Hormone and Beyond Symposium
September 25-27, 2020 | Salt Lake City, UT + Live Stream
Recently I received an email from a practitioner that I would like to share with everyone:
Neal – Thank you for everything you have taught me. You have made me a better physician. I was named the Best Obstetrician & Gynecologist 2020 in New Orleans by the premiere corporate and business publication in Louisiana. So many patients have told me I have changed their lives and I share that credit with you!!
– Katie Swing, M.D.
Well, a big congrats to you. Wow. What an honor. With all that is going on around us, there is finally some good news. The best part about this award is that it is bestowed upon you by your patients and that’s exactly why we became physicians in the first place. To successfully help another human being when no one else can or knows how to, makes our lives fulfilled. The fact that this has changed your life, and that of your patients, also changes my life too. So, thank you for the feedback and keep up the good work.
Unfortunately, the training that we receive in our residency falls far short of that which we should know, understand, and embrace as far as our medical knowledge in treating patients is concerned. I try my best to provide all the EBM literature in the WLM 4 part series to enable all of us to better understand medicine and how we can better treat patients. Still, even after 4 courses, there is so much data, literature, and clinical pearls that I simply just can’t cram into Parts 1-4. As the result, every year I try to keep everyone updated on what I find to be the most important literature and topics that I feel everyone should know. Each year the Beyond Hormones/Part 5 Symposia is different from prior seminars as I try to provide you with the latest literature that I have not been able to provide before. It is a daunting task of sifting through tons of articles, controversies, and concepts that I think are profound topics of importance that I cannot fit into Parts 1-4 and that I haven’t covered in any of the past WLM annual symposiums. And this year is no different as I attempt to provide the education that will keep you abreast of important areas of medicine and enable you to help your patients where no one else can. My hope and goal is to provide the knowledge, cases, literature, and enthusiasm to allow you to become Katie Swings. Hopefully this training will improve your knowledge and skills as a physician and continue to make medicine fun. There is no other venue in medical education that I have encountered that provides this type of update. And there is no better reward in medicine as to when your patients tell you that YOU gave them their life back.
Not a day goes by without someone asking me my opinion of a paper or study. Even though you know the results do not make sense, you are surprised that such papers get published. So each year I select a new set of published literature that requires critical thinking and insight to understand why the results and conclusions are not credible. This will also be a good literature review and will cover many recent papers on hormones. With time and practice, you will become an expert when reviewing these studies. It becomes confusing when the observational studies conflict with randomized trials.
For years there has been a buzz around AMPK and metformin. AMPK functions within the mitochondria but the effect that metformin has on AMPK and metabolism is considerably weak in comparison with other AMPK stimulators. The supposed mechanism of metformin in reducing cancer risk has to do with stimulation of the AMPK pathway and metabolism but we will discover there are far better therapies to stimulate AMPK pathways, improve metabolism, and reduce cancer risk than with metformin.
Is metformin the antiaging wonder drug? We’ll review those studies. However, are there any outcome RCTs that prove benefit or are all the studies observational with a strong bias? What therapies have strong literature support in outcome studies that demonstrate far better cancer protection than metformin? Despite the hype of metformin and AMPK pathway, all of the studies claiming wonderful benefits for metformin are observational. Many other therapies have much better evidentiary support for cancer protection yet are simply ignored. We’ll review both sides of this controversy and let the science and literature provides the evidence that the experts miss or ignore. I’m not down on the AMPK pathway, but I am down on completely ignoring the literature that demonstrates superior outcomes of other therapies that metformin does not provide.
Understanding the mechanism of breast cancer initiation allows us to better understand how to prevent breast cancer and other cancers. It is not the level of estrogen in the serum that drives the initiation of breast cancer rather it is the estrogen inside the breast fat that drives the disease that is increased by aromatase enzyme. The problem here is the reliance on the use of aromatase inhibitors to decrease intracellular estrogen, but that is not the source of the problem. The problem is the increase in intracellular glucose and fat which is what drives the disease process in the first place. Blocking estrogen does not address the source of the problem. So, who is the best doctor to prevent this accumulation of intracellular glucose and fatty acids? The oncologist? Nope, LOL. It’s Dr. Swing. And you. We’ll explore the mechanisms and what has been efficacious in preventing breast cancer. So it is you that is the best specialist to prevent breast cancer and we’ll review the outcome studies. It should be your job to make sure that the patient never needs to go to the oncologist in the first place. It’s called preventive medicine.
