavored with natural peppermint oil, menthol and tea tree oil. The result is an elegant and tasty all natural toothpaste which passes the David test…no snoring!

While I realize that this toothpaste may not produce the same dramatic results for everyone that I have enjoyed, it is certainly worth trying when dealing with a snoring family member. Having toothpaste with a very clean chemical profile and all natural ingredients helps us all sleep better! The toothpaste will be marketed under the Local Economy label and can be purchased at the pharmacy.

And to say my life changed is no exaggeration….

Healthy living (and a good night of rest) with John Hollis Pharmacy!

Our New Medicinal Teas

To continue our support for women’s healthcare, John Hollis Laboratories is developing a series of medicinal teas to help in promoting optimal health. All of our teas are from organic sources, and are free trade certified sourced whenever possible. Please note that our teas contain all active ingredients with no "fillers."

The first in the series is our PMS Serenity Tea which contains our proprietary formula of:

Vitex (Chaste Berries) – approved by German Commission E to support healthy and regular menstrual cycles

Black Cohosh - approved by German Commission E for premenstrual discomfort and pain

Dandelion – helps balance menstrual cycle, natural diuretic*

Hibiscus – provides high levels of antioxidants**

Chamomile – naturally calming^

One heaping spoonful steeped in 8 ounces of hot water for 3 to 5 minutes is a sufficient amount. This can be enjoyed throughout the day; however, we suggest the last cup in early evening.

We also have our Menopausal Wisdom Tea which contains:

Vitex (Chaste Berries) – Used in conjunction with Black Cohosh and Dong Quai to support the menopausal transition#

Dong Quai Root- Chinese herb traditionally used to help with menopausal symptoms#

Black Cohosh – used for healthy menopause#

Wild Yam – used in China for women’s health support

Dandelion – helps cleanse the system*

Hibiscus – provides high levels of antioxidants**

Chamomile – naturally calming and renowned for its health benefits^

Steep one heaping spoonful in 8 ounces of boiling water for 3 to 5 minutes for maximum benefit. We suggest enjoying a cup early in the evening to prevent the natural diuretic effects of the tea from disturbing sleep.

Caution: These are not for use in our pregnant or lactating patients.
*Clare BA, Conroy RS, Spelman K. The diuretic effect in human subjects of an extract of Taraxacum officinale folium over a single day. J Altern Complement Med.2009 Aug;15(8):929-34.

**Mohamed R, Fernandez J, Penada M, Aguilar M. Roselle (Hibiscus sabdariffa) seed oil is a rich source of gamma-tocopherol. J Food Sci 2007;72:S207-11

^Amsterdam JD, Li Y, Soeller I, et a. A randomized, double-blind, placebo controlled trial of oral Matricaria recutita (chamomile) extract therapy for generalized anxiety disorder. J Clin Psychopharmacol.2009;29(4):378-382.

#Hudson TS, Standish L, Breed C, and et al. Clinical and endocrinological effects of a menopausal botanical formula. J Naturopathic Med 1998;7:73-77

Vitamin C in Facial Serums and Creams

I like to use vitamin C on my face in the form of a serum as it helps with collagen production and because it seems to decrease age spots (which I started getting in my 30s!) and redness. I was frustrated when my expensive name brand vitamin C serum gradually turned from clear to a deep yellow, and even more frustrated when I was told that it was simply oxidation and not to worry. As a pharmacist, I know that oxidation decreases effectiveness, so I have been on a search for a vitamin serum.

All vitamin C is not the same.

There are some versions that are more safe than others.

Some versions of vitamin C actually become toxic when exposed to ultraviolet radiation (the sun) and can contribute to formation of skin cancers.

The safest form to use is the water soluble L-ascorbic acid or ascorbic acid, which is the form of vitamin C found in nature and used by the body to repair wounds, build skin, and protect the body from disease. Magnesium or sodium ascorbyl phosphate or ascorbic acid phosphate is also safe as it has simply had a phosphate added for preservation.

The form to avoid is ascorbyl palmitate or any version of this, especially in liposome form. Ascorbyl palmitate (also known as tetrahexyldecyl ascorbate) is an oil soluble derivative. While the idea of making an oil soluble form seemed sound because it would increase penetration of the layers of the skin, studies have shown that ultraviolet exposure makes this form toxic to skin cells. Using the liposome form means that the palmitate is wrapped in lipids so that it is even further absorbed in the skin, which in this case, is a bad idea.

