Over the years, benign prostatic hyperplasia has been known by many names: benign prostatic enlargement, benign prostatic hypertrophy, prostatism, or bladder outlet obstruction. Today, the accurate name is benign prostatic hyperplasia (BPH).

Pathology: What Is BPH?

Hyperplasia (excess growth) in the prostate compresses the narrow urethra that passes through it, and may also lead to thickening of the lower bladder wall. In turn, this leads to a condition called chronic bladder outlet obstruction, where urine flow from the bladder is reduced or intermittent (starts and stops). Complications include bladder sensitivity, incomplete emptying of the bladder, urinary retention, renal (kidney) insufficiency, recurrent urine infections, blood in the urine, and kidney stones.

Causes and Risk Factors

The exact cause of BPH is uncertain, but it’s strongly linked to an imbalance in male hormones. Research suggests that certain risk factors make it more likely for men to develop BPH, including:

• Increasing age
• Abdominal obesity
• Metabolic syndrome and diabetes
• Smoking
• High blood pressure
• Prostatitis (prostate inflammation)
• Lack of physical exercise.

BPH Symptoms

In the early stages, a man may be blissfully unaware that he has BPH, as onset is usually gradual. When symptoms do develop, they can become very bothersome and interfere significantly with daily life.

BPH is known to cause lower urinary tract symptoms (LUTS), but it’s by no means the only cause. Potential complications of obstructive BPH include:

• Acute urinary retention: A sudden onset complete inability to pass urine, accompanied by severe pain. This is a medical emergency: Go to the ER immediately.
• Abnormal kidney function detected with a blood test. This is a warning sign of impending renal failure.

It is important to report these symptoms to your doctor. Prompt diagnosis and treatment usually results in better outcomes.

Screening

Your doctor may recommend a digital rectal examination (DRE) as part of your annual medical examination. While many men find it unpleasant, a DRE is an easy and inexpensive screening tool for possible BPH. In carrying out the DRE, your physician may pick up enlargement of the prostate before you’re even aware of its presence. You may also be offered a PSA blood test as part of screening, but this is to screen for prostate cancer, not BPH.

Diagnostic Evaluation

The American Urological Association (AUA) offers guidelines for testing and diagnosis of BPH:

Basic Evaluation. Full medical history, including symptoms, medications, and past surgeries.

• Full physical examination of all body systems, including a DRE.
• Symptoms assessment
• Urine test to look for infection, blood, glucose, and perhaps biomarkers for prostate cancer.
• Blood test to look at general health markers, and a PSA blood test to check for cancer.

Advanced Investigations. Depending on the outcome of basic testing, your doctor may recommend:

• A urinary flow test: measures the speed of urine flowing over time.
• Urinary frequency and volume charts: a personal record of how much and how often you urinate.
• An ultrasound: looks for residual urine and prostate size and to look at the surrounding organs.
• A catheter test: detects residual urine in bladder after emptying.
• An intravenous urogram: looks for urethral obstruction. Contrast dye is injected into a vein; it then passes through the kidneys, into the ureters, bladder, and, finally, urethra.
• Cystoscopy: uses a flexible scope with a camera, which is inserted into the bladder through the penis to check for obstruction in the urethra.

How Does BPH Progress?

The progression of BPH is extremely variable. Some men get mild symptoms that plateau and do not progress. Some experience a slow but steady deterioration. Others suffer a rapid progression into acute urinary retention—an inability to urinate, which is rare but very serious. The prostate can vary in size from that of a walnut to the size of an orange. BPH can be more severe and progressive in African-American men, although it is not more common.

BPH Treatments

Treatment of BPH depends on how bothersome the symptoms are. Men who work in environments where they can go to the bathroom frequently and with little disruption may barely notice the symptoms. For men who have busy, active lives or travel frequently, even mild symptoms can be an absolute nuisance. You know you have a problem when you dread the “Fasten Seatbelt” sign on an airplane or have to sit on the end of the row in the movie theater!

Step 1: Watchful Waiting and Lifestyle Change

Watchful waiting is a strategy commonly used for men with BPH that’s tolerable within their everyday lifestyle. For most men with mild BPH, disease progression is slow. It is very hard to predict who will go on to have significant symptoms. Provided that symptoms do not worsen rapidly, an annual review with a urologist is recommended.

This watchful waiting period is the perfect time to implement lifestyle changes, which may reduce the risk of progression and make symptoms more bearable.

Chapter 1 contains ­comprehensive advice on changes that might reduce the risk of BPH and improve symptoms. Here’s a quick recap, with BPH-specific recommendations:

• Improve your diet: It may help reduce symptoms of BPH by calming inflammation, reducing abdominal fat, and stabilizing blood sugar control.
• Exercise regularly: Exercise may reduce the impact of BPH, especially bladder control and nocturnal symptoms.
• Practice stress reduction and relaxation techniques: These may reduce anxiety and frequency of urination.
• Avoid decongestant and antihistamine medications: The ingredients may tighten the urethra and reduce flow.
• Don’t rush bathroom trips: Relax and don’t be impatient with your flow. Take your time to completely empty your bladder; this will save you from having to make another trip soon. Urinate when you first feel the urge. Some men find it helpful to “double void”—that is, to urinate a second time when you feel like you’re done, as this can help completely empty the bladder.
• Reduce fluid intake late in the day: Avoiding caffeine and alcohol consumption in the evening may reduce the need to urinate during sleep hours.
• Plan ahead: If you are about to take a flight or attend a long meeting, reduce fluid intake an hour before and avoid caffeine and alcohol.
• Stay warm: A cold environment can increase the need to urinate.

Please note: If you have underlying medical conditions such as heart disease, diabetes, or cancer, discuss lifestyle changes with your medical practitioner.

Step 2: BPH Medications

If lifestyle changes do not help, or if symptoms become bothersome, the next step is to try medications.

There are three types of medications approved by the FDA for BPH treatment:

• Alpha-blockers
• 5-alpha reductase inhibitors (5-ARIs)
• PDE5 inhibitors

Preliminary research suggests that these drugs improve symptoms in 30 to 60 percent of men taking them, but it is not yet possible to predict who will respond to which therapy.

Alpha-Blockers. These oral medications have two effects. First they widen (dilate) arteries to improve blood flow. Next they relax muscles, including those of the bladder outlet, to improve urine flow and bladder emptying. They provide fast relief, working within days of commencing treatment. They provide symptom relief but do not slow the progression of BPH.

• Examples: Non-selective alpha-blockers: Prazosin (Minipress), terazosin (Hytrin), doxazosin (Cardura). Selective alpha-blockers (less effective on blood pressure): Alfuzosin (Uroxatral), silodosin (Rapaflo), tamsulosin (Flomax).
• Potential side effects: Alpha-blockers may cause side effects such as hypotension (low blood pressure), dizziness, and possible fainting. Blood pressure should be monitored; irregular heartbeat (fast heartbeat or fluttering in chest) or chest pain; ejaculation problems; priapism (painful erection lasting four hours or more); tiredness or weakness; swelling of hands, feet, or ankles; headache; nausea or stomach upset; allergic reaction; and, a rare, but serious complication can occur with cataract surgery, so should be avoided if surgery is planned.

5-Alpha Reductase Inhibitors (5-ARIs). These oral medications work to reduce prostate volume, which in turn relaxes pressure on the urethra, helping to reduce symptoms. Taking 5-ARIs is useful in men with significant prostatic enlargement and elevated PSA levels. One disadvantage is that they take months to show improvement, requiring follow-up three months into treatment.

• Examples: Dutasteride (Avodart) and finasteride (Proscar).
• Potential side effects: Side effects are uncommon but may include breast enlargement and tenderness, impotence, decreased libido (which may continue after treatment stopped), and reduced semen volume. Because 5-ARIs can lower PSA levels, they can complicate the interpretation of PSA screening results.

Combination Therapy. As alpha-blockers and 5-ARIs have different mechanisms, treatments have emerged that combine the two, thus relieving symptoms while the somewhat slow disease regression occurs.

• Examples: Jalyn combines dutasteride and tamsulosin.

Phosphodiesterase-5 Inhibitors (PDE-5s). PDE-5s relax the smooth muscle in the penis and improve blood flow. They are primarily used to treat erectile dysfunction, but can also help with BPH symptoms. They should not be used by men taking nitrates for chest pain (known as angina), and should be used cautiously in those taking an alpha-blocker.

• Examples: Tadalafil (Cialis) is an FDA- approved BPH treatment. Sildenafil (Viagra) and vardenafil (Levitra) also may be helpful.
• Potential side effects: Headache, indigestion, stuffy or runny nose, back pain and muscle aches, bluish or blurred vision, an erection that will not go away, sudden decrease, or loss of vision or hearing (rare).

Antimuscarinics. For men with BPH and an overactive bladder, antimuscarinic drugs may relax the bladder and reduce symptoms of frequency and urgency. They are available as a pill, gel (Gelnique), or patch (Oxytrol). They do not alter the progression of BPH. They can be used alone or with alpha-blockers and 5ARIs.

• Examples: Darifenacin (Enablex), fesoterodine (Toviaz), oxybutynin (Ditropan XL, Gelnique, Oyxtrol), solifenacin (VESIcare), and tolterodine (Detrol).
• Potential side effects: Dry eyes and mouth, constipation, dizziness, and headaches. They can also lead to a decline in cognitive and physical function, so they need to be used cautiously in the elderly.

Beta-3 Adrenergic Agonists. These can help with overactive bladder and urinary incontinence, as they relax the bladder muscle and improve bladder volume. They should be used with extreme caution in men with high blood pressure, kidney or liver disease, and bladder outlet obstruction.

• Examples: Mirabegron (Myrbetriq)
• Potential side effects: Cold-like symptoms, urinary tract infections, constipation, abdominal pain, headache, and an increase in blood pressure and heart rate.

Botulinum Toxin. Best known for its use in cosmetic surgery, botulinum toxin (Botox) can be useful in managing an overactive bladder. It is injected laparoscopically to relax the muscles of the bladder and prostate, and may improve urinary flow and lower urinary tract infections (LUTIs).

• Examples: Onabotulinumtoxin A
• Potential side effects: LUTIs, urinary retention, fatigue, and insomnia.

Anti-Inflammatory Drugs and Supplements. Emerging evidence links chronic inflammation, obesity, metabolic syndrome, and erectile dysfunction with BPH. There is potential for the use of nonsteroidal anti-inflammatory drugs (NSAIDs), statins and antioxidant supplements in the management of BPH, but the body of research is small and inconclusive.

Herbs and Natural Supplements. Natural remedies have been used to treat urinary symptoms for centuries, long before modern drugs and surgical treatments were developed, but do they work?

The short answer is that we’re not sure. The majority of urologists and medical authorities such as the American Urological Association and the Centers for Disease Control and Prevention do not recommend the use of natural remedies for BPH. This doesn’t mean they don’t work, however; it just means that the evidence is not strong enough to recommend treatment.

There are several problems with evaluating and recommending natural remedies. The quality of herbal and natural supplements varies and is poorly regulated. Unlike surgical and drug treatments, there’s very little funding for natural treatment research. The studies that do exist tend to be small and of varying quality.

Herbal remedies, like drugs, can cause side effects and interact with other medications. That said, there are several herbs and natural supplements for which there is at least some evidence of benefit:

• Beta-sitosterols: A literature review in 1999 in the well-respected Cochrane database found that beta-sitosterols were “well tolerated and improved urinary symptoms and flow measures in men with mild to moderate BPH.” Beta-sitosterols are plant compounds thought to reduce inflammation; they occur naturally in pumpkin seeds, soy, flaxseed, peanuts, olive oil, and some other plant foods.
• Pygeum or African plum extract (Pygeum africanum): This herb—extracted from tree bark—is “the most popular treatment for symptoms of BPH in France and is commonly used for this condition in Italy and the United States.” It has been well researched and shown to reduce inflammation and improve hormone balance. Several studies show statistically significant improvement in urinary symptoms.
• Grass pollen (Secale cereale), such as Cernilton: There is a small body of evidence that this may improve BPH symptoms.
• Saw palmetto (Serenoa repens): This once-promising herbal treatment has lost favor in recent years as larger research studies have failed to prove its effectiveness.

If you’re in the watchful waiting stage of BPH management, you may wish to consider trying natural supplements as part of an attempt to improve general health and reduce symptoms. However, if you have other medical conditions such as diabetes, heart disease, or allergies or are taking any medication, it is vital that you talk to your medical practitioner before trying these treatments.

Always buy supplements from a reputable source, and ensure that they are verified by a reputable organization such as the U.S. Pharmacopeia. The supplement industry is unregulated in the U.S., and scams frequently emerge.

Step 3: Surgery

Despite watchful waiting, lifestyle changes, and drug treatment, some men develop symptoms that warrant surgery. Side effects are common, so surgical intervention is not to be entered into lightly. The aim of surgery is to reduce the pressure on the urethra from the enlarged prostate. This in turn should improve urine flow and bladder emptying while reducing the risk of serious urological complications.

For many years, the mainstay of surgery for BPH has been transurethral resection of the prostate (TURP). TURP has the longest record of studies on risks and benefits, and for that reason other procedures tend to be measured against it. In recent years, a wide variety of new surgical approaches have emerged in an attempt to reduce complications and improve outcomes. This can make surgical options overwhelming and confusing for many men.

The decision will ultimately come down to your surgeon’s opinion and experience; your view on the treatment risks and benefits; your specific symptoms and how they impact your unique lifestyle; and what you can afford or your insurance company will approve.

Conventional BPH Surgeries

Generally speaking, conventional surgery is more invasive, has more complications, and likely requires a longer recovery period. The upside of conventional surgery is that symptom relief is often better and relapse is less common.

Transurethral Resection of the Prostate (TURP)

TURP is a surgical procedure used to treat urinary problems associated with an enlarged prostate.

TURP is performed under general or spinal anesthesia in the operating room. The surgery takes 60 to 90 minutes. An instrument called a resectoscope is passed into the penis through the urethra. There is no incision on the abdomen. A wire loop removes the prostatic tissue that is pressing on the urethra (debulking) and cauterizes (seals) the blood vessels as it cuts. The area is continuously flushed with a sterile fluid to remove debris and blood.

The TURP procedure has been around since 1909 but has been refined many times to reduce complications and improve effectiveness.

A hospital stay of one to two days is typical, and you’ll need to wear a urinary catheter for one to three days until normal urination returns. Patients can usually start to resume their normal activities toward the end of the first month. The recovery period is four to six weeks. Patients are advised to drink plenty, eat a healthy diet, and take laxatives in the first month postoperatively.

In 85 to 90 percent of men, TURP improves urine flow. In some, there is further growth of the prostatic tissue, leading to a return of symptoms and the need for further treatment. This is more common in younger men.