Cancer and CVD are stated to be inflammatory disease states. And where does that inflammation come from? And how do we reduce it? Everything occurs in the mitochondria, so how do we improve metabolism within the mitochondria? Has metformin been proven to cause weight loss in any RCT? No. If everything happens in the mitochondria, then how do we treat the mitochondria? And how do we treat the estrogen dominance, by lowering estrogen with an AI? But it was loss of estrogen in the first place that caused the problem to occur as premenopausal women appear to be protected by high levels of estrogen. We’ll also explore how to prevent the recidivism of diet and exercise.
So which treatment is best to reduce BC mortality, estrogen or AI? Aromatase Enzyme switches gene suppressors to gene promotors within breast tissue with obesity.
Finally, let’s understand and grasp the concept that ovarian produced estrogen, and exogenous estrogen, protect against BC and do not cause it.
This is in stark contrast to that which occurs within breast tissue after menopause.
But loss of estrogen increases obesity which increases estrogen production which then increases BC risk? YES! How does lowering estrogen make sense when it is the loss of estrogen in the first place that is to blame?
Realize that it may be the local production of estrogen within breast tissue that increases BC risk through aromatase, and NOT systemic estrogen. Understanding these concepts is paramount in understanding how to prevent breast cancer. Should we initiate a cancer prevention specialty? What a concept!
There are multiple medicines that can be used to prevent and treat breast cancer. However, only one medicine has been proven in long term RCTs to decrease breast cancer and breast cancer mortality. Which one would you prefer? We’ll explore what’s on the other side of the coin by looking at the literature that proves harm to many of the drugs that we use for treating and preventing breast cancer. Do the benefits outweigh the risks? Yes, according to popular oncologic opinion but consensus of opinion is not reality or EBM. The recent paper in JAMA last week succinctly reviewed that estrogen is the best therapy to decrease breast cancer mortality.
The secret formula to increase breast cancer risk is: avoid estrogen, progesterone, and testosterone, add a progestin, add a statin, or add anything that increases IR and intracellular glucose. We’ll review those recent studies that suggest harm over benefit with some drugs, despite their being SOC. We’ll also review the most recent literature updates on the treatment of breast cancer with estrogen, progesterone, and testosterone. It is still consensus of opinion to never use estrogen in breast cancer survivors even if Dr. Bluming does. However, again, evidence based medicine suggests that GPs offer estrogen to breast cancer survivors which is verboten in the oncologic world. We’ll review both sides of this controversy to decide which therapy is of most benefit for long term survival, as well as who to treat or not treat.
A lecture on breast cancer would not be complete without reviewing the side effects, risks, complications, and outcome studies on SERMs and aromatase inhibitors. As the result of internet surfing and development of shared decision making, many women are opting out of traditional therapies. Should we support them or provide them with relief when they can’t tolerate traditional therapies? There is so much that we can offer patients that is simply ignored or not appreciated by the oncologic world. And whose responsibility is that? It’s yours! Don’t expect the oncologist to know the literature.
Several researchers have published superb studies in Maturitas on the benefit of testosterone in treating breast cancer. If testosterone is so beneficial as a treatment, how about as a preventive therapy? In vivo and in vitro data support the anti-angiogenic and pro-apoptotic effects of testosterone. Plus it eliminates the side effects of the commonly used cancer drugs. Levels and doses of efficacy will be reviewed, and they are NOT physiologic doses. That really upsets some of our peers, but the results speak for themselves.
Are there any studies demonstrating that E2 & P4 are harmful or increase cancer risk? Not that I can find, in fact it is just the opposite. Are there any studies that demonstrate HRT is harmful or contraindicated in patients with a positive family history or BRCA gene? Not that I can find, and in fact it is just the opposite. I feel that all practitioners that treat women with hormones should understand this literature and have access to it. Each and every study that I review, you will have access to in order to put in your library and patient’s charts. I’ll try to cram as much information into my allotted time slot that I can.
Although our intended venue in New Mexico has been cancelled, it has been rescheduled in the only Five Star hotel in SLC. The Hotel has promised the safest venue possible. If you haven’t stayed in a five star hotel lately, now is your chance, and this one is superb. Whether you attend to in person or live stream, Dana and her team have endeavored to make this a premier event. If you are attending in person I look forward to our usual evening dinner and entertainment and great exchange of stories and networking. Hope to see you all soon.
Neal Rouzier, MD