Read the labels and look for either L-ascorbic acid or the phosphate form.

At John Hollis Pharmacy, we use the sodium ascorbyl phosphate version. I started using this and my vitamin C serum no longer oxidizes, so I am delighted.

Also, oral vitamin C 500 mg daily is great for skin integrity. If your skin on your arms seems more fragile, vitamin C can help!

Healthy living and more vibrant skin with John Hollis Pharmacy!

Sunscreen and Sun Safety

It is that time! Warm weather has arrived, and I know that all of you are looking at your white legs and your summer shorts and skirts and thinking that you need color! This is the time of year when I am relentlessly hounding my children with a tube in my hand, with those famous words…."You’ll thank me when you’re thirty!!!" They won’t.

All this to say, wear sunscreen. Twenty minutes is the maximum outside without it.

Wear sunglasses. I have too many friends developing macular degeneration and having to have shots in the eyeball to preserve vision.

As for sunscreen types, I have strong opinions. Surprised? Hah! The skin is the largest organ of your body. Therefore, what you put on it matters. There are chemical sunscreens and there are physical sunscreens. I prefer physical sunscreens because these do not introduce a chemical into your body and I really do believe that the fewer chemicals introduced into our systems, the better. Doesn’t this simply make sense? The physical sunscreens are inert minerals that stay on the surface of the skin and actually form a physical barrier to UV radiation. The two minerals used are titanium dioxide and zinc oxide. And yes, that was the icky white paste that lifeguards once spread on their noses to prevent sunburn. It works! Now there are different forms of these minerals that are more cosmetically appealing. Look for the micronized form of zinc oxide or titanium dioxide. I DO NOT want you to use the nano-particles of these minerals. This form is too small and could potentially be absorbed in the body. The jury is still out on this formulation. Cosmetically, it is transparent on the skin, which is great, but I have concerns about absorption into the body. The micronized version will look a little white on your skin, but we are talking about preventing cancer and reducing chemicals in the body, so give a little, okay?

These sunscreens are more expensive than the familiar brand name sunscreens, but are a healthier choice. Reading the label is essential. Do not be mislead by the marketing label that says "Mineral Sunscreen" when the label on the back reads "zinc oxide 1%, oxybenzone 9%, etc." This is not what you want. Also, the SPF is not as important as re-applying. Sweating and swimming remove sunscreen, so re-apply regularly. As for brand recommendations, Costco carries The Honest Company brand of sunscreen with zinc oxide as the primary ingredient. It is PABA and dye free, and I use it at home. Blue Lizard is a good brand that most drug stores carry. This web address http://www.ewg.org/sunsafety/astore.php is a link to the Environmental Working Group and contains both a link to specific sunscreen products and more information on sun safety. I know that a thicker sunscreen is more of a pain to use, but this is important. Introducing fewer chemicals into your body is important. Stay safe!

Healthy summer living with John Hollis Pharmacy!

The Pollen Tsunami

It is definitely springtime in Nashville as any item left outside for two hours or more will reappear as a yellow tinged object. This does include children and pets. Even if your loved ones do not look jaundiced, don’t be deceived. They walk in the door with a mother lode of pollen which will wreak havoc on your allergies. We are taking a detour from vitamins today because the lunchroom topic was all about defense mode for the Nashville spring, and the staff agreed that everyone needed a pollen primer.

Take showers at night. Physically removing pollen by washing it down the drain is the first step. At the very least, change the pillow case often. Rolling around in pollen all night helps no one.

We have great over the counter medications, but these need to be started early! It is absolutely okay and even important to begin these medications before symptoms start if you suffer from allergies. One of my physician friends starts her family on a nasal steroid and an oral antihistamine around the time of the Final Four each year and continues until the pollen leaves. Flonase and Nasacort nasal sprays are both available without a prescription, and either one will work. Any of the non-drowsy antihistamines (Zyrtec, Allegra, Claritin) in generic form will be effective. Take it daily. If your antihistamine no longer seems to provide relief, switch from one to another. This usually helps. I have no real preference on brands.

Using a saline spray or Neti-Pot (disgusting, I know, but it works) will also help remove the pollen from the nasal passages. While the pollen count is high, stay inside with the air conditioning on and make sure that your air filters have been changed.

