Hormone Replacement Therapy

This interview was originally posted in May of 2017, based on recommendations provided by Dr. Carter Black. I have since developed new articles and resources for Hashimoto’s that might be helpful for you. For the latest information on female hormones and finding a pharmacist to work with you, please visit the following:

• Estrogen Dominance as a Trigger for Hashimoto’s
• Pharmacists in Functional Medicine

I had a chance to interview my pharmacist friend Carter Black about hormone replacement therapy. Carter has been a pharmacist for over 30 years and is my go-to resources on all things female hormones!

Watch the video or read the transcript below!

Note: Time stamps – in brackets are “start times” for that particular portion of the video/audio

Hi everybody! Welcome! This is Dr. Izabella Wentz your Thyroid Pharmacist.

Carter’s Bio

Today, I’m visiting with my dear friend, Carter Black, registered Pharmacist. He is a graduate of the University of Illinois, College of Pharmacy with undergraduate work at the University of Illinois at Champaign/Urbana. He is a preceptor for Pharmacy students and a consultant by doctor referral for women and men’s health, hormone, and thyroid issues.

Carter Black has five years experience as a Professor of Pharmacology at Pacific College of Oriental Medicine. Mr. Black also has extensive training through the Institute of Functional Medicine, Hacking Hashimoto’s, and the Hashimoto’s Institute.

He has over 40 years experience working with compounded medications, bio-identical hormones, and he is my go-to resource for compounding medications. He has been really helping me a lot since 2011 when I moved back to Chicago and started visiting his compounding pharmacy. He is one of the first people that told me to look into my adrenals as a potential root cause and a potential trigger. And so, Carter, thank you so much for being here and thank you for the work that you do to help people especially me. You’ve helped me so much in my health journey.

CARTER: Well, thank you.

How Carter first became interested in women’s hormones

[00:01:15]
DR. WENTZ: I really wanted to pick your brain. This has been long overdue because you are really my go-to expert on women’s hormones and you are just so passionate about women’s health, and so knowledgeable. Can you tell me how you first became interested in women’s hormones?

[00:01:34]
CARTER: Well, I think that working in a compounding pharmacy, I’ve always felt that women are marginalized in their health, and as a matter of fact, it’s well documented that (and I’ll get to this later) women’s health, in heart health, which is a major health factor in women is; they’re not treated the same as men. They don’t get the same attention. I’ve known that forever. And then, what happened was I was in the compounding pharmacy and someone needed to be the information source for women because a major market was women’s hormones, and this was back in 1998 when I started.

DR. WENTZ: Mm-hmm

CARTER: The internet wasn’t what it was then. And there’s no real good information except maybe word of mouth, and some of that was wrong. And, there was a lot of books, so I was the pharmacist that would answer the questions for the women, and we had a major practice down the street from us. And so we did a lot of women’s hormones, and I just enjoyed it. And, I started the compounding practice with another pharmacist and basically from zero. And we just decided that this would be a better way to go. And compounding to define it is really making custom medication to a patient’s need. And sometimes commercial medicines can’t fill the requirement. There’s a lot of your thyroid patients that need gluten-free or corn-free, or dye-free medicines, and this is one of the first things we did way back, 20 years ago because people were discovering that even common medicines were giving them a big problem. So, they would come to us and we’d make dye-free medicine.

And then, I spent a lot of my time trying to master this subject. And at that time, we had to read books. We had to go to the seminars. There weren’t webinars. And I talked to a lot of colleagues, too. So, it was then the more interest you have in something, the more people come to you, and the more experience you got.

[00:04:21]
DR. WENTZ: Yeah, and one of the things I was really struggling with my adrenals. What we know that adrenals and thyroid health are oftentimes connected, and I was getting compounded thyroid medications from the pharmacy where you were working, and they were helping. But at the same time I just hit a plateau and you were the first one that let me know that this could be an adrenal issue. And you’re just; you’re one of those people that I’ve always trusted because you really care about the patient, and you really care about the outcomes, and you’re not somebody that’s just trying to pull a fast one or trying to just tell people things because you have a product to sell. You’ve never been that person, and I’ve just seen you interact with patients and I really, really appreciate it.

