Anyone offering Bioidentical Hormone services? I'm currently reading Dr Taylor's book and listening to his DVDs. How do you go about charging for the service? Our consultations up to this point have been free and we do not bill insurance at all. I assume a basic office charge, then a discounted follow up. They send in their own saliva test and can submit it to insurance and they pay the pharmacy for the prescription. I was just curious if anyone found an easy way.

Thanks!

I am skeptical of the accuracy of saliva tests. On many occasions pts will submit them to us and they do not match the serum assays. If you notice Dr Taylor's Saliva Reference Summary, the references sited are 8 to over 30 yrs old. serum assays have come along way since then. The tests are limited to some hormones and you need much more additional information thru blood work to accurately R/O or define etiology of possible deficiencies. Not to mention the importance of a HIGHLY detailed history, ROS and PE. Better off setting up lab accounts, there is profit in it and the pt came submit them to Ins if they have it.

This is time consuming and requires complex medical decision making at times if done properly with the pts best interests in mind. Yearly fees vary, average I have seen is 2500-3500 dollars (fee includes frequent f/u labs and visits). Initial visits range 300-1500 depending on bells and whistles. I would definitely have the pts fill Rx at pharmacy. Being a dispensing clinic is an open invitation for frequent violation phishing trips from state DOH.

Treatment goals should be symptom alleviation, reversal/treatment of deficiency sequelae and quality of life. If you are ethical and legal, anti-aging and longevity are not in your vocabulary. This is a hot political topic. Even treatment of sarcopenia is questionable at best to some govt and medical bodies because they deem feeling shitty, old, achy, weak, fat with no libido and decreased mood/cognitive ability "normal" aging.

Just my opinion and some food for thought.

I'm interested in adding bio-identical hormone therapy to my practice. Where is the best place to learn and get info. Thanks

I agree with Florida PA. Saliva tests are not necessary. We do all our hormone management with history/ physical, ROS, and blood levels.

I went down to a bioidentical hormone seminar in San Diego mainly for myself. Some of the speakers thought saliva was the answer for detecting deficiencies while others thought it was blood and 24 hour urine tests were the best. Your thoughts on that would be helpful.
Also, I have a question on fees. Are physicians charging the $2500 - $3500 fee annual as a retainer or as a lump sum that includes all the lab they would need for that year? Or, are they charging an annual fee, plus a fee for the initial visit and subsequent visits and then also for any testing that is done(which makes more sense)?

PacificMedDoc

I personally think saliva tests are worthless, limited and accuracy is questionable. 24hr urine has no purpose for metabolites. Cortisone is variable depending on pt endocrine state. If pt is Addison's/Cushing's you will know with s/s, ROS and PE. Blood is the way to go, accurate and with clinical correlation, diagnosis (or reasonable evidence for a therapeutic trial) is easy. If you suspect a zebra additional tests will give you an answer. Low/low normal - labs and symptoms with testosterone free and total warrant FSH, LH, SHBG to r/o secondary hypogonadism. Extremely low = MRI to r/o pituitary tumor. You cannot get any of this from SPIT.

This is just one example of the complexity of clinical HRT. I could go all day, in fact I have been studying and practicing HRT for about six years. I have written evidenced based training manuals with lectures on age management/HRT and currently looking to copyright my material. It pisses me off that some Docs lecture bullshit quackery to make a quick buck. On the other hand medicine is full of "opinions". Bio identical is merely a marketing buzz word, Susan Summers hormone experience is limited to "Threes Company" but I see pts that take it as gospel.

Whew! got that out of my system. What do I know, I'm a PA. Well, I know HRT is complex and is about symptom alleviation and quality of life. Also pts deserve quality of care and not the BS some pass off because they are sick of real medicine and "teach" quackery (which may actually be harmful to pts) for money.

Fees depend on what the market bares. There are many different models. $2500-3500 usually covers eval, labs and medical monitoring with f/u visits. There are a lot of different models so you need to find what works for you and your pts.

By the way, I see the same BS with weight loss. Fad diets with some off label med use for big $$$, that do pt no good in the long run.

Florida Pa,
As a fellow PA, I would love to see some of your training manuals. Where can I find your information.

Thanks
Matt pa

mattf,

The protocol training manuals are not released too the public as of yet. I work with a Florida based age management/HRT company with physician affiliations nationwide. The protocols were developed to create a "standard of care" with our affiliates which they can deviate prn per pt need. Trying to create a Cenegenics or Bodylogic type of model. All evidenced based with over two thousand pts over a six yr period to back up FDA approved and off label treatments when in pt best interest. I am involved in a start up Internet medical marketing company to ensure new Docs grow a pt base.