Potential complications can include:

• Bleeding: Blood in the urine (hematuria) is normal immediately after surgery but should resolve before discharge from hospital, not to return again. Significant hematuria, especially clots, is not normal and should be reported to the surgical team right away.
• Pain: In the early days after surgery, some men experience dysuria (pain during urination).
• Incontinence: Urgency, dribbling, and poor control of urine flow are normal but should resolve quickly, not to return.
• Sexual function: Problems occur in 30 percent of men postoperatively and may last up to a year. The main complication of TURP is retrograde ejaculation (semen backs up into the bladder), which can make it more difficult to father children. Erectile problems are also possible.
• TURP syndrome: This rare (less than 2 percent) but serious complication is caused by absorption of irrigation fluid into the bloodstream, which can lead to dangerously low sodium levels. Symptoms include confusion, nausea, vomiting, high blood pressure, and visual distortions. New and improved surgical tools and procedures have reduced this risk substantially.

As with all surgeries, complications do arise due to anesthesia, but these are rare. Serious complications occur in 5 to 10 percent of patients.

Adaptation of TURP. Transurethral electrovaporization of the prostate techniques (TUEVP or TVP) are similar to TURP but use an electrode to cut.

Transurethral Incision of the Prostate

TUIP is a less-invasive procedure than TURP with a shorter recovery period.

Transurethral incision of the prostate (TUIP) is similar to TURP. A resectoscope is inserted via the penis into the prostate, but instead of debulking the prostate, the surgeon makes small incisions into the prostate. That allows the urethral channel to expand, allowing improved flow of urine.

TUIP is reserved for milder cases of BPH and relatively small prostates. Because the prostate is not debulked, it may continue to enlarge, requiring further treatment. Eighty percent of patients report reduction in symptoms.

A urinary catheter is needed for up to a week, postoperatively. A hospital stay of one to three days is usual. Recovery is quicker than with TURP. Potential complications include the risk of urinary retention in the post-op period.

Open Prostatectomy

Open surgery is performed in rare cases of BPH where the prostate is very large and there are complications, such as a bladder diverticula (a small pouch protruding from the bladder) or bladder stones.

Open prostatectomy requires an incision in the lower abdomen, then an incision into the prostate. The surgeon then debulks the prostate and attends to other issues in the pelvis. A hospital stay of three to five days is usual, with a catheter inserted for at least two days. The accuracy afforded by the open surgery leads to excellent outcomes, and the need for further surgery is low.

Potential complications can include:

• Bleeding: Blood in the urine (hematuria) is normal in the immediate postoperative period but should resolve before discharge from hospital, not to return again. Significant hematuria, especially clots, is not normal and should be reported to the surgical team immediately.
• Pain: In the early days after surgery, dysuria (pain on urination) is common.
• Incontinence: Urgency, dribbling, and poor control of urine flow are normal but should resolve quickly, not to return.
• Sexual function: Erectile dysfunction is an issue in less than 5 percent of patients, as is retrograde ejaculation (when semen goes into bladder).
• Wound infection: Most post-op wound infections show up within the first 30 days after surgery.
• Overactive bladder: The need to urinate frequently, even when bladder does not seem full, is another potential complication.

Minimally Invasive Surgeries

The following techniques do not involve significant surgery or abdominal incision. These surgeries are performed using a scope (flexible tube) to destroy prostatic tissue. They can be carried out under general or spinal anesthesia, and as with any surgery there are anesthesia-related risks. Some procedures may be carried out in the doctor’s office, others in the operating room. Catheterization is usually needed for some time following surgery. Recovery time and hospital stays vary among patients, surgeons, and technique. The downside of these surgeries is that tissue can be destroyed, making it difficult to biopsy the prostate, meaning some early-stage cancers could be missed. Return of symptoms is more common than with conventional surgery.

In this fast-evolving field, new procedures are emerging each year; however, it takes time to prove their effectiveness and train surgeons. Conventional surgeries are also being constantly refined and improved, making it even more confusing to compare the pros and cons of each surgical option.

Vaporization Techniques

These surgeries use a flexible fiber-optic scope and high-energy sources to destroy the hyperplastic tissue causing pressure on the urethra. The main types are:

• Laser vaporization: Several techniques exist, all with subtle differences in technique and type of laser used.
• Transurethral electrovaporization of the prostate (TUEVP): This is often called the “button TURP” procedure. A tiny, round-tipped electrode is used to rapidly heat and vaporize overgrown prostate tissue and seal off blood vessels.
• Transurethral microwave therapy (TUMT): This is less common today, since it is slightly less effective than TURP and newer vaporization techniques. It may not require anesthesia but does require an overnight stay.
• High-intensity-focused ultrasound (HIFU): New technique, not yet well researched.
• Transurethral needle ablation (TUNA): In TUNA, tiny needles are used to heat and shrink the prostate from the inside with high-frequency radio energy. Research has shown TUNA is not very effective or long lasting, and it is generally no longer practiced or recommended.

Potential Complications of Vaporization.

Complications are less common than in conventional surgical techniques but include:

• Incontinence: Urgency, dribbling and poor control of urine flow are normal postoperatively, but should resolve quickly
• Passing debris is common in the days after the surgery
• Pain on urination (dysuria) is common in the first few days
• Retrograde ejaculation (semen going into bladder)
• Urinary tract infection
• Urinary retention is but more common than in TURP

Prostatic Artery Embolization (PAE)

This is a new procedure, lacking in long-term data. It can be done as an outpatient. A radiologist inserts a tiny catheter into the prostate, via the femoral artery in the groin.

Microscopic grain-like particles are used to block the blood vessels, causing the gland to atrophy (shrivel) and volume is reduced within a week. The developer of this procedure reports symptom improvement in 85 to 90 percent of patients, but further study is needed. Early research points to fewer long-term complications compared with TURP. In its 2018 practice guideline, the AUA recommended that PAE be used only in the setting of clinical trials and not in general practice.

Problems with urinary flow may worsen initially as the prostate becomes inflamed, but this passes.

Convective Water Vapor Energy Ablation (WAVE)

In the WAVE procedure, marketed as Rezu–m, the surgeon uses a fine needle to inject tiny jets of steam into the overgrown area of the prostate. Heat from the steam then leads to prostate shrinkage. WAVE is suitable for small to moderately sized prostates and can potentially reduce the risk of retrograde ejaculation or erectile problems, although its track record is still relatively limited.

Prostatic Urethral Stents

A “stent” is a small cylinder of mesh that forms a spring. It is inserted into the narrowed area of the urethra, forcing the channel to expand and allowing urine to flow more freely. It is a relatively safe procedure, but obstruction usually returns. Stents are useful in those men who are not fit for more invasive surgery.

Prostatic Urethral Lift (PUL)

In the PUL procedure, tiny stitches are placed in the prostate to compress and pull it away from the urethra to improve urine flow. The “lifts” are short lengths of monofilament—similar to fishing line—permanently implanted in the gland. You may see this marketed as UroLift, which refers to an FDA-approved device used to insert the stitches from inside the urethra. Early research points to fewer side effects, although it may not relieve symptoms as well as TURP and is limited to treating relatively small prostates.

BPH and Other Conditions

BPH can exist alongside other conditions of the reproductive or urinary tract. It’s important to get a thorough diagnosis to make sure you get the right treatments.

BPH and Cancer

There is conflicting evidence over whether BPH causes prostate cancer. A large systematic review concluded, “BPH is associated with an increased risk of prostate cancer and bladder cancer. The risk of prostate cancer is particularly high in Asian BPH patients.”

Experts urge caution, however, in interpreting such results. Other studies have found no increased risk. What is known is that BPH and prostate cancer share common risk factors such as advanced age, inflammation, and hormonal imbalance. The medical monitoring of men with BPH may lead to early diagnosis—a point when prostate cancer is often slow-growing and not life-threatening.

BPH and Erectile Dysfunction (ED)

Both BPH and ED increase with age and are often seen at the same time in men. Again, as with the BPH and cancer link, it is very hard to tease out what is cause and what is coincidence.

BPH, Urinary Problems, and General Health

BPH, isolated urinary problems such as nocturia, and sleep apnea are often seen in the same men. There is speculation that the reason for this is a shared cause: inflammation and poor general health.

The post 3. Benign Prostatic Hyperplasia appeared first on University Health News.

Over the years, benign prostatic hyperplasia has been known by many names: benign prostatic enlargement, benign prostatic hypertrophy, prostatism, or bladder outlet obstruction. Today, the accurate name is benign prostatic hyperplasia, or BPH, so we’ll use that terminology here.

Pathology: What Is BPH?

Hyperplasia in the prostate compresses the narrow urethra that passes through it, and may lead to thickening of the lower bladder wall. In turn, this leads to a condition called chronic bladder outlet obstruction, where urine flow from the bladder is reduced or intermittent. Complications include bladder sensitivity, incomplete emptying of the bladder, urinary retention, renal (kidney) insufficiency, recurrent urine infections, blood in the urine, and kidney stones.

Causes and Risk Factors

The exact cause of BPH has not been established but there is a strong association with an imbalance in male hormones.

Research suggests that certain risk factors are associated with BPH including:

• Increasing age
• Abdominal obesity
• Metabolic syndrome and diabetes
• Smoking
• High blood pressure
• Prostatitis (prostate inflammation)
• Lack of physical exercise.

BPH Symptoms

In the early stages, a man may be blissfully unaware that he has BPH, as onset is usually gradual. When symptoms do develop, they can significantly interfere with daily life.

BPH is known to cause lower urinary tract symptoms (LUTS), but it’s by no means the only cause.

Common symptoms include:

• Increased frequency of urination, often accompanied by passing dwindling volumes of urine.
• Urgency—the need to urinate right away.
• Difficulty in initiating urination.
• Dribbling of urine or leaking.
• Nocturia—the need to urinate at night.
• Poor stream or fluctuating force of urine. Some men experience an annoying stop-start flow.
• Incomplete emptying of the bladder—a feeling like you still need to go when you have just finished.

Potential complications of obstructive BPH include:

• Acute urinary retention: A sudden onset complete inability to pass urine, accompanied by severe pain. This is a medical emergency: Go to the ER immediately.
• Abnormal kidney function detected with a blood test. This is a warning sign of impending renal failure.

It is important to report these symptoms to your doctor. Prompt diagnosis and treatment usually results in better outcomes.

Screening

Your doctor may recommend a digital rectal examination (DRE) as part of your annual medical examination. While unpleasant, it is an easy and inexpensive screening tool. In carrying out the DRE, your physician may pick up enlargement of the prostate before you’re even aware of its presence. You may be offered a PSA blood test as part of screening, but this is to screen for prostate cancer, not BPH.

Diagnostic Evaluation

The American Urological Association (AUA) offers useful guidelines for testing and diagnosis of BPH:

Basic Evaluation

• Full medical history, including symptoms, medications and past surgeries.
• Full physical examination of all body systems, including a DRE.
• Symptoms assessment using a checklist, such as the AUA Symptom Index (see Chapter 1).
• Urine test to look for infection, blood, glucose, and perhaps biomarkers for prostate cancer.
• Blood test to look at general health markers, and a PSA blood test to check for cancer (see Chapter 2).

Advanced Investigations

Depending on the outcome of basic testing, your doctor may recommend:

• A urinary flow test: measures the amount of urine flowing over time.
• Urinary frequency and volume charts: a personal record of how much and how often you urinate.
• An ultrasound: looks for residual urine and prostate size and to look at the surrounding organs.
• A catheter test: detects residual urine in bladder after emptying.
• An intravenous urogram: looks for urethral obstruction. Contrast dye is injected into a vein; it then passes through the kidneys, into the ureters, bladder, and, finally, urethra.
• Cystoscopy: uses a flexible scope with a camera which is inserted into the penis to check for obstruction in the urethra.

How Does BPH Progress?

The course of progression of BPH is extremely variable. Some men get mild symptoms that plateau and do not progress. Some get a slow but steady deterioration. Others suffer a rapid progression into acute urinary retention—an inability to urinate, which is rare but very serious. The prostate can vary in size from that of a walnut to the size of an orange. BPH can be more severe and progressive in African-American men, although it is not more common.

BPH Treatment

Treatment of BPH depends on how bothersome the symptoms are. A man who works in an environment where he can go to the bathroom frequently and with little disruption may barely notice his symptoms. For men who have busy, active lives or travel frequently, even mild symptoms can be an absolute nuisance. You know you have a problem when you dread the “Fasten Seatbelt” sign on an airplane or have to sit on the end of the row in the movie theater!

Step 1: Watchful Waiting and Lifestyle Change

Watchful waiting is a strategy commonly used for men with BPH that’s tolerable within their everyday lifestyle. For the majority of men with mild BPH, disease progression is slow. It is very hard to predict who will go on to have significant symptoms. Provided that symptoms do not worsen rapidly, an annual review with a urologist is recommended.

This watchful waiting period is the perfect time for men to implement lifestyle changes, which may reduce the risk of progression and make symptoms more bearable.

Chapter 1 contains comprehensive advice on changes that might reduce the risk of BPH and improve symptoms. Here’s a quick recap, with BPH-specific recommendations:

• Improve your diet: may help reduce symptoms of BPH by calming inflammation, reducing abdominal fat, and stabilizing blood sugar control.
• Exercise regularly: may reduce the impact of BPH, especially bladder control and nocturnal symptoms.
• Stress reduction and relaxation techniques: may reduce anxiety and frequency of urination.
• Avoid decongestant and antihistamine medications: which tighten the urethra and reduce flow.
• Don’t rush bathroom trips: relax and don’t be impatient with your flow. Take your time to completely empty your bladder; this will save you from having to make another trip soon. Urinate when you first feel the urge. Some men find it helpful to “double void”—that is, to urinate a second time when you feel like you’re done, as this can help completely empty the bladder.
• Reduce fluid intake late in the day: avoiding caffeine and alcohol consumption in the evening may improve nocturnal symptoms.
• Plan ahead: If you are about to take a flight or attend a long meeting, reduce fluid intake an hour before and avoid caffeine and alcohol.
• Stay warm: A cold environment can increase the need to urinate.
• Please note: If you have underlying medical conditions such as heart disease, diabetes, or cancer, discuss lifestyle changes with your medical practitioner.

Step 2: BPH Medications

If lifestyle changes do not help, or if symptoms become bothersome, the next step is to try medications.

There are three types of medications approved by the FDA for BPH treatment:

• Alpha-blockers
• 5-alpha reductase inhibitors (5-ARIs)
• PDE5 inhibitors

Preliminary research suggests that these drugs improve symptoms in 30 to 60 percent of men taking them, but it is not yet possible to predict who will respond to which therapy.