Wrap your mattresses and pillows with allergy covers. These are inexpensive and will help. Wash sheets and mattress pads often. We use a cool mist humidifier with essential oils, also. Get plenty of rest. Going to battle with pollen daily is an exhausting process, and nothing taps out your immune system as quickly as a lack of sleep. Drink fluids, especially water.

If your eyes are prickly feeling or red and itchy, there are several eye drops like Zaditor that were once prescription items but are now available over the counter. Just remember to remove those contacts before using the drops! The bottom line is that there are now a number of medications that were once prescription that are available for use and can help during this rough season. Hang in there!

Healthy living with John Hollis Pharmacy!

Vitamin Confusion

As long as I am pontificating on vitamins, I wanted to take the opportunity to let you know that not everyone needs all vitamins at all times.  There are tons of supplements that can be added to the diet, and we can easily go over the edge trying to keep up with them!  Therefore, I wanted to provide a few hard and fast rules:

1.  Make sure your doctor knows which vitamins/supplements you take daily.  Nothing is completely harmless.  B12 comes close, but we have already covered that.

2.  Recommendations change as information changes.  Remember when vitamin E was all the rage?  New studies associate it with stroke, so only use this if your prescriber directs.

3.  Even aspirin is getting a second look.  Last year, everyone over 40 was supposed to be taking an aspirin a day.  This year, new studies point to the risk of increased bleeding in enough patients that the risk outweighs the benefit in a patient who has not been diagnosed with a medical need.

4.  Remember that all these vitamin suggestions are the equivalent of going to a cafeteria.  Just as no one takes all items from the line, no one needs to take all vitamins.  Take specific vitamins for specific needs based on your prescriber’s recommendation.

5.  Essentials:  In my opinion, it is great to have a vitamin D level and I would suggest vitamin D for anyone over 45 if levels are low.  I think Co Q 10 is great for anyone over 45, and I personally love the B vitamins but if your energy level is fabulous and you have nerves of steel….not necessary!

6.  Other than that, eat a balanced healthy diet and exercise.  More next week.

Healthy living with John Hollis Pharmacy!

Vitamins and Depression

The current buzz in depression treatment involves L-5 methylfolate. Studies indicate that around 70% of depressed patients have low levels of the enzyme needed to convert folic acid to the active L-5 methylfolate. In the body, L-5 methylfolate is responsible for reducing homocysteine levels and increasing levels of neurotransmitters. Prescription antidepressants work by blocking the uptake of neurotransmitters, but not actually increasing the amount in the body. L-5 methylfolate actually increases the amount of neurotransmitters (like serotonin) that your body makes.

Scanning the literature, it is easy to find information on L-5 methylfolate for treatment for everything from Alzheimer’s disease and dementia to heart disease, including help with short term memory, concentration, sleep, motor control, motivation, mood stability and even hormone levels. I recommend only taking L-5 methylfolate under the care of a physician and this is why: there are medications (like the commonly used pain reliever tramadol) that interact with increased levels of serotonin and can cause serious side effects. Some antidepressants can have serious side effects when used with L-5 methylfolate. With all this being said, I do think that it is an important vitamin to have available, and I would consider this first for mild depression because of the low side effect profile. Any time that we can use the body’s natural resources to overcome disease states, we are moving in the right direction. Your doctor can determine if antidepressants need to be used along with this for optimal results.

On the web, there are several forms of methylfolate for sale. Be aware that not all L-5 methylfolate is the same. Only the LEVO isomer of L-5 methylfolate is effective, and currently, it is expensive. There are two prescription forms available, and at John Hollis Pharmacy, we do compound L-5 methylfolate with other B vitamins for absorption and efficacy. The less expensive forms on the web are the "R" form or D-5-methylfolate. These are NOT effective and should be avoided. If you have a question, ask your pharmacist or physician. Under a physician’s care, doses of 5 to 15 mg of L-5 methylfolate are used. I would allow 90 days of treatment before evaluating effectiveness. Using the natural process of the body is a slower but healthier option. So the bottom line is that L-5 methylfolate (the real kind) is an attractive option for treatment of mild cognitive function issues (including depression) but only under the care of a physician.

Healthy living with John Hollis Pharmacy!

Vitamins, Anxiety, and Depression, Oh My!