[00:05:12]
Women, typically we have a harder time getting the cure that we need because we’re oftentimes labeled as hypochondriacs and a lot of times we are told that everything is in our head. A lot of times there are problems that women are experiencing are just not validated by others, and I know you’ve helped so many women just by your kindness and your knowledge, and just sitting down and talking with them, one-on-one about their hormones and about their health, and just giving them a few tools; getting them started on the right path.

[00:05:44]
CARTER: Well, that hit home, hit me very hard when I was working on women’s health that there were so many things that I could have done. My mother passed away, a heart attack when I was 21, and I look back at that and I knew kind of what the things were going on but I had no knowledge. And, I would never let things happen the way they did – the lack of care, the lack of testing, the lack of medication. I mean that was my, another motivation. And the way I got drawn into thyroid and adrenals is because I could not get my women stabilized on just hormones. So, it had to be something else, so I went to the adrenals. And that was good but then I found out it has to be something else. So yes, it was the thyroid, and you have really increased my knowledge of that. I mean I don’t think I’ve mastered it but at least, I have a better appreciation of what can be done and why I’m not getting the control I want.

[00:07:04]
DR. WENTZ: Mm-hmm, yeah. And it’s really important to know because a lot of times the various hormones, they interact with one another so it’s not just estrogen that lives by itself in a vacuum. It’s not just thyroid hormone that lives by itself in a vacuum. It’s not just the adrenals. So, a lot of times we’ve got a whole hormone soup, the whole hormone symphony, and we want to make sure that we’re looking at all of the aspects of the clinical picture with the patient. And so, a lot of times we’ll find sometimes stabilizing the thyroid will help to stabilize the female hormones.

CARTER: Right, that’s true.

DR. WENTZ: Sometimes stabilizing the adrenals will help to stabilize the female hormones, but not in all cases. So, when we have a person who maybe has their thyroid dialed in and their adrenal dialed in, sometimes they still may have hormonal imbalances. And that’s where I think the art and science of female hormone balancing really comes in. And it’s such a controversial topic right now because back in the day we were giving every postmenopausal women hormone replacement therapy, and then there was this big study that showed that it actually have some adverse consequences. And now, we’re coming back into the realm of things and we’re thinking about, “Ok well, were we complete off our rocker to just deny women hormone replacement therapy?” because now there’s been shown that maybe these studies didn’t have everything dialled and maybe there were some other kind of compounding variables and in some cases, the hormonal therapy may actually be safe and effective.

Bio-identical hormones

[00:08:41]
So, where do bio-identical hormones come into the picture? Can you talk about this whole hormone controversy that we…

CARTER: Right. Yeah, right. I mean honestly, I went through that whole thing – the big study was too old, too. And right before then, in the early 80’s, everyone gave unopposed estrogen. And there was a big study there and there were quite a few uterine cancers. So, that was changed in the early 80’s. So that you didn’t just give estrogen, and what ended up to be the wrong thing to do is they gave progestin which caused less endometrial cancer or uterine cancer. But now, fast forward, we found out that the progestin, not real progesterone was causing the problems with the heart, that 2002 Women’s Health Institute (WHI) program caused, and that’s the push for bio-identicals. And it’s not necessarily the estrogen that was the problem with that. It was the false progesterone or progestin. When people talk about progestins or commercial progestins and progesterone in the same sentence and they really can’t. The progestin acts more like a testosterone than real progesterone, and it doesn’t counter the estrogen like it should. The false progesterone has an increase of heart attacks because it affects the cholesterol. And so there was the Hurst study that showed that even any estrogen you give with a real progesterone was superior than the product that they used in the Women’s Health Institute.

[00:11:08]
So, bio-identicals really what the term bio-identical if you want to define it is body natural – what the body would produce. And that’s what bio-identical to me means, and there’s probably other definitions. And then, there’s this term floating around called natural, and natural is interesting because herbs are natural and you can manage hormone problems with herbs at times. I taught at the traditional Chinese medicine college and so they were adept at using acupuncture and herbs for menopause symptoms. But even they would admit that sometimes you just need the real hormones. So, we had a very good relationship – the students and the professors and I, and we taught each other. But the thing that’s normally used commercially is Premarin which is – Premarin is from horses and it is natural. But it’s really not bio-identical to the woman.

DR. WENTZ: Got it.