Alpha-Blockers

These oral medications have a two-fold effect. First they dilate arteries to improve blood flow. Next they relax muscles, including those of the bladder outlet, to improve urine flow and bladder emptying. They provide fast relief, working within days of commencing treatment. They provide symptom relief but do not slow the progression of BPH.

Examples: Non-selective alpha-blockers: Prazosin (Minipress), terazosin (Hytrin), doxazosin (Cardura). Selective alpha-blockers (less effect on blood pressure): Alfuzosin (Uroxatral), silodosin (Rapaflo), tamsulosin (Flomax).

Potential side effects: Alpha-blockers may cause side effects such as:

• Hypotension (low blood pressure), dizziness, and possible fainting. Blood pressure should be monitored.
• Irregular heartbeat (fast heartbeat or fluttering in chest) or chest pain.
• Ejaculation problems.
• Priapism (painful erection lasting four hours or more).
• Tiredness or weakness.
• Swelling of hands, feet, or ankles.
• Headache.
• Nausea or stomach upset.
• Allergic reaction.
• A rare, but serious complication can occur with cataract surgery, so should be avoided if surgery is planned.

5-Alpha Reductase Inhibitors

These oral medications halt disease progression by shrinking the prostate, which in turn relaxes pressure on the urethra, helping to reduce symptoms. 5-ARIs are useful in men with significant prostatic enlargement and raised PSA levels. One disadvantage is that they take months to show improvement, requiring follow-up three months into treatment.

• Examples: Dutasteride (Avodart) and finasteride (Proscar).
• Potential side effects: Side effects are uncommon but may include breast enlargement and tenderness, impotence, decreased libido (which may continue after treatment stopped), and reduced semen volume. Because 5-ARIs can lower PSA levels, they can complicate the interpretation of PSA results.

Combination Therapy

As alpha-blockers and 5-ARIs have different mechanisms, treatments have emerged that combine the two, thus relieving symptoms while the somewhat slow disease regression occurs.

• Examples: Jalyn combines dutasteride and tamsulosin.

Phosphodiesterase-5 Inhibitors (PDE-5s)

PDE-5s relax the smooth muscle in the penis and improve blood flow. They are primarily used to treat erectile dysfunction, but can also help with BPH symptoms. They should not be used by men taking nitrates for chest pain (known as angina), and should be used cautiously in those taking an alpha-blocker.

• Examples: Tadalafil (Cialis) is an FDA- approved BPH treatment. Sildenafil (Viagra) and vardenafil (Levitra) also may be helpful.
• Potential side effects: Headache, indigestion, stuffy or runny nose, back pain and muscle aches, bluish or blurred vision, an erection that will not go away, sudden decrease, or loss of vision or hearing (rare).

Anticholinergics (Antimuscarinics)

For men with BPH and an overactive bladder, anticholinergic drugs may relax the bladder and reduce symptoms of frequency and urgency. They are available as a pill, gel (Gelnique), or patch (Oxytrol). They do not alter the progression of BPH. They can be used alone or with alpha-blockers and 5ARIs.

• Examples: Darifenacin (Enablex), fesoterodine (Toviaz), oxybutynin (Ditropan XL, Gelnique, Oyxtrol), solifenacin (VESIcare), and tolterodine (Detrol).
• Potential side effects: Dry eyes and mouth, constipation, dizziness, and headaches. They can also lead to a decline in cognitive and physical function, so they need to be used cautiously in the elderly.

Beta-3 Adrenergic Agonists

These can help with overactive bladder and urinary incontinence, as they relax the bladder muscle and improve bladder volume. They should be used with extreme caution in men with high blood pressure, kidney or liver disease, and bladder outlet obstruction.

• Examples: Mirabegron (Myrbetriq)
• Potential side effects: Cold-like symptoms, urinary tract infections, constipation, abdominal pain, headache, and an increase in blood pressure and heart rate.

Botulinum Toxin

Best known for its use in cosmetic surgery, botulinum toxin (Botox) can be useful in managing an overactive bladder. It is injected laparoscopically and relaxes the muscles of the bladder and prostate, and may improve urinary flow and lower urinary tract infections (LUTIs).

• Examples: Onabotulinumtoxin A
• Potential side effects: LUTIs, urinary retention, fatigue, and insomnia.

Anti-Inflammatory Drugs and Supplements

Emerging evidence links chronic inflammation, obesity, metabolic syndrome, and erectile dysfunction with BPH. There is potential for the use of nonsteroidal anti-inflammatory drugs (NSAIDs), statins and antioxidant supplements in the management of BPH, but the body of research is small and inconclusive.

Herbs and Natural Supplements

Natural remedies have been used to treat urinary symptoms for centuries, long before modern drugs and surgical treatments were developed, but do they work?

The short answer is that we’re not sure. The majority of urologists and medical authorities such as the American Urological Association and the Centers for Disease Control and Prevention do not recommend the use of natural remedies for BPH. This doesn’t mean they don’t work, however; it just means that the evidence is not strong enough to recommend treatment.

There are several problems with evaluating and recommending natural remedies:

• The quality of herbal and natural supplements varies and is poorly regulated.
• Unlike surgical and drug treatments, there’s very little funding for natural treatment research.
• The studies that do exist tend to be small and of varying quality.

Herbal remedies, like drugs, can cause side effects and interact with other medications. That said, there are several herbs and natural supplements for which there is at least some evidence of benefit:

Beta-sitosterols: One literature review in the well-respected Cochrane database found that beta-sitosterols were “well tolerated and improved urinary symptoms and flow measures in men with mild to moderate BPH.” Beta-sitosterols are plant compounds thought to reduce inflammation; they occur naturally in pumpkin seeds.

Pygeum or African plum extract (Pygeum africanum): According to Medscape, this herb—extracted from tree bark—is “the most popular treatment for symptoms of BPH in France and is commonly used for this condition in Italy and the United States.” It has been well researched and shown to reduce inflammation and improve hormone balance. Several studies show statistically significant improvement in urinary symptoms.

Grass pollen (Secale cereale), such as Cernilton: There is a small body of evidence that this may improve BPH symptoms.

Saw palmetto (Serenoa repens): This once-promising herbal treatment has lost favor in recent years as larger research studies have failed to prove its effectiveness.

If you’re in the watchful waiting stage of BPH management, you may wish to consider trying natural supplements as part of an attempt to improve general health and reduce symptoms. If you have other medical conditions such as diabetes, heart disease, or allergies or are taking any medication, it is vital that you talk to your medical practitioner before trying these treatments.

Always buy supplements from a reputable source: The supplement industry is unregulated in the U.S., and scams frequently emerge.

Step 3: Surgery

Despite watchful waiting, lifestyle changes, and drug treatment, some men develop symptoms that warrant surgery. Side effects are common, so surgical intervention is not to be entered into lightly. Surgery is recommended to those with these types of conditions and symptoms:

• Kidney damage due to inadequate bladder emptying and reverse flow of urine (it is only ever meant to flow down and away from the kidneys)
• An episode of acute urinary retention—complete inability to urinate, leading to bladder extension and extreme pain
• Frequent incontinence
• Bladder stones
• Recurrent bladder infection due to incomplete emptying
• Recurrent severe hematuria (blood in urine)
• LUTS that fail to respond to medication and significantly impact quality of life.

The aim of surgery is to reduce the pressure on the urethra from the enlarged prostate. This in turn should improve urine flow and bladder emptying while reducing the risk of serious urological complications.

Surgical Options

For many years, the mainstay of surgery for BPH was transurethral resection of the prostate (TURP). In recent years, a plethora of surgical interventions has emerged in an attempt to reduce complications and improve outcomes. This can make surgical options overwhelming and confusing for many men.

The decision will ultimately come down to your surgeon’s opinion and experience; your view on the treatment risks and benefits; your specific symptoms and how they impact your unique lifestyle; and what you can afford or your insurance company will approve.

There are two main types of surgery:

Conventional surgery:

• Transurethral resection of the prostate (TURP)
• Transurethral incision of the prostate (TUIP)
• Open prostatectomy.

Minimally invasive surgery:

• Vaporization techniques
• Prostatic artery embolization (PAE)
• Water vapor energy ablation (Aquablation)
• Prostatic urethral stents and lifts
• Neuromodulation.

Generally speaking, conventional surgery is more invasive, has more complications, and likely requires a longer recovery period. The upside of conventional surgery is that symptom relief is often better and relapse is less common.

Transurethral Resection of the Prostate

Procedure: Transurethral resection of the prostate (TURP) is performed under general or spinal anesthesia in the operating room. The surgery takes 60 to 90 minutes. An instrument called a resectoscope is passed into the penis through the urethra. There is no incision on the abdomen. A wire loop removes the prostatic tissue that is pressing on the urethra (debulking) and cauterizes (seals) the blood vessels as it cuts. The area is continuously irrigated to remove debris and blood.

The TURP procedure has been around since 1909 but has been refined many times in order to reduce complications and improve effectiveness.

A hospital stay of at least 24 hours (usually two to three days) is necessary, and a urinary catheter is needed for one to three days, until normal urination returns. For at least the first two weeks, heavy physical activity must be avoided. Light work can usually be resumed towards the end of the first month. The recovery period is four to six weeks. Patients are advised to drink plenty, eat a healthy diet, and take laxatives in the first month postoperatively.

TURP Outcome

Some 85 to 95 percent of men who undergo TURP report symptom relief. In some, there is further growth of the prostatic tissue, leading to a return of symptoms and the need for further treatment. This is more common in younger men.

Potential Complications

Bleeding: Blood in the urine (hematuria) is normal immediately after surgery but should resolve before discharge from hospital, not to return again. Significant hematuria, especially clots, is not normal and should be reported to the surgical team right away.

• Pain: In the early days after surgery, some men experience dysuria (pain during urination).
• Incontinence: Urgency, dribbling, and poor control of urine flow are normal but should resolve quickly, not to return.
• Sexual function: Problems occur in 30 percent of men postoperatively and may last up to a year. They include erectile dysfunction and retrograde ejaculation (semen goes into bladder), which can cause infertility.
• TURP syndrome: This rare (less than 2 percent) but serious complication is caused by absorption of irrigation fluid into the bloodstream. Symptoms include confusion, nausea, vomiting, high blood pressure, and visual distortions.

As with all surgeries, complications do arise due to anesthesia, but these are rare. Serious complications occur in 5 to 10 percent of patients.

Adaptation of TURP

Transurethral electrovaporization of the prostate techniques (TUEVP or TVP) are similar to TURP but use an electrode to cut.

Transurethral Incision of the Prostate

Procedure: Transurethral incision of the prostate (TUIP) is similar to the TURP. A resectoscope is inserted via the penis into the prostate, but instead of debulking the prostate, the surgeon makes small incisions into the prostate. That allows the urethral channel to expand, allowing improved flow of urine.

TUIP is reserved for milder cases of BPH, and because the prostate is not debulked, it may continue to enlarge, requiring further treatment. Eighty percent of patients report reduction in symptoms.

Catheterization is needed for up to a week, postoperatively. A hospital stay of one to three days is usual. Recovery is quicker than with the TURP. Potential complications include the risk of urinary retention in the post-op period.

Open Prostatectomy

Open surgery is performed in rare cases of BPH where the prostate is very large and there are complications, such as a bladder diverticula (a small pouch protruding from the bladder) or bladder stones.

Procedure: Open prostatectomy requires an incision in the lower abdomen, then an incision into the prostate. The surgeon then debulks the prostate and attends to other issues in the pelvis. A hospital stay of three to five days is usual, with a catheter inserted for at least two days. The accuracy afforded by the open surgery leads to excellent outcomes, and the need for further surgery is low.

Potential Complications

Bleeding: Blood in the urine (hematuria) is normal in the immediate postoperative period but should resolve before discharge from hospital, not to return again. Significant hematuria, especially clots, is not normal and should be reported to the surgical team immediately.

Pain: In the early days after surgery, dysuria (pain on urination) is common.

Incontinence: Urgency, dribbling, and poor control of urine flow are normal but should resolve quickly, not to return.

Sexual function: Erectile dysfunction is an issue in less than 5 percent of patients, as is retrograde ejaculation (when semen goes into bladder).

Wound infection: Most post-op wound infections show up within the first 30 days after surgery.

Overactive bladder: The need to urinate frequently, even when bladder does not seem full, is another potential complication.

Minimally Invasive Surgeries

The following techniques do not involve significant surgery or abdominal incision. These surgeries are performed using a scope (flexible tube) to destroy prostatic tissue. They can be carried out under general or spinal anesthesia, and as with any surgery there are anesthesia-related risks. Some procedures may be carried out in the doctor’s office, others in the operating room. Catheterization is usually needed for some time following surgery. Recovery time and hospital stays vary between patients, surgeons and technique. The down side of these surgeries is that tissue can be destroyed, making it difficult to biopsy the prostate, meaning some early-stage cancers could be missed. Return of symptoms is more common than with conventional surgery.

In this fast-evolving field, new procedures are emerging each year; however, it takes time to prove their effectiveness and train surgeons. Conventional surgeries are also being constantly refined and improved, making it even more confusing to compare the pros and cons of each surgical option.

Vaporization Techniques

These surgeries use a flexible fiber-optic scope and high-energy sources to destroy the hyperplastic tissue causing pressure on the urethra. Main types:

Laser vaporization: Several techniques exist, all with subtle differences in technique and type of laser used. Common subtypes include:

• Photoselective vaporization of the prostate (PVP) or greenlight therapy. Overnight stay may not be needed.
• Holmium laser enucleation of prostate (HoLEP). Shown to be as effective as TURP but with fewer side effects.
• Bipolar plasma vaporization (BPV, or “button” procedure).

Microwave: Transurethral microwave therapy (TUMT) is less common today as it is slightly less effective than TURP and newer vaporization techniques. It may not require anesthesia but does require an overnight stay.

High-intensity-focused ultrasound (HIFU): New technique, not yet well researched.

Transurethral needle ablation (TUNA): May be done on an outpatient basis with local anesthetic. It is less effective than TURP and newer vaporization techniques, with up to 14 percent of patients requiring further treatment.

Potential complications: Complications are less common than in conventional surgical techniques but include:

• Incontinence: Urgency, dribbling and poor control of urine flow are normal postoperatively, but should resolve quickly.
• Passing debris is common in the days after the surgery.
• Pain on urination (dysuria) is common in the first few days.
• Retrograde ejaculation (semen goes into bladder) is another possible complication.
• Urinary tract infection.
• Urinary retention: Rare but more common than in TURP

Prostatic Artery Embolization (PAE)

This is a new procedure, lacking in long-term data. It can be done as an outpatient. A radiologist inserts a tiny catheter into prostate, via the femoral artery in the groin.