Second only by a hair in my top vitamin line-up is vitamin B12 which is vital to proper functioning of the brain and nervous system. B12 helps with fatigue, weakness, memory loss, and depression to name just a few. Once again, chemo played the introductory role for me, in that after my final treatment, I found it difficult to walk or to even hold a coffee cup due to the pain in my hands and feet. My internist suggested drawing a B12 level, and while my lab values indicated a low normal, she suggested treatment with an oral tablet. My symptoms went away and my anxiety decreased.

This low normal level is not unusual. The Tufts Framingham Offspring Study found that approximately 40% of patients (age range 26-83) had a low normal and that patients could still have neurological symptoms at a low normal. Interestingly enough, the lab standard used in Japan and Europe doubles the threshold for normal (U.S low is less than 258 picomoles per liter, and European standard is 500-550). Scary. Even levels of 500 have been associated with memory loss.

It is not necessary to hasten to get a B12 level drawn. It can be expensive. Just know that decreased B12 absorption is part of the aging process and there are few of us who get enough in our diets. I suggest supplementing with 1000 mcg B12 along with a B complex vitamin. All the B vitamins help with the nervous system, but B12 is quickly metabolized by the liver when given orally so greater amounts must be taken. The B vitamins are water soluble, so the body eliminates what it does not use. Also, eat fortified breakfast cereal. These are inexpensive and easy fixes. Other dosage options are the sublingual and injectable forms.

Next week, we are going to discuss the role of B12 and another vitamin, L-5 methylfolate, in depression so stay tuned!

Healthy living with John Hollis Pharmacy!

Vitamin 101 Continues.....

My first choice in discussing vitamins (and I will use vitamins/supplements/minerals interchangeably for convenience) is one that is close to my heart…hah! Coenzyme Q 10 is an enzyme produced by the body that helps with energy production and supports heart health. I know that everyone is concerned about cancer these days, but heart disease kills more women than all cancers combined. Interestingly enough, cancer led me to CoQ10.

I underwent treatment for Hodgkin’s Lymphoma several years ago, and I was diagnosed with diastolic dypsnea (shortness of breath) as a result of chemo. Not wanting to let cancer "win" another organ system, I began researching and found that the chemo had impacted the mitochondria of the cell. The mitochondria are the energy powerhouses at the cellular level. Further digging revealed that CoQ10 worked at the mitochondrial level to repair and restore. CoQ10 has been used extensively in Japan for years for heart health and has a strong safety record. Also, in patients who are taking statins for cholesterol, CoQ10 levels in the body are decreased and taking supplemental CoQ10 can sometimes help relieve side effects.

Back to the diastolic dypsnea….after taking CoQ10 for several weeks and a return to the cardiologist, I no longer had the diagnosis. While my cardiologist was not willing to give CoQ10 the credit, I am not willing to stop taking it. My heart health is great, the side effect profile of CoQ10 is minimal (usually mild stomach upset at most), it does not accumulate in the body, and, according to Mayo Clinic, there is good scientific evidence to support the use of CoQ10 for heart failure and high blood pressure. The list of other potential benefits of CoQ10 ranges from decreased cancer risk to better eye health and even anti-aging (!) benefits.

As for me, I will continue my 100 mg of CoQ10 daily….without dypsnea. I generally suggest this dose for all aged 45 years and older as the levels of CoQ10 in the body decrease with age.

Healthy living with John Hollis Pharmacy!

Vitamins 101

We are going to spend a few weeks on vitamins because there are so many out there! Today, I want to start with supplements for teens as this is easy.

Children and teens are great at getting the majority of what they need from the foods they normally eat along with a good multivitamin. The exception enters the equation when a child is heavily involved in a sporting activity and has a rigorous training schedule. Also, if the family is on a gluten-free or paleo diet, or any diet that is selective in food categories, the teen may not be getting necessary vitamins or minerals.

Teens with a robust training schedule need iron. Teens often drink truckloads of milk. However, milk interferes with the absorption of iron. If you have an active milk-guzzling teen who does not really care for meat, this can create a perfect storm of iron depletion. I experienced this firsthand with my teen who is a competitive rower. Her winter training schedule kicked in and it became more and more difficult to wake her in the morning. We went to her pediatrician (eventually), and she presented with lethargy, fast heart rate, and pallor. Fortunately, her pediatrician is a great diagnostician and did not settle for simply checking her hemoglobin, which was normal. The problem was in her ferritin levels. Ferritin is the iron storage system in the body. Her body was doing everything it could to keep the system as intact as possible which was why her hemoglobin and hematocrit levels were fine. Low ferritin levels are common in young athletes according to our pediatrician. Fortunately, this was an easy fix. She was put on supplemental iron for a few weeks, and she now takes a multivitamin with iron daily. She eats more meat, drinks less milk and more water.