I would be glad to discuss specific or general topics in open forum or you can contact me at oncallmed@hotmail.com

Every day we get closer to the end of using synthetic hormones and orally administered hormones.

For women, the ovary has made estrogen, progesterone and testosterone -- and this is exactly what is needed when levels fall. Not synthetic molecules with weird receptor activity. Physiologic doses only. Transdermal is great -- no first pass through the liver and no unwanted metabolites. Progesterone is so important.

Serum tests greatly underestimate the delivered doses of less polar steroids delivered transdermally thus leading to overdosage. Saliva tests are easy to administer and correlate well with symptoms and therapy. Spit is BEST for cortisol -- no stress of drawing and easy to check diurnal patterns thru the day. Check thyroid in blood.

BHRT safer than synthetics? you bet! Check out Kenna Stephanson's presentation to the American Heart Association Nov. 11 2008. Improved thrombotic and inflammatory markers, improved stress, depression and climacteric scores and high patient satisfaction in a randomized trial against traditional hormones (mostly prempro).

Read John Lee's book -- What your doctor never told you about menopause. Attend a ZRT conference. Read the WHI study. Its as plain as can be and open for all to see.

wrong for twenty years

Post is not very scientifically sound. Sounds like a sales pitch.

I was on "traditional" HRT for 5 years with little or no relief of symptoms no matter how high the dosage or method of delivery.. One of the results is a severe case of vascular Rosacea. Always thought "bio-identicals" was snake oil, especially with Suzanne Summmers pitching it. Suddenly Oprah ( I'm not a fan) jumped on the band wagon and friends suggested I seek out a competent, experienced doctor. After completing EXTENSIVE blood tests it was discovered that my estrogen level was only 10% of what I needed. I see the doctor often- initially every 2 weeks for shots and blood tests once a month. My insurance - United Health Care, one of the largest insurance companies in the U.S. has covered it all.So this is not a quick, easy, don't have to deal with insurance, way to make a quick buck.
Arlene

Here's a fun test. If you are a woman check your blood hormone levels for a few days morning, noon and night. See the fluctuations you get even before and after breakfast. Same goes for testosterone. Give me a break. Estrogen in whatever form goes down when you age. Some people have more pronounced symptoms and benefit from hormone replacement. Like WHI says, the indication is menopausal symptoms such as vasomotor, mood changes. If you are one of those people who try it and like it then you should take hormones for the shortest period of time that you need it to improve your quality of life. Then as you get older you have to weigh the benefits and the risks because the risks become more pronounced. And like the WHI pointed out, it may be progesterone that may be more risky.
I am an OB/GYN and I have never had any desire to read Ms. Somers' book. But I was told by one of my patients that she has some lady in there who is on HRT and menstruating in her 80's!!!!! Don't quote me....it is just hearsay. It is just wrong, wrong, wrong and bad medicine. Your saliva and blood tests are a good example of what is wrong with healthcare in this country even if your patients can afford to dish out the cash. What a waste.
Oh, and by the way....prempro hormones are derived from mare's urine and many of the other formulations are from plants. So I don't know what you mean by "synthetic".

I have looked into Cenegenics and any physician knows that it is a big business which promotes the use of HGH human growth hormone and steroids. If you want to get an idea of what happens to you when you prescribe such things why don't you google Bruce Nadler who was a Long Island body builder plastic surgeon who committed a murder-suicide and one of the biggest proponents of these hormones. It happened just like with Chris Benoit. How many people have to die so that these people can make a buck?

TAD: you're more than a tad wrong abount Cenegenics. They promote neutraceuticals, diet, excercise and only HRT if blood tests show people are deficient. Bruce Nadler and Chris Benoit were not Cenegenics patients and most likely "juicing " their hormone injection to Supra-normal levels for sports enhancement. Cenegenics physicians never treat professional athletes even if deficient for many reasons. I took the training and thought it was great (No, I'm not on HGH); you should invest the money in training. I think Cenegenics has great training, as a GYN you have a population interested in Bio-Identical hormone therapy...I'm sure your societies have advanced training-CME-available. good luck