Microscopic grain-like particles are used to block the blood vessels, causing the gland to atrophy (shrivel) and volume is reduced within a week. The developer reports symptom improvement in 85 to 90 percent of patients, but further study is needed. Early research points to lower long-term complications than TURP.

Potential Complications: Problems with urinary flow may worsen initially as the prostate becomes inflamed, but this passes.

Convective Water Vapor Energy Ablation

In this procedure, marketed at Rezum, the surgeon uses a small scope, inserting it into the urethra and then injecting water vapor into the prostatic urethra. The water vapor condenses, turning from steam into liquid water, and releases thermal energy, which destroys the prostate tissue.

Prostatic Urethral Stents

A “stent” is a small cylinder of mesh that forms a spring. It is inserted into the narrowed area of the urethra, forcing the channel to expand and allowing urine to flow more freely. It is a relatively safe procedure, but obstruction usually returns. Stents are useful in those men who are not fit for more invasive surgery.

Prostatic Urethral Lift (UroLift)

Microfilaments are injected into the prostate and act rather like a stent to “lift” the back lobes of the prostate, thus relieving pressure on the urethra. Early research points to lower side effects but increased relapse rates compared to TURP.

Neuromodulation

This treatment is used specifically to relieve bladder overactivity, which may remain after drug treatment.

Procedure: A small device known as a neurostimulator (or “InterStim”) stimulates the nerves that control the muscles of the bladder and pelvic floor. It causes the bladder to relax and become less irritable. To test for suitability, there is a weeklong trial period where an external device is used, before a permanent device is inserted under the skin of the upper buttock. Each implant has a lifespan of five years. The insertion is carried out under local anesthesia or light anesthesia.

Potential complications: In a minority of patients, the neurostimulator device shifts and has to be relocated. In some, the settings need to be adjusted due to bowel or urinary symptoms.

BPH and Other Conditions

BPH can exist alongside other conditions of the reproductive or urinary tract.

BPH and Cancer

There is conflicting evidence over whether BPH causes prostate cancer. A large systematic review concluded, “BPH is associated with an increased risk of prostate cancer and bladder cancer. The risk of prostate cancer is particularly high in Asian BPH patients.”

Experts urge caution, however, in interpreting such results. Other studies have found no increased risk. What is known is that BPH and prostate cancer share common risk factors such as advanced age, inflammation, and hormonal imbalance. The medical monitoring of men with BPH may lead to early diagnosis—a point when prostate cancer is often slow-growing and not life-threatening.

BPH and Erectile Dysfunction (ED)

Both BPH and ED increase with age and are often seen at the same time in men. Again, as with the BPH and cancer link, it is very hard to tease out what is cause and what is coincidence.

BPH, Urinary Problems, and General Health

BPH, isolated urinary problems such as nocturia, and sleep apnea are often seen in the same men. There is speculation that the reason for this is a shared cause: inflammation and poor general health.

The post 3. Benign Prostatic Hyperplasia appeared first on University Health News.

BPH stands for benign prostatic hyperplasia, a very common condition occurring in approximately 25 percent of men by the age of 55 and 50 percent of men by the age of 75. Despite this prevalence, treatment for BPH is not always necessary.

In fact, only 20 to 30 percent of men by the age of 80 need treatment for BPH. It is not yet clear why BPH occurs, although scientists expect that fluctuations in male hormones and genetic factors play a role. It’s important to note that BPH is not a pre-cancerous condition.

Risk Factors for BPH

Researchers have identified a number of risk factors for developing BPH.

• Age: Based on the current understanding of the disease, age appears to be the most significant risk factor for BPH. Some evidence suggests that by the age of 85, some 85 percent of men will have BPH. It is very uncommon for men under the age of 40 to have symptoms of BPH.
• Genetics: Men with a family history of BPH, particularly in their father or brother(s), are at increased risk of developing the disease.
• Heart disease: Research has demonstrated that having heart disease might be a risk factor for BPH.
• Diabetes: Some studies have seen a link between diabetes and BPH.
• Low HDL level: Having low levels of high density lipoprotein cholesterol (HDL), known as “good” cholesterol, has been associated with an increased risk of BPH.
• Race: African-American men and Caucasian men have a higher risk of developing BPH than do Asian-American men.
• Obesity: Obese men have a greater risk of BPH than men of normal weight.

Symptoms of BPH

The symptoms that occur in BPH are all ultimately consequences of the enlarged prostate tissue impeding the flow of urine through the urethra, the tube that carries urine from the bladder to the penis.

Your prostate rests underneath the bladder and the ureter passes through it. An enlargement of the prostate, called benign prostatic hyperplasia or BPH, constricts the ureter and leads to difficulties urinating.

Some of these symptoms are the direct mechanical result of obstructed urine flow and some are the result of the changes to the bladder that occur because of chronic obstruction. The former are often called “obstructive” symptoms. The latter are often called “irritative” symptoms because the bladder becomes irritated by urinary retention and the need to work harder to empty urine.

BPH: Obstructive Symptoms

• Urinary hesitancy: Men with BPH will often have trouble initiating urination despite significant straining and despite the urge to urinate.
• Weak urine stream: The urine stream may be weak and punctuated by periods of interruption (a “start-stop” pattern).

BPH: Irritative Symptoms

• Urinary urgency: Changes to the bladder from chronic obstruction can cause men with BPH to feel the sudden and immediate urge to urinate.
• Urinary frequency: An irritated or hypersensitive bladder can also result in the sensation that one has to urinate frequently.
• Incomplete bladder emptying: Some men with BPH may feel as though they are not able to fully empty their bladder.
• Nocturia: The need to urinate frequently at night is often present in men with BPH.

If you suspect you have BPH you should contact your doctor. There are many treatment options available to help relieve symptoms and restore your quality of life.

Detailed view showing normal prostate, left, and enlarged prostate, right, with attendant restrictions in ureter.

Originally published in April 2016 and updated.

The post What Is BPH? Defining Benign Prostatic Hyperplasia appeared first on University Health News.

Over the years, benign prostatic hyperplasia has been known by many names: benign prostatic enlargement, benign prostatic hypertrophy, prostatism, or bladder outlet obstruction. Today, the accurate name is benign prostatic hyperplasia,or BPH, so we’ll use that terminology her.

Pathology: What Is BPH?

Hyperplasia in the prostate compresses the narrow urethra that passes through it, and may lead to thickening of the lower bladder wall. In turn, this leads to a condition called chronic bladder outlet obstruction, where urine flow from the bladder is reduced or intermittent. Complications include bladder sensitivity, incomplete emptying of the bladder, urinary retention, renal (kidney) insufficiency, recurrent urine infections, blood in the urine, and kidney stones.

Causes and Risk Factors

BPH Causes and Risk Factors

The exact cause has not been established but there is a strong association with an imbalance in male hormones.

Research shows that certain men are at increased risk of BPH. Risk factors include:

• Increasing age
• Abdominal obesity
• Metabolic syndrome and diabetes
• Smoking
• High blood pressure
• Prostatitis (inflammation of the prostate)
• Lack of physical exercise.

BPH Symptoms

In the early stages, many men are blissfully unaware that they have BPH, as onset is usually gradual. When symptoms do develop, they can significantly interfere with daily life.

BPH is known to cause lower urinary tract symptoms (LUTS), but it’s by no means the only cause.

Common symptoms include:

• Increased frequency of urination, often accompanied by passing dwindling volumes of urine.
• Urgency—the need to urinate right away.
• Difficulty in initiating urination.
• Dribbling of urine or leaking.
• Nocturia—the need to urinate at night.
• Poor stream or fluctuating force of urine. (Some men experience an annoying stop-start flow.)
• Incomplete emptying of the bladder—a feeling like you still need to go when you have just finished.
• Blood in urine.
• Recurrent urinary tract infections.
• Kidney stones.
• Acute urinary retention: A sudden onset complete inability to pass urine, accompanied by severe pain. This is a medical emergency: Go to the ER immediately.
• Abnormal kidney function, a warning sign of impending renal failure.

It is important to report these symptoms to your doctor, whatever the cause. Prompt treatment usually results in better outcomes. 

Screening

Your doctor may recommend a digital rectal examination (DRE) as part of your annual medical examination. While unpleasant, it is an easy and inexpensive screening tool. In carrying out the DRE, your physician may pick up enlargement of the prostate before you’re even aware of its presence. You may be offered a PSA blood test as part of screening, but this is to screen for prostate cancer, not BPH.

Diagnostic Evaluation

The American Urological Association (AUA) offers useful guidelines for testing and diagnosis of BPH:

Basic Evaluation

• Full medical history, including symptoms, surgeries, and medications.
• Full physical examination of all body systems, including a digital rectal exam.
• Symptoms assessment using a checklist, such as the AUA Symptom Index (see Chapter 1).
• Urine test to look for infection, blood, glucose, and perhaps biomarkers for prostate cancer.
• Blood test to look at general health markers, and a PSA blood test to check for cancer (see Chapter 2).

Advanced Investigations

Depending on the outcome of basic testing, your doctor may recommend:

• A urinary flow test, which measures the amount of urine flowing over time.
• Urinary frequency and volume charts: A personal record of how much and how often you urinate.
• An ultrasound to look for residual urine and prostate size and to look at the surrounding organs.
• A catheter test to see if your bladder has any residual urine after emptying.
• An intravenous urogram to look for urethral obstruction. Contrast dye is injected into a vein; it then passes through the kidneys, into the ureters, bladder, and, finally, urethra.
• Cystoscopy, during which a flexible scope with a camera is inserted into the penis to check for obstruction in the urethra.

How Does BPH Progress?

The course of progression of BPH is extremely variable. Some men get mild symptoms that plateau and do not progress. Some get a slow but steady deterioration. Others suffer a rapid progression into acute urinary retention—an inability to urinate, which is a rare but very serious. The prostate can vary in size from that of a walnut to the size of an orange. BPH can be more severe and progressive in African-American men, although not more common.

BPH Treatment

Treatment of BPH depends on how bothersome the symptoms are. A man who works in an environment where he can go to the bathroom frequently and with little disruption may barely notice his symptoms. For men who have busy, active lives or travel frequently, even mild symptoms can be an absolute nuisance. You know you have a problem when you dread the “Fasten Seatbelt” sign on an airplane!

Step 1: Watchful Waiting and Lifestyle Change

Watchful waiting is a strategy commonly used for men with BPH that’s tolerable within their everyday lifestyle. For the majority of men with mild BPH, disease progression is slow. It is very hard to predict who will go on to have significant symptoms. Provided that symptoms do not worsen rapidly, an annual review with a urologist is recommended.

This watchful waiting period is the perfect time for men to implement lifestyle changes, which may reduce the risk of progression and make symptoms more bearable.

Chapter 1 contains comprehensive advice on changes that reduce the risk of BPH and improve symptoms. Here’s a quick recap, with BPH-specific recommendations:

• Improve your diet: This may help reduce symptoms of BPH by calming inflammation, reducing abdominal fat, and stabilizing blood sugar control.
• Exercise regularly: This may reduce the impact of BPH, especially bladder control and nocturnal symptoms.
• Stress reduction and relaxation techniques may reduce anxiety and frequency of urination.
• Avoid decongestant and antihistamine medications, which tighten the urethra and reduce flow.
• Don’t rush bathroom trips: Relax and don’t be impatient with your flow. Take your time to completely empty your bladder; this will save you having to make another trip soon. Urinate when you first feel the urge. Some men find it helpful to “double void”—that is, to urinate a second time when you feel like you’re done, as this can help completely empty the bladder.
• Reduce fluid intake late in the day: Many men also find that avoiding caffeine and alcohol consumption in the evening improves nocturnal symptoms.
• Plan ahead: If you are about to take a flight or attend a long meeting, reduce fluid intake an hour before and avoid caffeine and alcohol.
• Stay warm: A cold environment can increase the need to urinate.

Please note: If you have underlying medical conditions such as heart disease, diabetes, or cancer, discuss lifestyle changes with your medical practitioner.

Step 2: BPH Medications

If lifestyle changes do not help, or if symptoms become bothersome, the next step is to try medications.

There are three types of medications approved by the FDA for BPH treatment:

• Alpha blockers
• 5-Alpha Reductase Inhibitors (5-ARIs)
• PDE5 inhibitors

Preliminary research suggests that these drugs improve symptoms in 30 to 60 percent of men taking them, but it is not yet possible to predict who will respond to which therapy.

Alpha-Blockers

These oral medications have a two-fold effect. First they dilate arteries to improve blood flow. Next they relax muscles, including those of the bladder outlet, to improve urine flow and bladder emptying. They provide fast relief, working within days of commencing treatment. They provide symptom relief but do not slow the progression of BPH.

Examples: Non-selective alpha-blockers: Prazosin (Minipress), terazosin (Hytrin), doxazosin (Cardura).  Selective alpha-blockers (less effect on blood pressure): Alfuzosin (Uroxatral), silodosin (Rapaflo), tamsulosin (Flomax).

Potential side effects: Alpha-blockers may cause side effects such as:

• Hypotension (low blood pressure), dizziness, and possible fainting. Blood pressure should be monitored.
• Irregular heartbeat (fast heartbeat or fluttering in chest) or chest pain.
• Ejaculation problems.
• Priapism (painful erection lasting four hours or more).
• Tiredness or weakness.
• Swelling of hands, feet, or ankles.
• Headache.
• Nausea or stomach upset.
• Allergic reaction.
• A rare, but serious complication can occur with cataract surgery, so should be avoided if surgery is planned.

5-Alpha Reductase Inhibitors

These oral medications halt disease progression by shrinking the prostate, which in turn relaxes pressure on the urethra, helping to reduce symptoms. 5ARIs are useful in men with significant prostatic enlargement and raised PSA levels. One disadvantage is that they take months to show improvement, requiring follow-up three months into treatment.

Examples: Dutasteride (Avodart) and finasteride (Proscar)

Potential side effects: Side effects are uncommon but may include breast enlargement and tenderness, impotence, decreased libido (which may continue after treatment stopped), and reduced semen volume. Because 5-ARIs can lower PSA levels, they can complicate the interpretation of PSA results.

Combination Therapy

As alpha-blockers and 5-ARIs have different mechanisms, treatments have emerged that combine the two, thus relieving symptoms while the somewhat slow disease regression occurs.

Exampless: Jalyn combines dutasteride and tamsulosin.

Phosphodiesterase-5 Inhibitors (PDE-5s)

PDE-5s relax the smooth muscle in the penis and improve blood flow. They are primarily used to treat erectile dysfunction, but can also help with BPH symptoms. They should not be used by men taking nitrates for chest pain (known as angina), and should be used cautiously in those taking an alpha-blocker.