Spring sports are beginning, so this is a great time to make sure your young athlete is well fed, and taking a good multivitamin…with iron as necessary!

We will begin our adult supplements review next week.

Healthy living with John Hollis Pharmacy!

Vaginal Dryness: Non-Hormone Option

While not life threatening, vaginal dryness can be like a pebble in your shoe.  It is irritating and unpleasant, but not all women want to go on hormone therapy to address this one issue.  Also, not all vaginal dryness is caused by reduced estrogen levels.  We are often asked about treating individual symptoms, and vaginal dryness can be at the top of the list.

One option is a non-hormonal vaginal maintenance cream.  At John Hollis Pharmacy, we compound a formulation with hyaluronic acid as the primary active ingredient and additional vitamins for increased relief.  Hyaluronic acid is a glycosaminoglycan normally found in our bodies that is part of extracellular maintenance and is secreted by the body during tissue repair.  It has a high safety profile, no hormone-like adverse effects, and it works rapidly to reduce symptoms of vaginal dryness.  This is a safe and effective treatment to restore the moisture barrier.  Have your doctor call us for this natural, non-hormonal alternative!

Happy Easter and healthy living with John Hollis Pharmacy!

Could It Be My Thyroid?

Hypothyroidism symptoms can mimic many other disorders, with fatigue, dry skin, changes in hair texture, and weight gain as the early symptoms. If your hormones are declining, these symptoms may sound familiar.

Hashimoto thyroiditis is an autoimmune disease of the thyroid and is the most common cause of hypothyroidism in the United States in patients over 6 years old. Originally thought to be rare, the incidence seems to be increasing, and it has probably been under diagnosed. It is 15 to 20 times more common in women than men.

On initial exam, simple thyroid testing may present as normal. Thyroid testing can include TSH (Thyroid Stimulating Hormone), T3, T4, and if ordered separately, Thyroid Antibody Testing. Usually, TSH is elevated in Hashimoto patients because the body is desperately trying to keep the thyroid levels normal in the serum, so Thyroid Stimulating Hormone is increased by the body and lab values will detect this. The trick is that in some individuals, TSH levels will appear normal, and even 10 to 15% of Hashimoto patients can test negative for thyroid antibodies.

This is when a good patient history can help. Make sure that your doctor knows if your mom, aunt, or other relatives were diagnosed with low thyroid. Treatment is simply taking supplemental thyroid for the majority of patients and this continues for life. If this is not effective, some patients may require dessicated thyroid or even compounded low dose naltrexone therapy to help balance the immune system cell response.

We recently had a patient with normal thyroid levels who was treated with hormone therapy but continued to have symptoms. Fortunately, the patient remembered her family history and asked her doctor to run thyroid antibody testing. She tested positive for thyroid antibodies, and was started on thyroid medication and is feeling much better.

The bottom line is that we are all more than the sum of our lab values. It is important to be an active partner on your health care team. Make sure that your doctor knows your full family history.

Healthy living with John Hollis Pharmacy!

Stress and Dementia

I have to veer slightly off topic today as I found a troubling article in the Wall Street Journal that arrested my attention. We all know that stress is bad for us and we know the detrimental impact on immunity and blood pressure and chronic disease states. This has always disturbed me; however, new information points to a relationship between stress and dementia.

This news should not be surprising based on information we already have. I think it comes down to this: dementia scares me. Other disease states can be managed, and while not always pleasant, symptoms can be diminished. Dementia is a beast.

Apparently, with uncontrollable stress, there is a significant increase in risk for developing dementia and other memory-related illnesses. Research using brain scans shows us that branches of brain cells can shrink and even disappear after traumatic events.

Neuroplasticity is the term to remember. This refers to the ability of the brain to regroup and form new neural connections. The brain is dynamic and damage can be reversed. The recipe for doing this will sound familiar:

Get the sleep you need.
Drink plenty of water.
Eat a healthy diet.
Exercise.
Manage your stress by reducing multi-tasking.
Get outdoors whenever possible.
Limit electronics.

Remember that your cell phone is not an appendage. We survived for many years without 24/7 connectivity. We all need downtime. Reverse that damage! Remember that a little stress keeps us sharp. Unmanageable stress is a killer.