CARTER: So, there are some problems there but the biggest problems really is with the false progesterone. In the hands of a good practitioner, bio-identical hormone therapy doesn’t really cause that many problems. I was talking to my colleagues today at the office. They’ve been in Ob-Gyne practice for 25 years and they really haven’t seen any problems with hormone therapy in all their years. And I said, “How funny”, and I haven’t really. So, when we do bio-identical hormones, I prefer topical administration rather than the orals that are commercially available. And there is a commercially available patch which has a bio-identical hormone. And then, I use a bio-identical progesterone. And the thing about it is, is when you do topical hormones, they go into the system, go to the target organ, and then are metabolized. So, they have lower doses and their risked of their metabolites are much lower. So, that’s why I’m a proponent of topical hormone therapy, except for progesterone. Oral progesterone, real oral progesterone has metabolites that the body recognizes and uses, and they’re not foreign to the body. And I use, probably my most successful therapy anytime, anyplace was oral progesterone for sleeping. It’s just wonderful and that’s one of the big problems with menopause – is sleeping.

[00:14:31]
DR. WENTZ: Mm-hmm. Let’s back up here for a minute. You just shared so much fabulous information. So, for estrogen you prefer topical products; so, compounded topical product or prescriptions ones that are already available commercially.

CARTER: Yeah, there are bio-identical commercially-prepared topical medicines, and one of them is the Vivelle-Dot. I’ve used that forever. They had a lot of strengths and you can even cut them. All the hormone is in this adhesion, in the adhesive. And then there’s quite a number of gels that are commercially available – Estradiol bio-identical, and I love those.

[00:15:19]
DR. WENTZ: That’s really helpful. And then, for progesterone, is this a compounded medication?

CARTER: Yeah. So, there’s plenty of commercial estrogens but there’s only one bio-identical progesterone that I would trust, and it’s Prometrium; and there are problems with Prometrium. It’s in peanut oil. People can get allergies to peanut oil, and it dissolves into the body so quickly that sometimes about 30% of my patients will get dizziness and so I have to use a compounded progesterone, a time-release which is excellent. And then, you get a blood level for about 8-12 hours and you don’t get the dizziness that the commercial product gives.

DR. WENTZ: That’s really helpful. Now, are there other, any kind of patients where you wouldn’t use, I guess, any hormones whatsoever, like maybe somebody with breast cancer and that was fuelled by estrogen or anything else like that, that you can think of?

[00:16:32]
CARTER: Yeah, there are several categories. First of all, I’ve had a few smokers as patients and they are fast metabolizers so I’ve had to have incredible amount of estrogens in them. I never felt comfortable in this. As a matter of fact that was my only breast cancer, in my practice ever, from a smoker. So, I don’t like to use estrogens in smokers. Also, breast cancer, that is a very hard place to be because there’s quite a number of hot flashes, vaginal dryness and women are even afraid to put estrogen vaginally even if it’s not absorbed. So, there’s a number of products that you can use. We actually use DHEA vaginally. Testosterone vaginally works very well. Progesterone works vaginally, really well. Or, if you use a bio-identical called Estriol; Estriol is huge. It’s made by the placenta during; when you’re pregnant, huge amounts of Estriol. And it’s a non-proliferative, so if you’re carrying a boy, you’re not going to feminize them but you’re still going to get the estrogen effects. So, Estriol can be used carefully in breast cancer patients. Rebecca Glaser who I went to a seminar about 20 years ago, and she taught me topical application of hormones to the vagina in smaller doses, that you could still achieve hot flash control, and you can get rid of vaginal dryness which is one of the major problems. And, you could keep it a low dose so that even lower dose than what I’ve used to not absorb into the system. So, that’s one case Factor V Leiden patients, where you have risk of clotting, and you understand those patients, I know. So, those are – anyone with a DVT…

DR. WENTZ: Deep Vein Thrombosis.

CARTER: Right. So, gallbladder problems obviously, that’s a risk. So, there’s what we call in the biz rule outs. In other words, we rule out those patients. But that’s the challenge. That really challenges me. Alright, I can’t just do the regular thing. Now, I have to come up with something tricky that will help these symptoms, and so I don’t mind that. And the women that can’t take the normal therapy – estrogen, progesterone and maybe even testosterone, they’re very pleased when you do conquer their symptoms. And some of them are really horrible. Another use; again, Rebecca Glaser uses testosterone in breast cancer patients. She’s a breast cancer surgeon in Ohio and has a very famous practice and nationally known.