Examples: Tadalafil (Cialis) is an FDA- approved BPH treatment. Sildenafil (Viagra) and vardenafil (Levitra) also may be helpful.

Potential side effects: Headache, indigestion, stuffy or runny nose, back pain and muscle aches, bluish or blurred vision, an erection that will not go away, sudden decrease, or loss of vision or hearing (rare).

Anticholinergics (Antimuscarinics)

For men with BPH and an overactive bladder, anticholinergic drugs may relax the bladder and reduce symptoms of frequency and urgency. They are available as a pill, gel (Gelnique), or patch (Oxytrol). They do not alter the progression of BPH. They can be used alone or with alpha-blockers and 5ARIs.

Examples: Darifenacin (Enablex), fesoterodine (Toviaz), oxybutynin (Ditropan XL, Gelnique, Oyxtrol), solifenacin (VESIcare), and tolterodine (Detrol).

Potential side effects: Dry eyes and mouth, constipation, dizziness, and headaches. They can also lead to a decline in cognitive and physical function, so they need to be used cautiously in the elderly.

Beta-3 Adrenergic Agonists

These can help with overactive bladder and urinary incontinence, as they relax the bladder muscle and improve bladder volume. They should be used with extreme caution in men with high blood pressure, kidney or liver disease, and bladder outlet obstruction.

Examples: Mirabegron (Myrbetriq)

Potential side effects: Cold-like symptoms, urinary tract infections, constipation, abdominal pain, headache, and an increase in blood pressure and heart rate.

Botulinum Toxin

Best known for its use in cosmetic surgery, Botulinum Toxin can be useful in managing an overactive bladder. It is injected laparoscopically and relaxes the muscles of the bladder and prostate, and may improve urinary flow and lower urinary tract infections (LUTIs). This treatment is currently at the clinical trial phase.

Examples: Onabotulinumtoxin A (Botox)

Potential side effects: LUTIs, urinary retention, fatigue, and insomnia.

Anti-Inflammatory Drugs and Supplements

Emerging evidence is linking chronic inflammation, obesity, metabolic syndrome, erectile dysfunction, and BPH. There is potential for the use of nonsteroidal anti-inflammatory drugs (NSAIDs), statins and antioxidant supplements in the management of BPH, but the body of research is small and inconclusive.

Herbs and Natural Supplements

Natural remedies have been used to treat urinary symptoms for centuries, long before drug and surgical treatments were developed, but do they work?

The short answer is that we’re not sure. The majority of urologists and medical authorities such as the American Urological Association and the Centers for Disease Control and Prevention do not recommend the use of natural remedies for BPH. This doesn’t mean they don’t work, however; it just means that the evidence is not strong enough to recommend treatment.

There are several problems with evaluating and recommending natural remedies:

• The quality of herbal and natural supplements varies and is poorly regulated.
• Unlike surgical and drug treatments, there’s very little funding for natural treatment research.
• The studies that do exist tend to be small and of varying quality.

Herbal remedies, like drugs, can cause side effects and interact with other medications. That said, there are several herbs and natural supplements for which there is at least some evidence of benefit:

Beta-sitosterols: One literature review in the well-respected Cochrane database found that beta-sitosterols were “well tolerated and improved urinary symptoms and flow measures in men with mild to moderate BPH.” Beta-sitosterols are plant compounds thought to reduce inflammation; they occur naturally in pumpkin seeds.

Pygeum or African plum extract (Pygeum africanum): According to Medscape, this herb—extracted from tree bark—is “the most popular treatment for symptoms of BPH in France and is commonly used for this condition in Italy and the United States.” It has been well researched and shown to reduce inflammation and improve hormone balance. Several studies show statistically significant improvement in urinary symptoms.

Grass pollen (Secale cereale), such as Cernilton: There is a small body of evidence that this may improve BPH symptoms.

Saw palmetto (Serenoa repens): This once-promising herbal treatment has lost favor in recent years as larger research studies have failed to prove its effectiveness.

If you’re in the watchful waiting stage of BPH management, you may wish to consider trying natural supplements as part of an attempt to improve general health and reduce symptoms. If you have other medical conditions such as diabetes, heart disease, or allergies or are taking any medication, it is vital that you talk to your medical practitioner before trying these treatments.

Always buy supplements from a reputable source: The supplement industry is unregulated in the U.S., and scams frequently emerge.

Step 3: Surgery

Despite watchful waiting, lifestyle changes, and drug treatment, some men develop symptoms that warrant surgery. Side effects are common, so surgical intervention is not to be entered into lightly. It’s recommended to those with these types of conditions and symptoms:

• Kidney damage due to inadequate bladder emptying and reverse flow of urine (it is only ever meant to flow down and away from the kidneys)
• An episode of acute urinary retention—complete inability to urinate, leading to bladder extension and extreme pain
• Frequent incontinence
• Bladder stones
• Recurrent bladder infection due to incomplete emptying
• Recurrent severe hematuria (blood in urine)
• LUTI symptoms that fail to respond to medication and significantly impact quality of life.

The aim of surgery is to reduce the pressure on the urethra from the enlarged prostate. This in turn should improve urine flow and bladder emptying while reducing the risk of serious urological complications.

Surgical Options

For many years, the mainstay of surgery for BPH was the transurethral resection of the prostate (TURP). In recent years, a plethora of surgical interventions has emerged in an attempt to reduce complications and improve outcome. This can make surgical options overwhelming and confusing for many men.

While we are about the provide you with a summary of current, commonly used surgical options, the decision will ultimately come down to your surgeon’s opinion and experience; your view on the treatment risks and benefits; your specific symptoms and how they impact your unique lifestyle; and what you can afford or your insurance company will approve.

There are two main types of surgery:

Conventional surgery:

• Transurethral resection of the prostate (TURP)
• Transurethral incision of the prostate (TUIP)
• Open prostatectomy.

Minimally invasive surgery:

• Vaporization techniques
• Prostatic artery embolization (PAE)
• Water vapor energy ablation
• Prostatic urethral stents and lifts
• Neuromodulation.

Generally speaking, conventional surgery is more invasive, has more complications, and likely requires a longer recovery period. The upside of conventional surgery is that symptom relief is often better and relapse is less common.

Transurethral Resection of the Prostate

Procedure

Transurethral Resection of the Prostate (TURP) is performed under general or spinal anesthesia in the operating room. The surgery takes 60 to 90 minutes. An instrument called a resectoscope is passed into the penis through the urethra. There is no incision on the abdomen. A wire loop removes the prostatic tissue that is narrowing the urethra (debulking) and cauterizes (seals) the blood vessels as it cuts. The area is continuously irrigated to remove debris and blood.

The TURP procedure has been around since 1909 but is continuously being refined to reduce complications and improve effectiveness.

A hospital stay of at least 24 hours (usually two to three days) is necessary, and a urinary catheter is needed for one to three days, until normal urination returns. For at least the first two weeks, heavy physical activity must be avoided. Light work can usually be resumed by the end of the first month. The recovery period is four to six weeks. Patients are advised to drink plenty, eat a healthy diet, and take laxatives in the first month post-operatively.

TURP Outcome

Some 85 to 95 percent of men who undergo TURP report symptom relief. In some, there is further growth of the prostatic tissue, leading to a return of symptoms and the need for further treatment. This is more common in younger men.

Potential Complications

Bleeding: Blood in the urine (hematuria) is normal immediately after surgery but should resolve before discharge from hospital, not to return again. Significant hematuria, especially clots, is not normal and should be reported to the surgical team right away.

Pain: In the early days after surgery, some men experience dysuria (pain on urination).

Incontinence: Urgency, dribbling, and poor control of urine flow are normal but should resolve quickly, not to return.

Sexual function: Problems occur in 30 percent of men postoperatively and may last up to a year. They include erectile dysfunction and retrograde ejaculation (semen goes into bladder), which can cause infertility.

TURP syndrome: This rare (less than 2 percent) but serious complication is caused by absorption of irrigation fluid into the bloodstream. Symptoms include confusion, nausea, vomiting, high blood pressure, and visual distortions.

As with all surgeries, complications do arise due to anesthesia, but these are rare. Serious complications occur in 5 to 10 percent of patients.

Adaptation of TURP

Transurethral electrovaporization of the prostate techniques (TUEVP or TVP) are similar to TURP but use an electrode to cut.

Transurethral Incision of the Prostate

Procedure

Transurethral incision of the prostate (TUIP) is similar to the TURP. A resectoscope is inserted via the penis into the prostate, but instead of debulking the prostate, the surgeon makes small incisions into the prostate. That allows it to expand and thus will relieve the compression on the urethra.

TUIP is reserved for milder cases of BPH, and because the prostate is not debulked, it may continue to enlarge, requiring further treatment. Eighty percent of patients report reduction in symptoms.

Catheterization is needed for up to a week, postoperatively. A hospital stay of one to three days is usual. Recovery is quicker than with the TURP.Potential complications include the risk of urinary retention in the post-op period.

Open Prostatectomy

Open surgery is performed in rare cases of BPH where the prostate is very large and there are complications, such as a bladder diverticula (a small pouch protruding from the bladder) or bladder stones.

Procedure

Open prostatectomy requires an incision in the lower abdomen and an incision into the prostate. The surgeon then debulks the prostate and attends to other issues in the pelvis. A hospital stay of three to five days is usual, with a catheter inserted for at least two days.

The accuracy afforded by the open surgery leads to excellent outcomes, and the need for further surgery is low.

Potential Complications

Bleeding: Blood in the urine (hematuria) is normal in the immediate postoperative period but should resolve before discharge from hospital, not to return again. Significant hematuria, especially clots, is not normal and should be reported to the surgical team immediately.

Pain: In the early days after surgery, dysuria (pain on urination) is common.

Incontinence: Urgency, dribbling, and poor control of urine flow are normal but should resolve quickly, not to return.

Sexual function: Erectile dysfunction is an issue in less than 5 percent of patients, as is retrograde ejaculation (when semen goes into bladder).

Wound infection: Most post-op wound infections show up within the first 30 days after surgery.

Overactive bladder: The need to urinate frequently, even when bladder does not seem full, is another potential complication.

Minimally Invasive Surgeries

The following techniques, as the name suggests, are minimally invasive—that is, they do not involve significant surgery or abdominal incision. These surgeries are performed using a scope (flexible tube) to destroy prostatic tissue. They can be carried out under general or spinal anesthetic, and as with any surgery there are anesthetic risks. Some procedures may be carried out in the doctor’s office, others in the operating room. Catheterization is usually needed for some time following surgery. Recovery time and hospital stays vary between patients, surgeons and technique. The down side of these surgeries is that tissue can be destroyed, making it difficult to biopsy the prostate, meaning some early-stage cancers coud be missed. Return of symptoms is more common than with conventional surgery.

In this fast-evolving field, new procedures are emerging each year; however, it takes time to prove their effectiveness and train surgeons. Conventional surgeries are also being constantly refined and improved, making it even more confusing to compare the pros and cons of each surgical option.

Vaporization Techniques

These surgeries use a flexible fiber-optic scope and high-energy sources to destroy the hyperplastic tissue causing pressure on the urethra. Main types:

Laser vaporization: Several techniques exist, all with subtle differences in technique and type of laser used. Common subtypes include:

• Photoselective vaporization of the prostate (PVP) or greenlight therapy. Overnight stay may not be needed.
• Holmium laser enucleation of prostate (HoLEP). Shown to be as effective as TURP but with fewer side effects.
• Bipolar plasma vaporization (BPV, or “button” procedure).

Microwave: Transurethral microwave therapy (TUMT) is less common today as it is slightly less effective than TURP and newer vaporization techniques. It may not require nesthesia but does require an overnight stay.

High-intensity focused ultrasound (HIFU): New technique, not yet well researched.

Transurethral needle ablation (TUNA): May be done on an outpatient basis with local anesthetic. It is less effective than TURP and newer vaporization techniques, with up to 14 percent of patients requiring further treatment.

Potential complications: Complications are less common than in conventional surgical techniques but include:

• Incontinence: Urgency, dribbling and poor control of urine flow are normal postoperatively, but should resolve quickly, not to return.
• Passing debris is common in the days after the surgery.
• Pain on urination (dysuria) is common in the first few days.
• Retrograde ejaculation (semen goes into bladder) is another possible complication.
• Urinary tract infection.
• Urinary retention: Rare but more common than in TURP

Prostatic Artery Embolization (PAE)

This is a new procedure, lacking in long-term data. It can be done as an outpatient. A radiologist inserts a tiny catheter into prostate, via the femoral artery in the groin.

Microscopic grain-like particles are used to block the blood vessels causing the gland to atrophy (shrivel) and volume is reduced within a week. The developer reports symptom improvement in 85 to 90 percent of patients, but further study is needed. Early research points to lower long-term complications than TURP.

Potential Complications: Problems with urinary flow may worsen initially as the prostate becomes inflamed, but this passes.

Convective Water Vapor Energy Ablation

In this procedure, the surgeon uses a small scope, inserting it into the urethra and then injecting water vapor into prostatic urethra. The water vapor condenses, turning from steam into liquid water, and releases thermal energy, which destroys the prostate tissue.

Prostatic Urethral Stents

A “stent” is a small cylinder of mesh that forms a spring. It is inserted into the narrowed area of the urethra, forcing the channel to widene and allowing urine to flow more freely. It is a relatively safe procedure, but obstruction usually returns. Stents are useful in those men who are not fit for more invasive surgery.

Prostatic Urethral Lifts (UroLift)

Microfilaments are injected into the prostate and act rather like a stent to “lift” the back lobes of the prostate, thus relieving pressure on the urethra. Early research points to lower side effects but increased relapse rates compared to TURP.

Neuromodulation 

This treatment is used specifically to relieve bladder overactivity, which may remain after drug treatment.

Procedure: A small device known as a neurostimulator (or “InterStim”) stimulates the nerves that control the muscles of the bladder and pelvic floor. It causes the bladder to relax and become less irritable. To test for suitability, there is a weeklong trial period where an external device is used, before a permanent device is inserted under the skin of the upper buttock. Each implant has a lifespan of five years. The insertion is carried out under local anesthesia or light anesthesia.

Potential complications: In a minority of patients, the neurostimulator device shifts and has to be relocated. In some, the settings need to be adjusted due to bowel or urinary symptoms.

BPH and Other Conditions

BPH can exist alongside other conditions of the reproductive or urinary tract.

BPH and Cancer

There is conflicting evidence over whether BPH causes prostate cancer. A large systematic review concluded, “BPH is associated with an increased risk of prostate cancer and bladder cancer. The risk of prostate cancer is particularly high in Asian BPH patients.”

Experts urge caution, however, in interpreting such results. Other studies have found no increased risk. What is known is that BPH and prostate cancer share common risk factors such as advanced age, inflammation, and hormonal imbalance. The medical monitoring of men with BPH may lead to early diagnosis—a point when prostate cancer is often slow-growing and not life-threatening.