If cenegenics is about diet and exercise then you are making it sound like a fancy Jenny Craig. The money is really in the doctor visits and the prescribed medications. I have all the knowledge and training about the risks and side effects of human growth hormone, testosterone, DHEA and the like. If you know how to read carefully, you would have comprehended that I never said that Nadler was associated with Cenegenics. He was just a proponent of HGH and other steroids. These are the same hormones that are prescribed by Cenegenics. How is this different? I also never said Chris Benoit was on it either. Really, I don't need to say anything about your reading comprehension. Read it again. It just stated that Nadler died in a similar manner in that he killed his wife and himself and it was suspected that the effects of the hormones contributed to both deaths. You can call it anything you want but they are the same hormones. Take a look to see what Nadler was prescribing on Long Island that caused him investigated and have his license taken away. The same hormones that Cenegenics uses!!!.
Maybe you should do some reading first about ACOG's position on bioidentical hormones. Granted, ACOG is conservative but there is no cogent evidence that these combinations of estradiol, estrone, and estriol are more effective than are other hormones or that they do not carry the risks found in the WHI. Talk about reinventing the wheel. Yes, we know that hormones help some in perimenopause. We've known it for a long time. Just another way to dupe the public into paying large sums of cash. And you didn't answer the question about how estrogen from mare's urine is any more "synthetic" than the preparations in bioidentical hormones. Informed patients are more disgusted about the urine but understand that it is from an organic source.

"Neutraceuticals, huh? That's pretty funny. Way to make up your own word, Cenegenics. No REAL doctor in his or her right mind would use his or her license to steal from patients. Or maybe cal lhemselves "dermaROGUE"....lol.

Tad and Jenny, sounds like you have a bone to pick with the Bio-Identical hormene board. The key is providing VALUE to patients. A Bentley and a Yugo are cars to get you from place to place, but which would you rather have if you could afford it? Tad, we all know horse derived estrogens as "natural", they contain estrogens found in humans..BUT, also 23 other equine estrogens that perhaps the human body was not meant to process and might be harmful. I never said that Bio-identical HRT had less risk than the WHI studies; but I think you would agree that it has less equine specific estrogen. Given the WHI risks and a hot-flashing wife which would you chose as more natural and "humanly" physiologic? I did read your post and you tried to connect all that is bad and shady with HRT gone bad with Cenegenics by association. Using your logic we can say that because Michael Jackson used Diprivan..all anesthesiologists are bad. All Cenegenics protocols are backed by evidence, they have associations with 2 medical schools whose residents rotate electively through their centers for education on age management medicine---not just HRT. In your mentioned humanly physiolologic mix of estradiol, estriol, and estrone...don't forget progesterone (I think prometrium is just fine).

PS Jenny I can't argue with stupid or many democrats, I'm thinking you're both.

Actually, dermaROGUE I don't have a problem with the board at all. It was directed at you. But it does sound like you are the one who wants to drive that Bentley after overcharging those patients who pay cash for your hormone consultations and sending them to the compounding pharmacies. Oh yes, you are really concerned with VALUE for the patient (or rather VAlUE in your pocket). Why don't we have a little discussion about what effect HGH and androgens really have on the body. I know...something you didn't want to mention.

jenny,

I would like to have that discussion.

I'm curious, please enlighten the medical community and the other readers of your vast knowledge of the endocrine system, steroids (meaning ALL hormones) and their effect on physiology, anatomy, and homeostasis.

If you would please define the following so we can be on the same page.

synthetic
hormone
natural
bio-identical
cellular receptor

Could you please tell us what effect HGH and androgens really have on the human body (male/female). What happens if there is too little? What if there is too much? What category does oral birth control fall in?

Why do HMO doctors treat middle aged men with textbook primary hypogonadism with viagra and zoloft?

And how do all obese patients know that they must have a thyroid problem???

I think this enough to get started. Looking forward to some good clinical discussion

Brock,

By your statement I assume you use HGH for AGHD (adult growth hormone deficiency) and need the medication for medicinal replacement purposes. This of course was diagnosed and followed up by a competent experienced clinician with your best health interest in mind and you are taking advantage of cost savings by filling your Rx outside the USA.

You are a joke!! It seems there are two crooks involved in your senario.

Actually I'm a body builder and I'm using it to keep myself huge, low in body fat and looking young. Nice try though.

My point, exactly!!

Jenny,I should appologize and would like to say sorry to "all democrats". Actually I drive a GMC; I don't think you're medically trained (in anything) and won't waste more time on you. Go to school and get informed.

jenny

I am a PA and DermaRouge is a physician, I assure you we are two different people. DermaRouge is obviously smarter than I in this situation, not because he/she is a physician but because he takes you even less serious than I do.