More on stress management to follow!

Healthy living with John Hollis Pharmacy!

Adrenal Fatigue: Fact or Fiction?

We are hearing from more patients who are concerned about "adrenal fatigue." The symptoms can include:

-fatigue

-body aches

-sleep disturbances

-weight loss or gain

-dry skin

-low sex drive

While adrenal fatigue is not an accepted medical diagnosis, alternative healthcare providers have estimated that it impacts up to 80% of the population and is a treatable condition. This is a huge disconnect, so let’s start with background information. The adrenal glands are composed of two parts: the adrenal medulla, which secretes epinephrine, norepinephrine and dopamine and then, the adrenal cortex, which releases aldosterone, cortisol, corticosterone and androgens (sex hormones). Epinephrine is also known as adrenalin and helps produce the "fight or flight response" in the body. It increases alertness, moves the body’s attention away from digestion and prepares it for a quick run, and stimulates heart rate. Norepinephrine is the precursor for epinephrine, and a depletion of norepinephrine is associated with depression. Cortisol prepares the body for stress and can concentrate fat stores in the abdominal area.

In adrenal fatigue, the theory is that the body is in a constant state of stress. This, in turn, depletes the adrenals of the normal operating levels of neurotransmitters with resulting symptoms of fatigue, sleep disturbances, and weight changes among others. Diagnosis is usually made with salivary testing and treatment often involves adrenal supplements.

We recognize that patients are coming in with very real symptoms that are often untreated with conventional means. One of the primary reasons for undertreatment is that our current medical system does not allow enough time for patients to review lifestyle, dietary habits, and other contributing issues during a 15-minute appointment. Decades ago, the family practitioner could more accurately diagnosis patients because of the communal relationship…when Jane Doe complained of a lack of energy and sleep loss, the doctor could take her level of community involvement, her concern over an aging parent and her anxiety over a rebellious teen into the equation. Our stress-laden, transient 21^{st century lifestyle has replaced community relationships, and it is to our detriment. So, what to do?}

First, get a good medical evaluation with blood (serum) testing including vitamin D, vitamin B12 and homocysteine levels along with electrolytes, cholesterol and standard testing. This does need to be fasting. Many treatable diagnoses can mimic adrenal fatigue, so these need to be addressed first. Also, realize that accurate saliva testing for cortisol needs to be taken between 11 pm and midnight for greatest accuracy according to Dr. Andrew Weill. These are the lowest levels of the 24-hour period and can give the most accurate picture for treatment.

Avoid adrenal supplements as too much cortisol can result in either depression or osteoporosis, and do not use the Internet for diagnosis or treatment of this, even though the ads are tempting!

For further treatment, a comprehensive lifestyle evaluation is necessary. Most women should be on additional B12 1000 mcg at least once daily. Our ability to absorb B12 decreases with age, and the popular gluten free and vegetarian diets can provide insufficient B12.

We will explore each of these suggestions in depth in the weeks to come, but for a quick overview:

-Limiting stress (I know easier said than done!) is essential

- Adequate sleep is vital

-Prayer and/or meditation is a proven stress reducer

-Eating a balanced diet and avoiding sugar can get you started

-Turning off the news and turning on relaxing music or music that makes you sing will help.

Pay attention to your body and listen to the messages…. We have enough stress inducers all around us. Unplug and go outside for a walk. The answer is not as simple as cutting out sugar and going outside for exercise but this is the start. More to follow!

Healthy for life with John Hollis Pharmacy!

Cold Facts on Hot Flashes

         

Because of our icy weather and emergency conditions in Tennessee, I have been glued to the news, monitoring school closings and road conditions.  Headlines yesterday posted “news” that many of my patients could have shared long ago:  hot flashes last longer than the medical community had previously acknowledged!  Is this a news flash to anyone?

I am currently working with a patient who has been experiencing hot flashes for years without relief, and her experience has inspired this week’s post.  For those of you who have yet to experience a hot flash, just think of it as an internal volcano.  The eruption begins, and progresses to a full explosion of discomfort that finds little relief from an external source because it all happens inside the body.  No one in the immediate vicinity understands why the person beside them is suddenly panting for breath and pulling at clothing in a futile effort for relief.