Gallbladder issues – a contraindication for using female hormones

[00:20:29]
DR. WENTZ: And so, couple of questions I have for you is, one – Why the gallbladder? So, how can gallbladder issues? Because I know some women with Hashimoto’s may have gallbladder issues and they are more common in Hashimoto’s than they are in the general population. So, why would that be a contraindication for using female hormones?

CARTER: You’ll notice that as a rule out on oral contraceptives and it tends to form gallstones. So it’s just one of the check box; boxes you check off.

DR. WENTZ: We don’t want to increase the risk of gallstones so that’s why we would have wanted to use hormones.

CARTER: Basically, I think it causes spasms – I have to check. I just don’t; it’s just a question I always ask – if you’ve ever had gallbladder problems, if you ever had gallstones; and then, “Oh, ok”. I mean it’s just something that you have to watch.

DR. WENTZ: Mm-hmm.

CARTER: It’s not an absolute rule out like breast cancer or to me, smoking. If a woman comes to me and they’re smoking now, I would not want to do hormone therapy unless they would quit.

DR. WENTZ: Yeah, and I totally agree with you on the smoking and the breast cancer. Now, for those patients, when they still continue to have symptoms, what’s kind of like your back up plan for them? You said you have some great tricks up your sleeves that you sometimes will figure out how to address those symptoms.

CARTER: Well, I mean – and by the way, I’ve had classes on every kind of adrenal fatigue or adrenal management. I mean I probably have seen every program on adrenal fatigue and your program is the cleanest, neatest, most simple. You really have a nice way, and in your book, too, of streamlining things and getting down to the nuggets, the important things. So, I use your adrenal program now.

DR. WENTZ: Thank you. Thank you. I appreciate that. And so, do you do fine with DHEA and pregnenolone? Would you consider those bio-identical? Would you put them in that category?

CARTER: Oh yes, absolutely. And pregnenolone turns into progesterone pretty directly. So, if we have a patient under adrenal fatigue, we try to balance pregnenolone with the DHEA. And, I do have to go to commercial things like if I have a breast cancer patient. I mean then I might be forced to use all the things like the antidepressants or gabapentin or some of the things such as the SERMs, you know, Raloxifene.

DR. WENTZ: Hm-hmm

CARTER: So, it’s neat that I’ve seen all of these things develop, and I’ve kind of put them in place where I place a therapy.

DR. WENTZ: And I really think that’s the best way to approach a patient because I personally believe that dogmas are very dangerous. So, if you’re saying that medications are the only way, or natural is the only way, you’re really doing a person a disservice because it should be what’s the right way for that person. Like, what are they going through right now; what can work best for them; and to really be the kindest and most compassionate to our patients and ourselves. We want to be pulling from all of the resources we can find, not just from one little bag of tricks that we have.

CARTER: Oh, I mean, yeah. I’m not married to any therapy. I know bio-identical but I also know traditional Chinese medicine and acupuncture. And obviously, you and I are both in a tradition of allopathic medicine and nothing that’s not FDA approved. That’s why you want to have a good practitioner, someone that will give you individual therapy and isn’t tied to one therapy.

Symptoms of hormone imbalance

[00:25:19]
DR. WENTZ: Yeah, I totally agree with you and I so appreciate that about you – that you really look at everything that’s involved. Now, with respect to symptoms of hormone imbalance – So, we know that women with thyroid disease just struggle with a lot of symptoms, in general. But, how would they know that they need to kind of think about and tune in more to their female hormones?

CARTER: Well, if it’s life modifying; if their hormones symptoms are life modifying, then we have to look into that. I spend a lot of time in my interview. I have a 12-page piece of information that I gain from them and I go through all the symptoms and see if they are hormonal, or if not. But yeah, the confusion is stress, thyroid, metabolic issues, thyroid issues, autoimmune and you have to work through each one of those things. It always seems like number one thing with women because they are … and I sympathize with them. My normal patient is either perimenopause or menopause. So they have their parents they’re taking care of on one side. Their children, they’re taking care of on the other side.

