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From the Townsend Letter
April 2013

From the Publisher
by Jonathan Collin, MD
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Is There an HIV/AIDS Alternative Medicine Treatment?
While complementary/alternative medicine, integrative medicine, and naturopathy have made great strides in public awareness and utilization, there remain many areas where conventional medicine remains sacrosanct. Emergency care, intensive care medicine, and surgery employ strictly "standard of care" procedures and interventional therapies. The treatment of chronic medical illness with multiple pharmaceutical therapies is prone to yield unexpected medical outcomes, adverse reactions, and medical failures. It is with chronic medical illness that integrative medicine and naturopathy offer the greatest promise. The management of HIV/AIDS, however, requires "standard of care" pharmaceutical treatment, and attempts at avoiding drug therapies generally fail.

A television drama has made the case that treating HIV/AIDS without pharmaceutical intervention is not only malpractice but also criminally negligent.
Law and Order is a show with police detectives investigating murders and unexplained deaths. One episode opened with a baby in respiratory distress. Examination revealed that the baby had HIV but was not receiving conventional HIV therapy. It turned out that the parents were taking the baby to a physician who refused to administer HIV drugs – he offered the family probiotics and nutrients only. The detectives were able to investigate other patients in the doctor's practice. Many of the patients had been diagnosed with HIV but none were administered antiretroviral drugs.

One patient, a 7-year-old girl, had died after a recent bronchial infection. The coroner had indicated the death was from a respiratory infection. However, post-mortem exam revealed that it was not an ordinary bacterial infection but
Pneumocystis carinii, a typical complication of untreated AIDS. The girl had been treated only with amoxicillin. Her mother was HIV positive but had stopped taking antiretroviral drugs years earlier because of their adverse effects. She had breast-fed her daughter without therapy. She had refused to test her daughter or son for HIV, believing that alternative immune treatments were sufficient to prevent HIV from advancing to AIDS. The Law and Order detectives and prosecutor were able to convince a judge that the doctor was engaged in criminal activity when he promised patients that their HIV could be managed only by alternative care without the use of antiretroviral drugs.

Of course this is only television and it is fiction. But the show reminds us that complementary/alternative medicine and naturopathy need to support the standard of care, especially when it is a matter of life or death. A pregnant woman with HIV needs antiretroviral therapy. After pregnancy, the woman should not breast-feed her baby. Children of HIV positive parents need HIV testing. The decision to administer HIV drugs to children and adults is a major one, as the standard of care now requires the use of at least three drugs, commonly referred to as highly active antiretroviral therapy (HAART). These drugs have a likely potential of serious side effects and are required to be administered for life. Discontinuation of HAART even for short periods of time poses a serious risk for drug resistance.

Alternative/complementary treatment and naturopathic care for HIV and AIDS should always be provided as an adjunct to HAART – never as a stand-alone treatment.

Klatz and WongA4M Las Vegas Meeting
The Las Vegas A4M conference in December may be the perfect combination of education, business, and entertainment. The rodeo is in town and doctors share the floors with cowboys. The Venetian and Palazzo Hotels are all decked out in Christmas regalia. There is a festive atmosphere afoot – it makes the lectures and company exhibits all a little more exciting. This last year's meeting did have inclement weather; walking inside the hotel along the Venetian canal with the gondolas and sitting in St. Mark's Square watching the mimes and jugglers and Italian carolers were heavenly. The restaurants were divine – there were too many to sample – but you could have the entire Las Vegas experience without leaving the Venetian and Palazzo. A4M had a great attendance, with ample opportunity to renew friendships with colleagues. The exhibit hall was a meeting in itself, with aisles of vitamin manufacturers, testing laboratories, aesthetic labs, and laser and equipment companies participating together with an eclectic blend of publishers, insurance companies, and electronic medical record software suppliers. A4M provides master's-level training and fellowships sponsored by the University of Southern Florida. Modules in aesthetics, cancer, endocrinology, dermatology, and longevity medicine were well attended – exams were administered and fellowship diplomas awarded. And the general congress lectures offered multiple tracks to participate in the afternoons – a nice plus for those looking for diversity.