Although we do not yet have a perfect solution, there is a scientific explanation.  Each person has a thermoneutral zone.  In simplest terms, this is the temperature tolerance range.  Go too far one way and shivering occurs.  Go too far the other way; sweating is the result.  In some postmenopausal women, this zone is greatly reduced, which means that a slight temperature variation can trigger flushing.  This slight temperature variation can also be tilted by stress because the chemicals that the body releases during stress can cause changes in the core body temperature and can be enough to initiate a hot flash.  Therefore, the postmenopausal woman can be supremely sensitive to physical and emotional changes in her surroundings that others will never feel.  Again, this is not news to my postmenopausal patients!

Having this information is useful because it helps us realize that there are environmental changes (like wearing lighter, looser clothing) that we can make to help hot flashes.  Although medications like gabapentin, clonidine and venlafaxine are being used for treatment, I would always suggest environmental changes first as any medication can have side effects.

Changes to make include stopping smoking!  We have already covered this, but it will always top the list.  Losing weight can help as the extra body fat works as insulation and can prolong the hot flash.  Wearing loose clothing and having a cool drink (water) at hand is useful.  Deep breathing and meditation exercises have been found to be helpful, so this is the time to begin yoga and to recall the Lamaze training.  Fans and air conditioning help, but initiating deep breathing at the onset of a hot flash has been shown to be the most effective at reducing symptoms.  The onset of a hot flash is like the beginning of a panic attack, so it is important to practice breathing exercises beforehand to be able to have any kind of good result.  Layered, loose clothing can help reduce the thermostat battle. 

The theme continues to be balanced diet, exercise, and stress reduction…..

Healthy for life with John Hollis Pharmacy!

Progesterone: The Flip Side of the Estrogen Coin

Women who have an intact uterus and are taking estrogen replacement therapy must also be on some form of progesterone. Estrogen, with all of its benefits, stimulates the tissues of the uterus and can set up the body for uterine cancer. The use of progesterone reduces this risk to that of a woman who is not on hormone replacement therapy. Progesterone can also minimize the impact of estrogen on any estrogen-dependent tumors; therefore, women on oral or topical estrogen therapy must be on progesterone also. This does not apply to women using vaginal estrogen cream or inserts, as the absorption seems to be minimal in the body.

Progesterone can be given as either medroxyprogesterone or micronized progesterone. Micronized progesterone is the bio-identical form of progesterone and is the preferred choice. It is manufactured from plants (Mexican wild yam and soy) and seems to have a lower side effect profile than medroxyprogesterone.

Besides the cancer protective benefit, progesterone can also:

-improve sleep

-decrease anxiety

-build and maintain bone density

-increase HDL, the "good" cholesterol component

Micronized progesterone helps to avoid the "first pass" effect that we discussed with estrogen; however, studies indicate that levels of micronized progesterone given orally return to baseline after approximately 8 hours. There is evidence that giving progesterone in a sublingual form allows levels to last for 24 hours when the sublingual tablets are compounded using cyclodextran, available by prescription through your compounding pharmacy. Progesterone cream is also an option and is also available through your compounding pharmacy.

There are recent reports of "dermal fatigue" with progesterone cream. In simple terms, this means that the tissue becomes oversaturated with progesterone that is stuck in a storage form, and a change to another dosage form of progesterone could be necessary. Symptoms may include breast tenderness and moodiness. Rotating the application sites with progesterone cream helps with this, and having a strong working relationship with your gynecologist is essential in gaining the maximum benefit..

Hormone levels fluctuate. I know….This is a "sky is blue; grass is green" statement! What is important about this is that your hormonal needs will change over time. This is why a great working relationship with your physician and pharmacist creates a healthier patient: keep those annual appointments!

As an additional note, situations can change and impact hormones also. I have been maintained on HRT, doing quite well with the generic oral micronized progesterone; however, our insurance changed resulting in a change of pharmacy. The new pharmacy carries a different generic brand. It has taken about two and a half weeks, but I am now having trouble sleeping through the night on the new form. I left my gynecologist’s office today with a prescription for sublingual micronized progesterone tablets. I will let you know how this works!

Healthy for life with John Hollis Pharmacy!

The Estrogen Dilemma

To replace or not to replace…that is the question. The answer is confusing. Most of the available information seems contradictory at best and frightening at the worst. To truly answer the question, we need to start with the definition of estrogen and the role it plays in the body. Estrogen is a term for a group of chemically similar hormones: estradiol and estrone, produced primarily by the ovaries, and estriol, primarily produced by the placenta during pregnancy.