DR. WENTZ: [Inaudible]

CARTER: Yeah. They probably have a job and then they have a marriage, and then they don’t feel well. And, it’s just incredible so a lot of it is stress management first. And that hurts your thyroid, and then your hormones. So, it’s around, around, around. It’s a balance.

[00:27:32]
DR. WENTZ: Yeah. Yeah, it really is. It’s kind of, I think an important thing is tuning in into your body and figuring out, to kind of listen to it, and trying to get on the right path, right?

CARTER: Well, and then, like as far as the percentage, I mean the biggest one is vaginal dryness. Then you have sleep issues. We talked about hot flashes and night sweats, and libido. And there’s a time to cure on those. So, like as far as hot flashes, I know that my therapy within 10 to 14 days if it’s not the right therapy. Let’s assume that we have the adrenals solid and the thyroid solid, and all I’m working with is the bio-identical or with the hormones, then 10-14 days if the hot flashes aren’t resolved, I know I’ve got to change those. And interestingly, it can be too much hormone because then you get a refractory receptor. So that’s what happens with a lot of obese patients. They haven’t balanced out their estrogen because they have so much estrogen coming out of them that they’re getting hot flashes, and why would that be because they have enough estrogen stored in their adipose tissue. So the receptors become refractory. Let’s say foggy thinking is huge in women. That can be cured overnight. As a matter of fact, I’ve had women call me. The next day they put the patch on and the next day they go, “Oh my God, it was like going blind. I didn’t know I was so bad.”

DR. WENTZ: Estrogen deficiency, the foggy thinking.

CARTER: Yeah, estrogen deficiency. Yeah, and there’s various symptoms are tied to deficiencies. And I would say libido is one that takes a while. It’s usually something that once you have all the hormones stabilized. Then, you see if there’s a relationship problem; if there’s a body self-image problem, or if it’s just you can lose feeling…

Low Libido

[00:30:16]
DR. WENTZ: Now, what works for libido in your experience? It’s one of those things that’s a little bit longer to pick up.

CARTER: It’s much longer, and again, you have to heal the adrenals and the thyroid. I mean that’s really, really… and then you got to really look at dyspareunia which is like the mechanical problem, so it’s dryness. Usually, we use a vaginal estrogen there. Again, I mentioned DHEA. There’s actually a DHEA commercial product coming out. It’s in stage 3 investigation, and that would be great for cancer patients, for vaginal dryness. We’ve been making it for about 20 years. But, what I’ve done, I’ve also applied testosterone. You have to look at testosterone levels, and not every woman needs testosterone. You really have to find out what your levels are. But if you detect a low level, you can give testosterone. I use topical, topical is better than oral. You can also use it by lozenge and I’ve even had it directly on the vagina. That works very well in the right dose. And there’s my favorite therapy of all is, I think I alluded to it, is vaginal therapy with estrogen and testosterone. It has a lot of success rate. I’ve learned it years ago and I’d seen quite a number of my practitioners use it. And, some women say it’s messy. You use a 1 ml amount so it’s like a fifth of a teaspoonful rubbed right on the vaginal tissues. Some feel that it’s messy and they don’t want to do it. But the ones that do do it really like it. And, I’ve used testosterone lozenges under the tongue, just like a Viagra, kind of, and that’s been successful. And then there are various creams that I’ve invented with many different ingredients like testosterone and niacin, and I think I had [inaudible] in there and l-arginine.

DR. WENTZ: I think you had something that you called Joy cream and it was a mixture.

CARTER: Right. I called it a Joy cream.

[00:33:16]
DR. WENTZ: Different compounds, and that works. And then, very low side effects as well, right?

CARTER: Really nothing except irritation. So, I’ve used that for many years. I kind of put that together, and it was nothing but; I just looked at everything on the market and said, “Let’s just throw it all together”, and it kind of worked. I mean, you know yourself there are different receptors and you just never know what receptor is going to be triggered. It’s just like when we make a number of things, I just sent one of my friends, for post-traumatic pain, a topical pain medicine and that’s how we did that one because there are some many receptors. So just throw everything into the cream and it seems to work out.

[00:34:12]
DR. WENTZ: Yeah. I feel like that kind of pharmacology is such as a lost art and I know you’ve formulated and created so many amazing products that will help people over the years.