BPH and Erectile Dysfunction (ED)

Both BPH and ED increase with age and are often seen at the same time in men. Again, as with the BPH and cancer link, it is very hard to tease out what is cause and what is coincidence.

BPH, Urinary Problems, and General Health

BPH, isolated urinary problems such as nocturia and sleep apnea are often seen in the same men. There is speculation that the reason for this is a shared cause: inflammation and poor general health.

The post 3. Benign Prostatic Hyperplasia appeared first on University Health News.

But there is much more to the depression/hormone connection than just that. Other hormones, such as thyroid, estrogen, and testosterone, are equally essential but may not be quite as obvious. The bottom line is that hormones influence almost every cell, organ, and function of our body, and they are very closely linked to proper brain function and depression. Inadequate levels of these hormones will cause your brain chemicals to not be able to function properly.

So the first major step in solving the underlying causes of depression will be to support and correct any endocrine gland dysfunction.

Do You Have Endocrine Gland Dysfunction?

Many integrative doctors can immediately spot hormone deficiencies just by talking to you. Do you have sagging energy levels around mid-afternoon, prompting you to prop yourself up with coffee or sodas? Do you crave carbohydrates or salt? These are just two of the indicators of adrenal gland dysfunction.

Oftentimes, however, your doctor will want to confirm his suspicions with laboratory testing. And you’ll likely need to see in black and white on a printed lab sheet your hormone level scores in order to motivate you to get serious and take action to correct these levels. As an example: For depressive patients, a lab test showing how completely exhausted their adrenal function really is will be quite motivating to do whatever is necessary to get that function back on track again.

Some of these lab tests are now available on a retail basis directly to you as the customer, so you don’t have to wait on your physician if you’re willing to pay the fee without insurance reimbursement. But a key will be to know how to interpret the results and then know what to do next.

Some individuals who are proactive and feel confident in knowing what to do can move forward in doing so. But most people will need the assistance of a qualified physician to help with ordering the tests and then making treatment decisions afterwards.

Hormone balancing is not a one-size-fits-all action plan. You’ll likely need to partner with your physician and then use her prescribed bioidentical hormone replacement therapy to get you going again.

If you’re interested in getting some of you own lab testing done directly, you can go search for at-home testing on the internet. (Generally speaking, most integrative doctors seem to prefer saliva testing for adrenal and sex hormone testing whereas blood testing seems to be more often preferred for thyroid levels.) The key is that the physician or provider knows how read and interpret the results.

Hormones and Depressive Symptoms

We need now to look in detail at each of these hormone deficiencies to see whether one or more of them could be a source of your depression. They are adrenal hormone deficiency, thyroid hormone deficiency and sex hormone deficiency.

Adrenal Hormone Deficiency

Do you suffer from fatigue, insomnia, weight gain, and depression? This combination of symptoms is often the complaint of people who suffer from adrenal gland dysfunction.

The primary role of your adrenal glands is to produce hormones that rally all your body’s resources to fight stressful situations you encounter. It seems fairly obvious then that if you suffer from clinical depression, it’s almost a given that your adrenal glands have become at least partially dysfunctional.

Depression is the outward manifestation of a body not dealing properly with the stressful attacks it is encountering. The good news is that adrenal gland dysfunction can be corrected with natural healing options, although it may take two to six months to do so, depending on the severity of your condition. But the effort is worth it. It’s important for you to understand how this can be accomplished so you can begin to implement the changes and start feeling better than you have in a long time.

Hormones to Fight Stress

“Fight or Flight” Mode: Your Adrenal Glands’ Primary Job. The adrenals are walnut-sized glands located on top of each kidney, and they manufacture some of the body’s critical hormones, such as adrenaline, cortisol, and DHEA. The fundamental task of your adrenal glands is to rally all of your body’s resources into “fight or flight” mode by increasing production of adrenaline and cortisol.

When your child playing in the front yard starts chasing the ball into the busy street, your body instantly jumps into high gear as your adrenal hormones increase your heart rate and blood pressure, release your energy store for immediate use, slow your digestion and sharpen your senses—all for the purpose of enabling you to instantly start running and catch that child before any harm occurs. This is a healthy stress response and it takes priority over all other metabolic functions at the time, but it is not intended to last long.

Chronic Stress Produces Exhausted Adrenals. The problem with us today in our society is that we endure “stress” on a chronic basis. Instead of occasional, acute demands followed by rest, we’re constantly overworked, undernourished, exposed to environmental toxins, and worrying about others—with no let-up. Our adrenals have to respond to all kinds of stress, not just the emotional kind involving an irate boss or a difficult teenager.

So the stress that can cause our adrenal glands to become dysfunctional can be emotional, mental, physical, or external (see sidebar below).

The Destructive Effect of High Cortisol Levels

Cortisol is the primary “stress hormone” produced by the adrenal glands. When you encounter any of these stressors shown above, the adrenals produce cortisol and it goes to work to prepare your body for that extra demanding event. For a short time, that’s okay. But at sustained high levels, cortisol overproduction wreaks havoc on your body, brain, and nervous system. It begins to ruin your hormone balance and that eventually can lead to depression, memory loss, and other problems.

DHEA (dehydroepiandrosterone) is another hormone produced by the adrenal glands and is the immediate precursor hormone to estrogen, progesterone, and testosterone. Normally, it helps to keep these sex hormones in proper balance, especially as we age and get less sex hormone production from the ovaries or testicles.

But if your adrenal glands are chronically overworked and are straining to maintain high cortisol levels to deal with stress, the adrenals will automatically give preference to producing more cortisol at the expense of DHEA production. Eventually, your DHEA supply will become deficient. And over time, low DHEA production leads to depression, fatigue, bone loss, loss of muscle mass, aching joints, decreased sex drive, and impaired immune function. All of this is the result of chronic stress.

The normal pattern for a person experiencing adrenal fatigue or adrenal exhaustion is as follows:

Early stages: The adrenal glands are still working but are pumping out high levels of cortisol that don’t go down because the stressors never end. Cortisol levels (which can be measured by standard saliva lab testing) are too high during the day and continue rising into the evening. This is sometimes called hyperadrenia. Insomnia often becomes a problem here because your cortisol level is just too high at night to allow you to settle down and sleep soundly.

Middle stages: Cortisol output may rise and fall unevenly throughout the day as the body struggles for balance against disruptions of caffeine, carbs, and stress, but levels are abnormal and typically much too high at night.

Advanced stage: This is the “adrenal exhaustion” phase, where the adrenals have become largely dysfunctional from overwork, and cortisol will never reach normal levels (hypoadrenia). Here your adrenals have basically burned out and are unable to produce nearly enough of their critically important hormones needed for regulating blood sugar and blood pressure, balancing mineral levels, and assisting your body in dealing with all the many sources of stress.

Adrenal Exhaustion

There basically is a three-step process to know for sure whether you have adrenal fatigue or adrenal exhaustion.

Many experienced integrative physicians can diagnose adrenal exhaustion from just listening to you describe your symptoms. Often, they are convinced enough of the proper diagnosis that they skip Step 2 and go directly to a regimen to help you rejuvenate your adrenals. But if you need to be convinced yourself, then all three of the following steps will be needed.

Step 1:
Adrenal Dysfunction Symptoms

Fatigue. We’ve all felt that listless lack of energy; it could be related to adrenal issues.

Insomnia. Daily cortisol production follows a curve from highest levels around 8 a.m., dropping throughout the day until the lowest levels are reached at about 11 p.m. However, in the early stages of adrenal fatigue, the body’s night-time cortisol level will be high rather than low. In this case, you would find it difficult to relax from the stress of the day and would have trouble going to sleep. High night-time cortisol results in reduced REM sleep, which is neither restful nor restorative.

Feeling tired despite sufficient hours of sleep—meaning your sleep was not the deep restorative type for the reasons described above.

Cravings for carbohydrates or sugars hypoglycemia (low blood sugar). One of the roles of cortisol is to raise low blood sugar levels. As adrenal fatigue progresses and less cortisol is available to perform that role, blood glucose levels will tend to fall too low. The body responds to this hypoglycemia by causing the person to crave anything that will rapidly raise blood sugar levels, such as a soda, candy bar, a cup of coffee, or even cigarettes. So a craving for those things is one of the signs of adrenal dysfunction. Often, adrenal fatigue leads to the abuse of alcohol, marijuana, and hard drugs because of the need to “fix” recurrent hypoglycemia. Restoring the adrenals can help in overcoming these destructive addictions as well as overcoming those cravings for sweets.

Weight gain, especially in the abdomen and waist areas.

Depression and other neurological problems. The adrenal gland hormones enable the brain chemicals (neurotransmitters) to work properly. Therefore, adrenal dysfunction influences mood (depression), behavior, and memory. Behavior changes frequently occur in both excess and deficient cortisol levels. Possible symptoms of adrenal fatigue would involve decreased tolerance (quick to anger), decreased clarity of thought, poor memory, and memory retrieval.

Dizziness or blood pressure change upon standing. When a person with normal adrenal function stands from a sitting or lying position, the systolic (top number) blood pressure usually rises about 10 points as blood vessels in the lower body constrict to force blood to the heart, lungs, and brain. In people with adrenal exhaustion, lack of cortisol prevents the blood vessels from being able to constrict, so blood pools in the abdomen and pelvis and blood pressure actually drops upon standing. The systolic blood pressure drop ranges from 10 to 40 points and is present in up to 90 percent of those who have adrenal dysfunction. Dizziness or lightheadedness is also often present on standing; however, in some people it is present intermittently or constantly throughout the day even as resting blood pressure is low.

Pupil dilation exam. In a darkened room, sit in a chair in front of a mirror. Hold a flashlight at the side of your head, shine it across one eye (not into the eye). Watch what happens in the mirror. You should see your pupil (black center) contract immediately after the light hits the eye. The pupil will normally stay contracted, but if you have adrenal fatigue, the pupil won’t be able to hold its contraction and will dilate (enlarge). This dilation will take place within two minutes and last for 30-45 seconds before it contracts again. Time how long the dilation lasts and record it along with the date. Retest monthly as it serves as an indicator of recovery. During adrenal insufficiency, there is a deficiency of sodium and an abundance of potassium, and this imbalance causes an inhibition of the sphincter muscles of the eye. These muscles normally initiate and hold pupil constriction in the presence of bright light. However, in adrenal fatigue, the pupils actually dilate when exposed to light.

Asthma, Bronchitis, or Chronic Cough. Any person with lung problems, especially asthma and bronchitis, should be checked for poor adrenal function. The lungs cannot respond appropriately to stress and allergens because of lack of cortisol. Asthma is often considered an emotional disease because stress can trigger an attack. Fix the adrenals so the body can respond normally to stress and the asthma will disappear.

Allergies. Most allergies involve an inflammation in the body as a part of the process. As the adrenal function decreases, allergies worsen. Generally, if the adrenal glands were functioning properly, the body would not respond to the allergen. This same anti-inflammatory effect is important in asthma also. As the adrenal glands heal, allergies are markedly reduced.

Salt craving. The adrenal glands produce many more hormones than just cortisol and DHEA. One very important hormone is aldosterone, a mineralocorticoid. (Mineralocorticoids are a class of corticosteroids, a type of steroid hormones. They influence salt and water balance.) Aldosterone regulates the concentration of sodium and potassium in the cell as well as outside the cell. This in turn has a direct effect on the amount of fluid in the body. Aldosterone therefore plays a ­significant role in regulation of blood pressure. It is important to note that in our body, sodium and water go hand in hand. Where sodium goes, water follows.

As the concentration of aldosterone rises in the body, the concentration of sodium and water rises, more fluid is retained in the body, and blood pressure rises. Conversely, when the level of aldosterone lowers (as during more advanced adrenal fatigue), sodium and water retention is compromised. This is called “salt wasting.” As the body’s water fluid volume is reduced, low blood pressure ensues. Cells get dehydrated and become sodium deficient. So as a general rule, most people with advanced adrenal fatigue report a low blood pressure as well as a salt craving.

The salt craving is because the body is in an absolute deficiency of sodium. Soft drinks, and electrolyte drinks like Gatorade are high in potassium and low in sodium, the opposite of what someone with low cortisol needs. Therefore, they should be avoided by those with adrenal fatigue in favor of salt water (see recipe, right).

Other adrenal dysfunction symptoms could include any of the following: Weight gain, especially in the abdomen and waist areas; hair loss; acne; reliance on stimulants like caffeine; poor immune function; and, intolerance to cold.

Step 2:
Adrenal Hormone Saliva Test

Do you suspect you have adrenal fatigue based on several of the symptoms listed above? Your integrative physician might go directly to a therapeutic trial of adrenal glandulars or other remedies, but often you’ll want to know the extent to which your adrenals are dysfunctional.

The conventional blood serum testing for adrenal function, called ACTH (adrenocorticotropic hormone) Challenge Test, recognizes extreme underproduction or overproduction of adrenal hormone levels, as shown by the top and bottom 2 percent of a bell curve. If hormone level results fall into the huge range in between these extremes, patients tested for adrenal functions may be told by their conventional doctor they are “normal.”

In reality, though, their adrenal glands are performing sub-optimally, with clear signs and symptoms as the body cries out for help and attention. So integrative physicians are more keenly aware of “subclinical adrenal dysfunction” and prefer saliva testing because it measures the amount of free and circulating hormones instead of bound hormones commonly measured in blood tests.

The patient doing a saliva test will generally take four saliva samples during the day (at 8 a.m., noon, 5 p.m., and before bedtime) so that cortisol levels can be measured at those times. With multiple samples taken throughout the day, lab results can clearly map the daily diurnal curve of free cortisol in the body relative to DHEA level and relative to the desired levels of cortisol at each of those times. This will give you a much clearer picture of true adrenal function.

Step 3:
Adrenal Rejuvenation “Trial”

This is the final step, the one that will conclusively confirm that you truly did have adrenal dysfunction. It’s the point that tells you to take action so you can start to feel better. So if you have the symptoms and your lab results confirm adrenal fatigue, it’s time to get busy with corrective action.

Properly functioning adrenals are the essential foundation for overcoming depression and preventing it from recurring. Restoring your adrenals may not by itself cause your depression to go away because there may be some neurotransmitter deficiencies (like serotonin) you have to also work on. You can address those at the same time you’re restoring your adrenals. But if you do all the other things to end your depression and don’t restore your adrenals, your chance of keeping depression at bay permanently will be very small. After all, your adrenal gland hormones are your “stress hormones,” and strong adrenals will allow your body in the future to handle stressful situations properly. These actions are well worth the effort!

Let’s get started.