Abraham Morgentaler, MD
Some of the talks deserve repeating. Abraham Morgentaler, MD, FACS, is an associate clinical professor of surgery at Harvard Medical School, a prominent urologist at Beth Israel Deaconess Medical Center in Boston, and the founder and director of Men's Health Boston, a center focusing on male sexual and reproductive health. Morgentaler has been invited to present his impression of testosterone treatment in 2011 and 2012, and the take-away message has been the same. There is a great misconception about testosterone and prostate cancer. The general consensus is that testosterone, particularly at higher levels, is a risk factor for developing prostate cancer. A long-standing strategy for treating prostate cancer has been to induce lower levels of testosterone in patients. In the 1970s and earlier, castration and estrogen administration were the means to lower testosterone. Since the 1980s, luteinizing hormone releasing hormone (LHRH) agonists have been employed to accomplish testosterone reduction. Since testosterone is considered the villain in prostate cancer, replacement therapy is viewed as dicey by most physicians. It is irksome, indeed, if one's patient develops prostate cancer while receiving testosterone. Morgentaler argues that testosterone plays no role in causing prostate cancer – but he does advise checking patients who have low testosterone levels for prostate cancer prior to providing testosterone replacement.

In 1996 Morgentaler and his colleagues published a paper in JAMA examining patients who had low testosterone levels and PSA scores below 4.0 ng/ml.1 Each of the patients had prostate biopsies. The rate of prostate cancer was 14%; this was a much higher incidence of prostate cancer than found previously in men with low PSA scores. A low testosterone level was a risk factor for developing prostate cancer. In 2006 Morgentaler and Rhoden examined 345 men who underwent hormone testing and prostate biopsy.2 They found a prostate cancer rate of 15% in men with low testosterone. Instead of confirming that testosterone is a risk factor, Morgentaler worried that men with low testosterone had a greater risk for developing prostate cancer.

Morgentaler was very impressed with a study published by Leonard Marks in 2005.3 Patients were administered testosterone or placebo every 2 weeks. All men had prostate biopsies before initiating the study. Testosterone levels were measured in the serum and within the prostate gland at the beginning and after 6 months of treatment. While serum levels of testosterone increased measurably in the treatment group there was no significant increase in prostate testosterone levels. Prostate biopsies done in the treated men showed no difference from the placebo group at 6 months; in other words, there was no increase in prostate cell growth in the testosterone treated men. Morgentaler believes that the prostate has a limited ability to respond to testosterone. If the serum testosterone level is low and prostate testosterone level is low, testosterone will enter prostate cells and induce cellular growth. However, once prostate testosterone level is normal, additional testosterone will not increase prostate gland testosterone and there will be no further prostate growth. This would explain the apparent contradiction that lowering testosterone levels in a prostate cancer patient reduces prostate cell growth, but increasing testosterone levels in a patient with normal testosterone levels does not induce increased cell growth.

The intriguing question for Morgentaler is whether testosterone treatment is useful for men who do have prostate cancer. He has been following a small group of men with prostate cancer who are being administered testosterone. Thus far he has seen that their prostate cancer has been stable. He admits that this is very risky work and requires meaningful consent and the understanding there is a high likelihood of litigation if things go amiss. In the interim he strongly supports the administration of testosterone to men with low testosterone levels but does recommend careful checking for prostate cancer as this group is at higher risk.

1.  Morgentaler, A, Bruning, C, Dewolf, W. Incidence of occult prostate cancer among men with low total or free serum testosterone. JAMA. 1996; 276: 1904-06.
2.  Morgentaler, A, Rhoden, E. Prevalence of prostate cancer among hypogonadal men with prostate-specific antigen of 4.0 ng/ml or less. Urology. 2006; 68:1263-67.
3.  Marks, L, Mazer, N, Mostaghel, E. Effect of testosterone replacement therapy on prostate tissue in men with late-onset hypogonadism: a randomized control study. JAMA. 2006; 1996:2351-61.