CARTER: And I think that was the success for our practices that we were inventive and we found a way to do things. The gentleman that started the compounding practice with me, he liked to tinker with these compounds. So, I would answer the phones and pick the women’s questions and he would tinker with the formulas and get them right – “Why don’t we try this? Why don’t we try that?”

DR. WENTZ: And then there’s a lot of different mechanisms. So, you’re looking at increased blood flow and all these other things that can improve the experience, right?

CARTER: Right. I mean nerve-ending sensitivity increase blood flow. There is a commercial product that just came out, Addyi, and it’s an oral tablet you take every day, it’s kind of expensive. There’s a card that you can get it for $15 or something but you can’t drink alcohol with it.

DR. WENTZ: And you know, I went to a pharmacist continuing education meeting this past January and they were talking about that product. It was like, they were like, “You can’t drink with it” and that’s fine. Not everybody needs to drink. And then you have to take it every day, and you get all these side effects. And then you’ve got all these issues with it, and come to find, it was like basically you had one more pleasurable experience in like a month or maybe in two months. It was like the data behind it was just so limited that I was like, you wouldn’t even bother going through all these different side effects to have this one commercial product where the product that you developed are just like targeted and they work topically, and they’re not working all over your body to cause so many different [inaudible 00:36:17] effects.

CARTER: Right. I mean even commercially, they’ve gone after that market. Procter and Gamble had a product in the early 90’s, testosterone topically and they tried to get it on the market. No, this was after the Women’s Health Initiative. Now, I can remember. And they spent a lot of money trying to get it on the market and it just, for whatever reason it didn’t get on the market. And again, I think women are marginalized so that when this came up, there are so many Viagra commercials and Cialis commercials. I think they just had to approve this. There are some more in the pipeline. I’ve seen the research. There’s an injection that’s going to come through and a couple of others. But yeah, I think this had to be rammed through because women were saying, “Hey, what about us?” But at least we have something in the market.

[00:37:29]
DR. WENTZ: It’s nice to have something at the market and I appreciate the effort, but at the same time the kind of pharmacology that wakes me up in the morning, that got me through pharmacy school, is a lot of the stuff that’s off-label. So like non-FDA approved uses of medications and compounds because there is actually a method of solving problems. So, my latest hashtag is, “treat cures not customers” because when you take a daily pill, you have to keep taking that to support your libido; whereas, with the lifestyle changes and then the topical creams, you can use that as needed. You don’t have to be on it day in and day out.

CARTER: Right.

DR. WENTZ: So, thanks for sharing that experience; just nice to have a little bit of pharmacist discussion back and forth, and always, the politics behind it as well as the stuff that’s out there.

CARTER: Well, and again, women are just marginalized. I mean why is so much ads space given to Cialis, and what are these poor women going to do? I mean, to me that’s crazy.

Estrogen dominance

[00:38:44]
DR. WENTZ: Mm-hmm, right. And so we talked about hormone imbalances and low libido, and a lot of times these are issues that are from inadequate hormones. But there’s also the problem of estrogen dominance which isn’t actually like, you can have low hormones and have estrogen dominance, right? So, can you talk about the symptoms of that and then how that all works and tie in to women’s health?

CARTER: Yeah. I’ve seen that in many, many ways. First of all, the symptoms of estrogen dominance – one of the big things is if you can get your rings on and off. And that’s kind of a bloating thing; bloating, spotting, bleeding, breast tenderness, things like that. Just think of just before your period – what that is like – because just before your period is when your progesterone levels dive. The support for the endometrium is not there so your endometrium starts shedding, and that’s a period of estrogen dominance. So, a woman would know what their estrogen dominance feels like just before their period – if they’re irritable, whenever they see breast tenderness is a very big thing. And there is possibility to be estrogen dominant without having a whole lot of hormones. I mean I’ve seen that. The typical blood test that I get in postmenopause is low estrogen but zero progesterone, and that’s explained. Progesterone comes from ovulation. So, if you don’t get any progesterone, you’re going to be estrogen dominant in menopause. And testosterone levels can be up or down also. Testosterone is a metabolite of estrogen. They equalize. Sometimes you can be metabolizing your testosterone to estrogen or the other way around. So, you might have a woman that has facial hair, bloating, irritable. And sometimes the cure to that is just adding some progesterone and balancing it out. And then you try to metabolize or clear out some of the estrogen that is recirculating. And you and I know all about that with the liver and recirculation of and toxins. Well, estrogen is a toxin, too if it’s oxidized and not eliminated especially the – a poor quality estrogen is the estrone. That is really the worst estrogen to have in your body because it has more to do with proliferation than the other two estrogens. There are three estrogens – estriol, estradiol, and estrone; and estrone is the one that has the most proliferation possibility. It’s the one that can be metabolized the most to profilerative hydroxy. We don’t want to go into that product.