1. Reduce the amount of high glycemic carbs you eat and stabilize your blood sugar level. If you’re trying to rejuvenate your adrenals, it will be essential for a period of time to lay off excessive high glycemic carbs so as to prevent the yo-yo effect of blood sugar level. This will make you feel better, will reduce your food cravings, and will give your exhausted adrenals an opportunity to begin regenerating. You won’t have to adhere to such a strict low carb diet forever, just long enough to rebuild your adrenals.
2. Take the adrenal support nutrients B5 and Vitamin C. These two nutrients in particular are needed to rebuild adrenal function. You probably will need to take the vitamins in supplement form because food sources may not provide the therapeutic levels you’ll need. Pantothenic acid (vitamin B5) forms the key enzyme that creates cortisol. Start with 500 mg twice a day and see how you do. You may need to work up to 2,000 mg twice a day. As your adrenal glands rebuild, you can lower the dosage.

Regarding vitamin C, it is recommended to combine ascorbic acid (vitamin C) and bioflavanoids. This vitamin C complex is very beneficial, not just ascorbic acid by itself. The ratio of bioflavonoids to ascorbic acid should be approximately 1:2; that is, 1 mg of bioflavonoids for every 2 mg of ascorbic acid. Bioflavonoids basically double the effectiveness of ascorbic acid in your body and allow its action to be more complete. During a period of adrenal gland repair, it is recommended that the individual should supplement vitamin C up to the level of bowel tolerance (just short of the point where the stools become somewhat loose). The most common point for this to occur is about 2,000 to 4,000 mg (2 to 4 grams) daily of ascorbic acid for people with adrenal fatigue, but it could be much higher depending on the severity of the adrenal dysfunction. Your body will tell you how much. You’ll want to spread your C supplements out through the day in order to keep a steady load of vitamin C in your bloodstream.

3. Take an adrenal glandular extract. This is a desiccated extract of animal glandulars, just as Armour Thyroid is a desiccated extract of thyroid glandulars used by thousands of people for thyroid support. These adrenal glandulars are available without prescription and are extremely important in the initial phases of adrenal repair since they provide the raw materials to support adrenal function.

When you take the complete extract rather than just a single hormone, you get all the other natural substances that maximize effectiveness. The use of adrenal glandulars can generally be eliminated after your own adrenals get fully rejuvenated, but these extracts are an important tool during the early phase of the repair process. One such brand, for example, is Drenamin, produced by Standard Process Laboratories. You might start with three tablets of Drenamin a day. For the greatest effect, break the tablets in half and chew a half-tablet six different times during the day, between meals. (In severe cases, start with six full tablets a day.) Most people will need to stay on three tablets a day for four months or sometimes even longer. After you begin to feel the benefits, you can adjust the dosage to what suits your particular needs.

4. Drink a glass of water with sea salt added to it. We’ve already explained in the section titled “Adrenal Exhaustion: Do You Have It?” how adrenal exhaustion causes salt wasting and dysfunction in water fluid levels in the body.



5. Always eat breakfast and also eat a snack mid-morning and mid-afternoon. This is another important step to help level off your blood sugar levels throughout the day to avoid overworking your adrenals during this time of restoration. Snacks will also keep your metabolism more constant and thus your energy level more constant. What would be a healthy snack? A small bowl of walnuts, almonds, and pumpkin seeds sweetened by a few dried blueberries or cherries is delightful to the taste, is nutritious, and will not spike your blood sugar. Other ideas of snacks would be cottage cheese and fruits; fresh or frozen blueberries; apple or celery stick with almond butter; legumes or beans; and salmon or tuna.
6. Give adrenals a rest by avoiding the stimulants and by getting quality sleep. Such stimulants as coffee, sodas, chocolate, and alcohol have been your props to keep you going during your time of adrenal exhaustion. But they have a “diminishing return” effect on your adrenals, and greater and greater amounts are required to have the same boosting effect. Over time, they devastate your adrenals and thus must be removed during the time of repair and restoration. They also adversely affect your quality of sleep—even if consumed early in the day—and deep restorative sleep is going to be critical for full adrenal recovery.

People with adrenal fatigue quite often have serious issues with insomnia; they either have trouble getting to sleep or wake up in the middle of the night and then feel tired the next day. Improper levels of cortisol due to adrenal fatigue are often the cause of this chronic insomnia—either too much cortisol or too little. The salivary hormone testing can give you an idea of which it might be, and then you’ll know what to do about it. If cortisol is too high before bedtime, some kind of relaxation exercise before bedtime—an epson salt bath or a massage from your spouse—can lower that cortisol level and help you sleep better. If your cortisol is too low, you can exercise in the evening before bed and it will raise cortisol levels.

5-HTP and Melatonin and are doubly beneficial: They will help you sleep better but they also will help rebalance some of those brain neuro­transmitters that may be causing depression.

Melatonin is a hormone secreted by the pineal gland in the brain. It helps regulate other hormones and maintains the body’s proper sleep cycle. When the level of light decreases at night, your pineal gland releases melatonin, helping you to fall asleep. In the morning, daylight signals your pineal gland to shut down melatonin production, helping you to wake up. If your serotonin levels are low (as in depression), chances are that you’re not producing enough melatonin. Studies show that taking the right amount of supplemental melatonin can restore sleep in adults over 50.

7. Remove the stressors. This seems so obvious that it shouldn’t even be listed. But, many people have to be forced to slow down or to deal with the source of their chronic stress. In adrenal exhaustion, it may be your body that shuts down and thus finally forces you to do what needed to be done in the first place. You may have to cut back on commitments or speaking engagements or working three jobs or late night parties. Emotional stressors such as marital, family, relationship, or financial problems need to be dealt with and normalized. What are your main stressors? How can you reduce these to manageable levels? Consider talking with a counselor to help you.
8. Use ashwagandha or other “adaptogen” stress busters. This Ayurvedic herb has been used for thousands of years in Indian medicine to boost stress tolerance and generally rejuvenate the body. It is one of the most effective of the so-called adaptogens, which are extracts from plants that grow in the most hostile environments on earth. These plants have survived heat, cold, drought and, amazingly, can pass along this ability to endure such stress to you when you consume an extract of its active ingredients. As an added bonus, clinical studies have also shown ashwagandha to improve cognitive function and memory.

Panax Ginseng, Rhodiola Rosea, and Astragalus are also well-known adaptogens, and scientific studies have confirmed their medicinal effects to include improved brain function as well as anti-fatigue and anti-stress effects.

Different people react differently to specific nutrients, and adaptogens may work for you but they may not. Some people claim the supplement helps “take the edge off,” and helps them deal with the everyday stresses of life.

9. Exercise—the silver bullet once again. This probably should have been listed first, because it’s that beneficial. Here’s what exercise will do for you: It is a wonderful stress-reducer, it will help you sleep more soundly, it increases blood flow, it normalizes levels of cortisol, insulin, blood glucose, growth hormones, and thyroid hormones, and it will make you feel generally better. No adrenal support program is complete or will be totally effective without some form of regular exercise.
10. Take low-dose prescription cortisol (hydrocortisone). The first nine steps in this rejuvenation program work for most people. But in severe cases, where the adrenal glands are thoroughly exhausted, your physician may want to help jump-start your adrenals with prescription hydrocortisone.

Patients are usually started at 5 to 10 mg twice a day. Sometimes the physician may add 10 to 25 mg of DHEA, the other major hormone made by your adrenals. The good news is you will not need to take hydrocortisone forever. Usually, a few months of administration along with the other components of the program is all it takes to bring your adrenals back. Once your adrenals are working properly, you stop the prescription with your doctor’s approval. This prescription med can be safely administered under the guidance and skill of your physician, but since it is a steroid you should always be working to a defined goal or weaning off this drug as soon as possible.

The Thyroid/Depression Connection

Could a low-functioning thyroid gland be a contributing factor to your depression? Consider:

• Thyroid hormones and depression are intricately connected—an under-active thyroid gland is associated with depressive symptoms.
• Low thyroid function is quite common, especially as we get older. Some experts suggest that as many as 40 percent of our population has an underactive thyroid problem because of the common thyroid inhibitors in our society
• Patients who have been diagnosed with hypothyroidism by their conventional doctor and who are taking synthetic forms of the thyroid hormone T4 often continue to experience clinical depression (Synthroid, Levoxyl, and Levothyroxine are examples of synthetic T4 products). On the other hand, patients who switch to a T4/T3 thyroid preparation like Armour Thyroid often gain relief from their depressive symptoms. This is because they are finally getting enough of the active T3 hormone.Your best efforts to treat your depression with or without drugs may be futile if you do not first address your thyroid issue.
• The good news is that hypothyroidism is highly treatable, and correcting your suboptimal thyroid function can improve your health in many other ways— including getting your high cholesterol numbers under control and the possibility of enabling you to lose weight when it has seemed virtually impossible in the past.

Low Thyroid Function

The thyroid, a butterfly-shaped gland located in the neck, produces thyroid hormones which regulate the overall metabolism of our body. Metabolism is the breakdown of food by the body and its transformation into energy—i.e., the process by which our body burns calories for energy. Every cell in our body needs thyroid hormone to perform the function it performs. Brain cells must have the thyroid present to generate cognitive functions.

If the thyroid gland is producing too little thyroid hormone—the condition called hypothyroidism—the body’s metabolism starts to slow down. Brain cells begin to malfunction in areas of energy, memory, cognition, and mood. Depression can be the result. But low metabolism also affects the way we burn calories and our ability to keep our body weight at a proper amount. If you cannot lose those extra pounds in spite of your best efforts at dieting and exercise, an underactive thyroid might be the missing link.

How prevalent is low thyroid function?

It’s important to understand that we are having almost an epidemic of hypothyroidism in America, meaning you could be affected. Doctors at Columbia Presbyterian Medical Center in New York estimate that 20 million people are currently being treated for a thyroid problem, and the University of Colorado Health Sciences study confirms that another 13 million people would be diagnosed with low thyroid if they only had minimal standard testing performed.

Do You Have Low Thyroid Function?

Getting a proper diagnosis of hypothyroidism is more difficult than it might seem. Certainly you can ask your doctor to run some blood tests, but those alone can often miss a legitimate case of low thyroid function. So getting an accurate diagnosis involves three steps, the first two of which you’ll do yourself. They are:

Step 1: Determine whether you have three of more of the common symptoms of hypothyroidism (see symptom checklist box on the top of this page). The more your symptoms match the typical profile of low thyroid function, the greater the likelihood you have suboptimal thyroid function.

Step 2: Conduct the Barnes Basal Body Temperature test. Since your thyroid hormone regulates metabolism in the body, your metabolism rate is a good measure of thyroid hormone function. In fact, according to the results of a study published in the European Journal of Clinical Nutrition, the basal metabolic rate is a much more reliable indicator of thyroid hormone deficiency than blood testing.

Step 3: Why not just skip the first two steps in this thyroid function test and go directly to the lab tests conducted by your doctor? Frankly, the standard TSH lab test performed by your doctor is often inadequate in detecting suboptimal thyroid function. If you go to your doctor as an informed patient and describe symptoms you may have that correspond to low thyroid, and if your results of the Barnes Basal Body Temperature Test point to the same, then there will be proper justification for the more accurate lab tests described below:

Standard Lab Tests Don’t Tell the Whole Story

TSH Testing. Doctors typically diagnose thyroid problems by testing your TSH (thyroid-stimulating hormone) levels and sometimes the free T4 level. TSH has traditionally been considered a good measure of thyroid levels. Why? When your body is low in thyroid hormone, your pituitary gland produces the thyroid-stimulating hormone (TSH) to rev up production of the thyroid hormone. So in theory, a low level of TSH means your body has plenty of thyroid, and a higher reading of TSH means your body needs more thyroid and the pituitary is trying to stimulate production with more TSH.

The TSH lab result has typically has been thought to be abnormal if it is higher than 5 mIU/L (milli-international units per liter). However, guidelines from the American College of Endocrinologists indicate that any TSH over 3 is abnormal.

In spite of this, many physicians find their hypothyroid patients don’t achieve optimum symptom relief until their TSH level is between 1 and 2 mIU/L and sometimes even less. There are various reasons for this, and we looked at some of them earlier. For example, if a patient has excessive fluoride and chlorine levels due to drinking unfiltered water and also has inadequate iodine, then the fluoride and chlorine attach to the thyroid hormone instead of the iodine, thus making it dysfunctional. The TSH blood test shows you have plenty of thyroid hormone, but it cannot recognize that it is the deactivated type that isn’t functioning properly.

T4 Conversion to T3: A Common Problem

Your thyroid gland produces two major thyroid hormones: T4 and T3. About 93 percent of the hormone produced by the gland is in the form of T4, the inactive form, and the remaining 7 percent produced is the active hormone T3. It is the T3 that sends messages to your DNA to turn up your metabolism, increase fat burning, and generally make every system in your body work at the right speed. You need T3 to lower your cholesterol, improve your memory, and keep you thin, plus a host of other critical functions.

The large amount of T4 produced by the thyroid gland serves as a reserve, and when your body needs the active hormone, your liver converts T4 into T3 with the help of an enzyme. But here is the rub: Many people do not adequately convert T4 to T3 because of the impaired function of this enzyme and other factors. Factors that can impair T4/T3 conversion include inadequate selenium, poor adrenal function, heavy metal toxicity, yeast over growth, excessive soy consumption, old age, many of the common pharmaceutical drugs, high stress, high chlorine and fluoride levels, low stomach acidity, and H. pylori infection. It’s easy to see why so many people may have plenty of T4 but are not able to convert it to the active hormone T3.

How to Treat Low Thyroid Function

Two major approaches are available to treat low thyroid function:

• Identify and treat the underlying causes of your low functioning thyroid.
• Use thyroid hormone replacement therapy.

It is always best to first treat your low thyroid function by correcting the underlying causes, but sometimes stubborn cases require additional help or, quite possibly, you may need an immediate fix to give quick relief to some of your severe symptoms. Here’s where actual thyroid hormone replacement with a prescription from your doctor can come to the rescue.

This is a good alternative for people experiencing depression or for those busy people who just don’t have the time or inclination to work on those underlying causes. A good plan for those of you who fall into that category would be to go ahead and proceed with hormone replacement therapy but at the same time begin working on the 11 actions described in our forthcoming section “Underlying Causes” (see p. 26). Doing so will not only allow you, after a number of months, to adjust downward your thyroid hormone replacement dosage, but many other nagging health problems may get solved when your body is getting enough iodine, clean water, vitamin D, omega-3s, and exercise.