Estradiol is the most potent form of estrogen in the body and estradiol is the form of estrogen that women lose at menopause. Estradiol is the bio-identical hormone replacement used in most patches or creams.

Estrone is the weakest of the naturally occurring estrogens and its only known function is to serve as a storage unit for functional estrogen. Estrone is produced in small amounts by fatty tissue and by the liver and adrenal glands and is increased by routine alcohol use. High levels of estrone can stimulate breast and uterine tissue, possibly increasing cancer risk. This could explain the increased cancer risk associated with excess alcohol use and high fat diets.

Estriol is interesting because it does not promote breast cancer. It also does not have the bone, heart, or brain protection of estradiol, but it can help lower cholesterol. Estriol has been used widely in Europe and Scandinavia. A combination of estriol and estradiol cream seems to maximize the relief of menopausal symptoms while minimizing cancer risk and this combination seems to hold the most promise for future research. There is no estriol /estradiol cream commercially available and this can only be obtained by prescription and through a compounding pharmacy.

Cancer risk is the dilemma with hormone replacement therapy. The initial studies with estrogen in women found that women taking estrogen only had an increased risk of uterine cancer. Women taking estrogen and progesterone did not have an increased risk, so the standard of practice is that a woman on estrogen replacement therapy must also use progesterone (next week’s topic) if she still has her uterus. Women using vaginal cream only generally do not need progesterone. Estrogen alone can increase the risk of estrogen dependent breast cancer; however, this risk is reduced by using topical estrogen and can be further reduced by using the estriol/estradiol combination.

Bottom line: Hormone replacement therapy has both risks and benefits associated. For myself, I had to evaluate the benefit of how much better I felt overall and the cariodprotective/bone-protective/neuroprotective benefits versus the risk. I had extensive discussions with my gynecologist to reach the decision that was right for me including a review of family history for cancer and cardiac risk and a commitment to a healthy lifestyle --more on that in future topics!

Making healthy choices for life at John Hollis Pharmacy!

Important note: estrogen levels are lower in smokers. Smokers often have more menopausal symptoms than non-smokers. Smokers have more wrinkles than non-smokers. There are nicotinic receptors in the bladder that lock on to the nicotine in cigarettes. This is why smokers also have to deal with incontinence at an earlier point in time. Bottom line: Don’t smoke! It wrecks your body!

Fast Facts About Estrogen Therapy

Hello! I am Cindy Franklin, one of the pharmacists at John Hollis Pharmacy, and I am currently on hormone replacement therapy. I asked John if I could start our series on Hormone Replacement Therapy (HRT) because I have such a strong personal interest in the topic! At John Hollis Pharmacy, we believe that an informed patient has the best outcome. We will be exploring HRT in depth, so know that this week will simply be a quick overview!

Topical estrogen is a better choice for most women.

It will take time to find the best hormone combination.

There are options.

Finally, yes, going through menopause can make you feel like you are losing your mind.

First, when taken orally, estrogen goes through a "first pass effect" in the liver. This means that the liver quickly metabolizes estrogen; so higher doses must be given to reach the desired level of estrogen in the body. Estrogen is well absorbed through the skin so using topical estrogen through a cream or transdermal patch avoids the liver and lower doses of estrogen can be used to achieve the same result. We want to always use the lowest dose possible to get the desired response as this lowers the chance of side effects.

Everyone is unique. There is no "one size fits all" in hormone replacement therapy. Make sure that you have a physician who will work with you, and know that your pharmacist is there to help. Communication and patience are the two keys in this process.

For some patients, a patch is the perfect solution. Another patient may have an allergy to the adhesive, or for others, the amount of estrogen is simply too strong or too weak. The beauty of compounding pharmacy is that your therapy can be customized to fit your needs. The important thing to know is that there are options that can be explored, including sublingual forms of hormones to avoid the first pass effect.

And finally, changes in hormone levels can wreak havoc with your mental state. One patient described it as "I can hear your words, but they feel like bricks that are bouncing off my head." Another talked about her thoughts racing to the point of incoherence prior to estrogen therapy. And this is in addition to the hot flashes, vaginal atrophy and bone loss!

Know that there is relief available, but it does take a working relationship with your physician and pharmacist to obtain the best results. Stay tuned for more information next week!

Making healthy choices for life with John Hollis Pharmacy!