Thierry Hertoghe, MD
Thierry Hertoghe, MD, of Brussels, Belgium, is the president of the World Society of Anti-Aging Medicine as well as the International Hormone Society. He is also the founder of the Hertoghe Medical School offering education to health practitioners in hormone, pro-aging, and lifespan therapies. He is a regular speaker and workshop lecturer at the A4M meetings. Dr. Hertoghe is best recognized for his extensive work in employing hormone therapies to support life extension. From Hertoghe's perspective, while hormone deficiency is part of the aging process, it is reasonable to administer hormones to slow or reverse aging. He disagrees that hormone administration plays a significant role in causing or accelerating the development of cancer. However, he only advocates the use of bioidentical hormone therapies and abhors the use of synthetic hormone analogues – for example the use of a progestogen instead of progesterone. Hertoghe would argue that hormone deficiency may arise at relatively early ages – younger individuals may have a few hormone deficiencies, while older individuals have more – typically five to seven deficiencies. Correcting these hormone deficiencies can subtract three to seven years from the aging process, particularly from an aesthetic viewpoint.

Hertoghe's most recent work has focused on growth hormone and insulin. He points out that insulin plays an important role in muscle strengthening. He likes to administer hormone combinations in a single injection. A preferred hormone combination would include growth hormone, IGF1, insulin, and melatonin stimulating hormone. Combination hormone therapies enable lower doses to have greater anti-aging effects. However, insulin, should be avoided in obese patients as it also encourages adipose deposition.
Hertoghe illustrated a multihormone replacement program with his personal daily regimen:

1.   thyroid 30 mg
2.   hydrocortisone 30 mg
3.   testosterone 10% (100 mg/g) 1 gram
4.   DHEA 40 mg
5.   growth hormone (combination inj.) 0.005 mg
6.   melatonin 0.1 mg
7.   fludrocortisone 100 ug
8.   pregnenolone 50 mg
9.   progesterone 100 mg
10. oytocin 5 iu
11. Finasteride 2.5 mg
12. Desmopressin sublingual 2 x 50 ug
13. IGF-1 (combination inj.) 0.04 mg
14. Melatonin 2 (combination inj.) 0.005 mg
15. Epithalon (combination inj.)
16. Thymosin – alpha 1 (combination inj.) 0.007 mg
17. Relaxin (combination inj.) 0.1 ug
18. Telomerase activator 65 2 x 250 IU (2 x 8 mg)
19. 5-hydroxy-tryptophan 25 mg am, 100 mg pm
20. Longer Life Pills 6 caps daily

Naturopathic Approaches to Infertility
The medical approach to infertility is a challenge for doctors and patients. Drug therapies pose risks, and in vitro fertilization is expensive and difficult. Naturopathic approaches to infertility are largely ignored in medicine but without good reason. Amy Terlisner, NMD, and Jaclyn Chasse, ND, explore this fascinating and important topic: Terlisner's article is titled "Sperm Meets Egg: An Initial Fertility Checklist," while Chasse writes about "Integrative Approaches to Infertility for Women." Terlisner emphasizes the need to determine if the woman is suffering with PCOS (polycystic ovarian syndrome) and has insulin resistance. If there is insulin resistance, Terlisner recommends dietary management with reduction of carbohydrates, increasing exercise, and nutrients helpful in improving insulin resistance. Chasse agrees that general lifestyle management is greatly helpful in improving fertility – addressing obesity, eating a Mediterranean diet, managing stress, and using adequate supplementation to support ovulation and sperm functioning. Chasse thinks that hormone supplementation with melatonin and DHEA may be necessary to improve ovarian functioning.

Sara Wood, ND, wonders if the insulin resistance and elevated androgens in PCOS have a "chicken and egg" relationship – which comes first? Wood argues that one cannot dismiss the diagnosis of PCOS in a patient simply because she is not obese. Lise Alschuler, ND, updates us on an integrative approach to breast cancer. She comments that thermography should not be used as a "stand-alone" evaluation for breast pathology. Her recommendations for naturopathic support include black cohosh, indole-3-carbinol, melatonin, mushrooms, and vitamin D. Tori Hudson, ND, offers us two remarkable pieces in this issue. First she does a 2012 review, then she has put together her list of the "Top Five Herbs in Women's Health." Many readers were intrigued with Dr. Jacob Schor's provocative article in the January issue, calling into question the theory of 2/16 estrogen metabolite ratios. In this issue, Jonathan Wright, MD, and Thomas Klug, PhD, respond to Dr. Schor's article, arguing that there is good science justifying continued testing of estrogen metabolites.

Jonathan Collin, MD

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