I have not had training with cenegenics as DermaRouge has but I am aware of their teaching. I think it is clinically sound. I do not agree with all they say, but that is just my clinical opinion. I do have a medical degree and if you look at all my previous posts you will see I am well educated and experienced. I do not have any questions and know the answers to what I have posted. My purpose was to start clinical dialogue or expose you as a blowhard, MD or not!

Lets see you put your money where your "biochemistry" mouth is and lets talk clinical. Are you afraid a lowly PA may teach you a thing or two about evidenced based HRT? It's an anonymous post, the least you could have done is cut and pasted something you have no knowledge of to save face instead of squawking about how smart and educated you think you are.

From your post I bet your patients (if you are really an MD) call you a quack! Are we going to talk clinical or do we already know who "needs to go back to school"???

I have no problem with PA's and I work with some good ones. But this is not the place for you to get a Cliff's notes medical education. If you have something to ask a question about then read, read, read. Go to a medical library. I doubt that any MD here wants to get into a debate with PA;s or anyone else about their use of treatments that are so controversial and not FDA approved for these uses. Maybe your fellow PA's who use these hormones would be willing to have this discussion with you.

(Note: This comment has been modified by an editor for profanity: Medical Spa MD)

tad,
Your condescending tone is really not necessary here. Looking at the pattern of your previous posts it seems that's the way you choose to communicate with others as well, so I won't take it personal.

Your generous tolerance of those you deem beneath you makes you a true humanitarian only in your own mind. Cliff note medical education, read...read...read, go to a medical library. Who do you think you are? Your arrogance blinds you to the fact my questions were written with sarcasm in a devil’s advocate role purposely to point out the absurdity of jenny’s following statement to DermaRogue.

“Why don't we have a little discussion about what effect HGH and androgens really have on the body. I know...something you didn't want to mention”.

Any clinician with a base knowledge of general medicine knows that there can be serious sequelae to deficiencies or supraphysiologic doses of these hormones. Those who leave such nonsense in an open ended statement in a clinical forum deserve to be called out.

You obviously would not understand this because it is something you could not regurgitate from WHI. In fact, I went back and read your previous posts. All I saw was you trying to belittle a fellow physician for their clinical views and where they received training. Don’t think you enlightened anyone with clinical pearls either, the only information you put forth can be found in Medpage today’s daily women’s health summary’s.

If you have any aptitude for paying attention to detail you will notice there are multiple previous posts now missing. One is from Brock about how he gets HGH from China. Two from jenny. The first is her claim to expertise because she was involved in some sort of biochemistry research in med school, the other was about how my education was flawed back to grammar school because I was illiterate and could not comprehend the English language. One was from me questioning whether jenny was really a doctor. No doubt removed by Jeff Barson or his staff due to the fact they do the website no good as far as relevant, original content on a subject is concerned.

tad, in short you can save your professional bullying, profession bashing and swelled ego for those who do not know any better. Remember “doctor” respect and professionalism is a two way street.

I suggest that it is better to actually read research articles and real medical publications rather than looking at a webpage on a daily women's health summary. Those webpages are generally written for laypeople and often do not tell the full story. Any true academic would not get there information in that manner. We are professionals so we are supposed to have a more complete understanding of medicine. I can't believe that in this professional forum that you would suggest that is where we get our information.
I also think that there is no room here, Florida PA, for you cursing (using four letter words) and I do hope they remove your posts). You reveal more of yourself with each post. If you are going to be that unprofessional and low, you should not be allowed to post here.

Yes, Jeff you are, of course right that the discussion should not get personal. In my attempts to explain why I didn't want to discuss things with the PA my explanation was taken personally and I shouldn't have attempted to explain it at all. I have repeatedly stated that I have respect for some of the PA's I work with. But I just have this question. You deleted several posts, rightfully so. But the PA from Florida's post of 7/18 also has no informational content. (the one that contained the low class profanity that you had to delete). Just a suggestion but you may want to delete that whole post also because it is also full of insults. I appreciate your forum. But you are right. I have not been sworn at in any forum by any professional in this field and I think it is inarguably a reflection of low class. I don't really have any desire to hear it and will no longer participate. Good luck.

I agree with reading to increase your knowledge on any subject.

When in a professional field act as a professional.

Can bio-identicals cure common hormonal problems? If so, which ones?