[00:42:28]
So, when the liver processes your estrogen to estrone and it’s not gotten rid of, it’s recirculated and it normally stays in the fats. So, you have another; really you have another organ that’s endocrine organ in you that’s storing the toxins, not only – we’ve had that discussion before – but also estrogen which is actually a toxin at that congener of estrogen. So, it’s important to balance the estrogens with progesterone, and then make sure they’re not recirculating, and recognizing. But one thing that I have seen most prominently is with oral contraceptive use and estrogen balance because many of them are dominant with estrogen, and that can affect the thyroid. And that’s one of your hallmarks in your book – getting off of oral contraceptives. So, it’s mainly, sometimes with the estrogen dominance in postmenopausal, you’re not really threatened with estrogen dominance with any kind of perimenopausal use of estrogen because it’s ten times less than the oral contraceptives. So, it’s mostly a supplement. It’s not on the order of oral contraceptives.

[00:44:22]
DR. WENTZ: So, women who take oral contraceptives [inaudible 00:44:25] that women have greatest risk for estrogen dominance in your opinion.

CARTER: I would think so. Yeah. And I’ve seen it clinically.

Tests for hormone imbalance

DR. WENTZ: You mentioned testing, so are there blood tests or saliva test? What kind of test do you recommend?

CARTER: Well, yes, I’ve dealt with every kind of test you can get. Normally, the doctors that refer to me give me the blood tests, and that’s a good starting point. It mainly gives me the relationship of the hormones to each other. The DHEA in the form of DHEAS is a very good test in the blood. Testosterone, and this is all controversial; testosterone – they actually brought the testosterone testing methods to the women and it’s a man’s test for their testosterone. But it seems to be; clinically to me it seems to be accurate. So, DHEA and testosterone are fairly accurate in the blood. And estrogen and progesterone are accurate as far as the mix of the hormones. I also like to see the sex hormone binding globulin which is the globulin that rounds around and binds estrogen and testosterone, and in that you can find out if the woman has a lot of estrogen or a lot of testosterone. The globulins are probably up. So, if you can release those globulins, you can get a better control. So there’s that kind of therapy and you use some herbs for that or you switch estrogens for that. And it’s always a good thing to get a better blood level with something that’s already existing, and then trying to put something back in.

[00:46:45]
Then there is a saliva test. A lot of people know about saliva testing. There’s blood spot testing which I’ve used a combination of saliva and blood spot. And then, there’s urine testing. I know some practitioners that use urine testing. And the metabolites – I don’t have that sophistication for urine testing. And maybe because I don’t have that sophistication I tend not to use it, but I do know, I’ve filled in prescriptions for practitioners that do very well using urine testing. But I saw a presentation by an expert in our field that it seems to show that saliva and/or saliva and blood spot tracks most of our doses pretty closely. The downside of the saliva and urine testing is that it’s an out of pocket expense usually. And, what can you do if you want to get good, accurate information? I will use a blood test and I will – because really, the refinement of therapy is with symptom relief. But if I can’t symptom relief, then I will go to a situation where I’ll use a saliva test or a saliva-blood spot test.

[00:48:23]
DR. WENTZ: Mm-hmm, mm-hmm. Now, are there labs that you like to use, like brand named labs or…?

CARTER: Yeah. I mean I’m hooked into all of them. I’m hooked in the ZRT Labs. I love them. I’ve used that forever. Genova, I’ve used them because of the GI test that they have, and they’re very good with trying to bill for insurance. I mean again, I just use whatever lab that will give me the best information and then, the patient can get the best price from. And I try not to, I’d stay away from the pricing in that because I want to have people pay me for my service. I don’t want to try to sell lab tests and to me, I don’t want to be seen as a practitioner that’s pushing lab tests. I only ask for a lab test if I can use it.

DR. WENTZ: Absolutely.

CARTER: And if I can get by with just using symptoms, and not costing a lot of money out, I’ll try to use the symptoms.

DR. WENTZ: Yeah, I totally agree with you. It’s like if the results are not going to make a difference then don’t do the test, right?

CARTER: Right, right.

Internet information

[00:49:47]
DR. WENTZ: The other question I had for you was with being in internet age, how do you handle all the information that’s out there?

CARTER: I’m glad you asked that. Yeah, because there are a lot of rumors, a lot of untruths and it’s just incredible. I think what I do is I try to explain compounding. I was looking at the Endocrine Society, they said that a third to a quarter of the hormone therapy now is compounding.

DR. WENTZ: Wow!

CARTER: Yeah. That’s an incredible amount, and they’re kind of worried about it because it’s off their purview because they don’t understand compounding and they don’t feel that compounding is valid; that the medications aren’t FDA approved. And I’ve heard it so many times, but if you go into a hospital and you need an IV, that’s a compound. It’s made with two FDA approved medications. You put them together. Yeah, there’s a commercial IV’s, but not many. And, the dose is adjusted to the patient. I mean, IV’s are prescribed with weight, kidney status, liver status, and even your race goes into what you prescribe with an IV. So, you don’t go into these compounding things lightly, and it’s the same technology in a compounding pharmacy. It’s not taken lightly. And the thing about it is like you do – some of these diabetics that we did deal with, they’re compounding. If they’re mixing insulins, that’s a compound and it’s very common for a diabetic patient to mix insulins together in the same syringe and shoot it. So, that’s a compound. So, everything is made, a compound is made with FDA approved chemicals, put together for specific patient, based on their symptoms and based on your experience, and also based on literature. There’s a lot of literature that is out there. No, it’s not 500,000 patients, but there are significant amounts in of this study which would be the amount of people that they studied, are in hundreds and thousands in some of these things.

[00:53:03]
And then the other thing about compounding is they’re not tested for absorption. Well, the major compounding association do testing on the absorption of their hormones. So, I read some of these things. I read everything and I’m puzzled by, in the statements they’re making, and they’re not doing enough research to make those statements.

DR. WENTZ: Oh, thank you so much for sharing that. I just feel like there’s a lot of misinformation out there about compounding. Sometimes I get scared because I feel like that big organizations want to take compounding away and compounding helps so many people.

CARTER: Well, yeah. I mean right now, you know yourself that we prescribe an antibiotic or a blood pressure pill whether you’re 50lbs. or 500lbs.; just like IV’s, no accommodation for anything. And I try to have enough information from my patients so that they can find good information and be able to make an informed judgment, and I don’t push anything on anyone because if they’re not comfortable with the therapy, I’m not going to push it.

Finding a compounding pharmacy

DR. WENTZ: I appreciate that about you. And now, I can really chat with you all day but I know you’ve got places to be in and I really appreciate you taking the time to chat with me. So, final question is how do you find a compounding pharmacy and what should people look for?

CARTER: Well, you want to find a pharmacy that’s in the major organizations. There are two major organizations. There’s Professional Compounding Centers of America and you could find them at www.pccarx.com, put in your zip code. The other one is International Academy of Compounding Pharmacist and that is IACP, and that is www.iacprx.org. And then there’s Further Accreditation and it’s www.pcab.org, and they accredit compounding pharmacies. But just generally, you want to look at the pharmacy – have they been in business a long time? What’s their status in the community? How do the people present themselves? Who do they have on the staff? Do they mentor people from the university? Are they active in the community? So, all those things are important to me, and probably there’s social media would tell you how good the pharmacy is but I don’t know anything about that.

DR. WENTZ: Well, Carter thank you so much for being here with me and thank you so much for sharing some of your wisdom with us. I really appreciate you taking this time and I really appreciate the work that you’re doing.

CARTER: Well, thank you. Thank you very much.

DR. WENTZ: And everybody at home. I hope that you enjoyed and you got as much value from Mr. Carter Black as I did.

[end of audio and transcript]

To learn more about Carter Black, RPh, please visit www.thyroidpharmacistconsulting.com