Low Thyroid Function: Actions for Treating Underlying Causes

1. Effectively deal with stress and optimize your adrenal hormone function. Almost all of us have stress, but do you have excessive chronic stress that has exhausted your adrenal gland function? If so, your thyroid repair effort will not be successful unless you also work on your exhausted adrenals at the same time. Inadequate adrenal function is a major cause for poor T4/T3 conversion and for suboptimal thyroid production.
2. Optimize your body’s iodine level. Iodine at adequate levels is absolutely essential to a healthy thyroid and efficient metabolism. It even comprises a large part of the thyroid hormone molecule itself —T4 has four attached iodine molecules, and T3 (the biologically active form of the hormone) has three, showing what an important part iodine plays in thyroid biochemistry. To increase your body’s levels of iodine, eat foods rich in iodine. That includes foods from the ocean—especially brown and red seaweeds—along with radishes, asparagus, carrots, tomatoes, spinach, rhubarb, potatoes, peas, strawberries, mushroom, lettuce, bananas, cabbage, egg yolk, and onions.
3. Optimize tyrosine. Your body uses tyrosine to make thyroid hormone. Many people need much more tyrosine than they get in their diets. Signs of a tyrosine deficiency include depression, difficulty concentrating and focusing, low blood pressure, and, of course, low thyroid. The usual dose is 500 mg taken in the morning, mid-morning, and early afternoon. If you have high blood pressure or are on any prescription medication, be sure to talk with your doctor before taking tyrosine.
4. Optimize selenium and zinc. Selenium facilitates one of the major enzymes necessary to convert T4 to T3. In elderly people, decreased selenium levels have been associated with decreased T3 levels. Check to make sure your daily multi-vitamin multi-mineral has 150 to 250 mcg of selenium daily or increase your food intake of nuts (Brazil nuts and walnuts), tuna, scallops, or turkey. Zinc is also important for thyroid function and can be found in adequate levels in seafood (especially oysters), oatmeal, chicken, liver, spinach, nuts, and pumpkin seeds.
5. Detox mercury. Mercury poisoning is a possible cause of disorders ranging from chronic fatigue and fibromyalgia to depression, anxiety, irritability, mood disorders, and autism to heart disease, autoimmune diseases, and others. Many health experts believe that because the thyroid affects all cells in the body, mercury’s toxic effect on thyroid function is a primary cause for such a wide variety of disorders. Mercury makes inactivate the enzymes in the thyroid gland that create thyroid hormone. Most of us get our excess mercury exposure from two primary sources: contaminated fish and amalgam dental fillings.

Sadly, most of the fish you buy from the supermarket or order at the local restaurant has excessive levels of mercury, PCBs, antibiotics, and other toxins that make it unsafe to eat. Therefore, eat only small cold-water fish such as striped bass, wild Alaskan salmon, herring, sardines, anchovies, and Alaskan halibut.

Regarding the second major source of mercury: If you have a mouth full of silver amalgams, you may have cause for concern. Silver dental fillings, or amalgams, contain inorganic mercury, and studies show that these fillings release mercury vapor and this is absorbed into your body, ending up in your urine and blood, and getting deposited in your organs, including your brain and thyroid gland, where it accumulates over time. Your regular dentist can remove silver amalgams and replace them with safe composite materials but special precautions need to be made in doing so in order to prevent an overload in mercury exposure to your body. You may want to go to a specially trained dentist who practices Biocompatible Dentistry and has received special training in the safe removal of amalgam fillings.

If you’re concerned, you can pursue mercury testing. The best way to assess mercury levels is with a challenged urine test. This involves the administration of a chelating agent—such as DMSA by mouth or DMPS by injection—that pulls mercury out of fat and other tissue where it may be stored. The mercury is excreted in urine, which is collected and sent to a lab for testing. The report you get back may cause you to be shocked at your excess mercury levels, and that may explain the source of some of your most significant health challenges.

What about mercury detox methods? Here are some of the best approaches:

• Use the cilantro/chlorella approach. Studies have shown that fresh cilantro—the herb used as a culinary seasoning—stimulates the body’s release of mercury and other heavy metals from the brain and central nervous system into other tissue. This facilitates the ability to remove mercury from the body using chlorella, a chlorophyll containing green-blue algae. Chlorella will thoroughly coat your intestine and bind like a sponge to any mercury that the cilantro liberates into the gut. Both cilantro and chlorella are needed for this approach to work. You can use fresh cilantro; it’s readily available at the grocery store. Use at least 1/4 cup (pressed down) per day of cilantro leaf and work it into your recipes or smoothies.
• Begin using saunas several times per week. When you sweat, you’re using one of your body’s major elimination channels.
• Make sure your bowels are moving. If you need to increase your bowel movement frequency, you can add ground chia seeds to smoothies or foods, or take psyllium (fiber) supplements.
• Drink plenty of water. Make sure you’re drinking pure filtered water to keep the elimination process moving.

6. Determine whether you need to go gluten-free. Gluten sensitivity is one of the more common causes of thyroid dysfunction. Gluten is a common protein found in wheat, barley, rye, oats, spelt, and kamut that can cause autoimmune responses in the body, including Hashimoto’s thyroiditis, a common autoimmune thyroid condition. While there are many causes for this autoimmune condition, about 30 percent of the patients Hashimoto’s thyroiditis have an abnormal reaction to gluten.

Testing for gluten and other food sensitivities involves measuring your antibodies IgG and IgA. However, many people find it easier and less expensive to simply conduct a trial period whereby they eliminate all gluten-containing foods from their diet. Doing so for one to three months while repairing the gut with probiotics (healthy bacteria) can usually reduce or eliminate the ill effects of these temporary delayed food sensitivities, if the patient truly has a gluten sensitivity problem.

Some people report feeling better just by following a gluten-free diet. These people find that such a diet not only helps their thyroid gland function, but it improves their energy and digestion and it can help relieve their headaches, arthritis, sinus problems, irritable bowel syndrome, acne, eczema, and more. Even if you know you’re not gluten intolerant (the serious form of gluten sensitivity, as in the case of celiac disease), you can run a trial period of gluten elimination and see whether it solves minor health challenges that have been plaguing you for some time.

7. Drink only filtered or distilled water. Do you drink regular tap water from your city’s public water supply and use it to make your coffee and tea and other drinks? Do you do so thinking it is harmless to your health? Consider this: The Environmental Working Group of 20 million water quality tests performed between 2004 and 2009 revealed that some local and regional water supplies are tainted with up to 316 different toxic chemicals, many of which are unregulated by current federal standards. Such chemicals being found in water are a result of discharge from agricultural pesticides and fertilizers, industrial pollutant runoff, and other wastewater treatment residue that makes its way into aquifers, reservoirs and groundwater supplies. Experts question the long-term safety of ingesting such tainted water, citing the fact that even existing federal laws about regulated chemicals suggest that tap water is unsafe for long-term ingestion. Health officials admit that current acceptable water contamination limits render water unsafe to drink.

The bottom line is that tap water could be a detriment to your good health efforts. If you have a concern, get your tap water evaluated.

8. Optimize vitamin D. Vitamin D, or “the sunshine vitamin,” is a critically important nutrient that affects many aspects of human physiology. For thyroid function, it is absolutely critical, as it helps the T3 thyroid hormone bind to the receptor on the nucleus that controls gene function and our overall metabolism. In addition to contributing to hypothyroidism, low vitamin D can also cause many other problems, including osteoporosis, cancer, heart disease, fatigue, depression, seasonal affective disorder (SAD), diabetes, inflammatory bowel disease, rheumatoid arthritis, and fibromyalgia.

Are you getting the vitamin D you need? Probably not. The correct blood test your doctor needs to order is 25-hydroxyvitamin D, also called 25(OH)D. The optimal value of vitamin D that you’re looking for is in the range of 50 ng/ml (115-128 nmol/l) to 75 ng/ml (nanograms per milliliter). Your vitamin D level should never be below 32 ng/ml, and any levels below 20 ng/ml are considered serious deficiency states, increasing your risk of breast and prostate cancers, autoimmune diseases, and many others. To get an idea of just how widespread vitamin D deficiency is, consider that the late winter average of 25-hydroxyvitamin D in the United States is only about 15-18 ng/ml!

If you find that you’re deficient, you have two good options:

• Get more sun exposure (this is by far the best option but is challenging for most people).
• Take a vitamin D3 supplement that gives you 3,000 to 10,000 IU of vitamin D3 daily and do that for several months. This higher dosage level is usually required to get your blood level up to the needed range of 50 to 75 ng/ml. Only a blood test can tell if you have reached that goal so retesting after three to six months is a good idea. Once you have your level in the desired range, the long-term maintenance doses of 1,000 to 2,000 units a day are usually adequate.

9. Do not take a thyroid glandular extract. These extracts are considered supplements and are not regulated by the FDA as in the case of Synthroid or Armour. Therefore, they will vary in consistency and potency. This is a case where Armour and the prescription thyroid meds are without question the best way to go. They have very few side effects, are inexpensive, and work.
10. Optimize omega-3 fats.These essential fatty acids found in cold water fish as well as certain nuts and seeds are critically important in the production of thyroid hormones. In fact, a variety of studies and physiological principles suggest that omega-3 fat in doses of 3 to 5 grams per day (via supplement) would be helpful in restoring thyroid function. Make sure the omega-3 supplement you choose is mercury-free.
11. Exercise: the silver bullet once again. We keep bringing up exercise for a reason: It’s a key component in so many aspects of overcoming depression. Find the sort of workout that appeals to you, whether it’s walking, running, hiking, tennis, or medicine-ball workouts, and stick to it. But once again, exercise is especially important to good thyroid function. It directly stimulates your thyroid gland to produce more thyroid hormone; just as important is the fact that it increases the sensitivity of all your tissues to thyroid hormone. Because thyroid hormone is needed in every cell of the body, it is even thought that many of the health benefits of exercise stem directly from improved thyroid function! No thyroid support program is complete or will be totally effective without some form of regular exercise.

Thyroid Replacement Options

Option 1: Synthetic Version. Brand names of thyroid replacement products include Synthroid, Levoxyl, Levothyroid, or Unithroid. The problem with Synthroid, as discussed earlier, is that it contains only T4, the inactive thyroid hormone. Your body must convert T4 into the active form, T3, on an as-needed basis, but a large number of people don’t convert very well. Poor T4-to-T3 conversion is caused by inadequate selenium, poor adrenal function, old age, high stress, high chlorine and fluoride levels and other factors, it’s easy to see why so many people do not respond well to the synthetic version of thyroid hormone replacement. They simply are not converting T4 to T3 and are still deficient in the active hormone.

Option 2: Natural Version. This includes Armour Thyroid or Nature-Thyroid or Westhroid. These preparations are a combination of T4, T3, and T2 made from desiccated, or dried, porcine thyroid. Armour Thyroid has received a bad rap over the years, perceived by some physicians to be unstable and unreliable in terms of dosage. However, many improvements have been made in the product, so it’s a safe and effective option for treating hypothyroidism today. In fact, research has shown that a combination of T4 and T3 is often more effective than T4 alone, and testimonies abound of patients who continued to feel bad under the synthetic version but thrive under the natural desiccated hormone replacement therapy. You’ll need to work with your physician to find the right dosage of this medication. Doctors will often start you off at one level and see how well it relieves your symptoms and then will continue to adjust accordingly until they have zeroed in on the right dosage. Periodic lab testing can be used to make sure you’re not getting too much of the T4/T3 hormone.

Sex Hormone Deficiency and Depression

When trying to dig down to depression’s underlying root causes, abnormalities in the level of sex hormones certainly is a major consideration. This is not referring to the normal fluctuations of estrogen and progesterone in women or testosterone in men—the normal changes can certainly cause major mood shifts and make you temporarily feel depressed, but these happen to most everyone, even to those without depression. On the contrary, chronic depression can occur when hormone levels do not rebalance or are either excessively high or low. In this scenario, unless you correct the reproductive hormone level abnormalities you likely will not achieve a complete long term healing from your depressive symptoms.

How Sex Hormones Affect Your Brain

Sex hormones act on the brain to directly affect mood and cognition. In women, for example, estrogen promotes the production of neurotransmitters, especially serotonin, making it a wonderful antidepressant and a great sleep aid. When estrogen levels take a dip, such as at menopause, mood can take a hit and insomnia can become a problem. Deficient estrogen levels therefore can combine with other biochemical imbalances with the end result being clinical depression in women.

Men have the same happen to them involving their primary reproductive hormone testosterone. There are receptors in the brain for men and women for all hormones including estrogen, testosterone, and the other reproductive hormones. The right amount of estrogen can be neuroprotective but too much can cause breast, uterine, and cervical cancer in women. So in the area of reproductive hormones, the goal is to get the right balance—not too much, not too little.

Here’s a list of the main reproductive hormones that are of most concern when trying to discover the root cause of depressive symptoms:

• Estradiol
• Estriol (women only)
• Estrone (women only)
• Progesterone
• Testosterone

Testosterone deserves a special mention. It is a wonderful brain-boosting hormone improving mood, memory, motivation, and overall cognitive function—in both men and women. It can be abnormal at any age for men or women for various reasons, but testosterone is known to drop significantly in women and men as they age, and it has an enormous impact on quality of life.

For example, if you lose optimal testosterone, you lose your sex drive and energy level as well as your sense of well-being. Too much testosterone, however, can cause nervousness, agitation, anxiety attacks, or insomnia.

Once again, balance is the key. Scientific studies confirm the relationship between testosterone and depression. One study involving elderly men showed that men in the group having the lowest free testosterone levels had three times the odds of having depression compared to men in the highest group. In another study, both men and women having low DHEA levels (precursor hormone to testosterone and estrogen) had a higher risk of depression.

Why do these hormones become deficient or get out of balance?

Hormone fluctuations related to a woman’s reproductive cycle can have a profound influence on her mood. In light of this possibility, you and your doctor should always look for connections between your depressive symptoms and the female reproductive cycle. Is your depression connected to your menstrual period and a possible effect of PMS? Postpartum depression and peri-menopausal depression are common.

For men, andropause is the menopause-like condition in aging men, where testosterone levels fall significantly below the normal range. This condition, which generally occurs between the ages of 40 and 55, can cause serious dysfunctional symptoms such as loss of libido and potency, nervousness, depression, impaired memory, the inability to concentrate, fatigue, insomnia, hot flushes, and sweating.

Certainly, our hormones in general decline as we age—as they did for our parents and grandparents. But our modern society contributes to this decline in ways that our ancestors did not have to face.

For most of us today, these hormones decline in large part because of weight gain, lack of exercise, chronic stress, and high-sugar diets—not because we are genetically designed to have less testosterone as we age.

What to Do About It?

First, run lab tests to determine if your sex hormones are excessively out of balance. If they are, you need to work with a physician to get your hormones balanced. This is a highly complex area that absolutely requires an experienced physician to help you with. Don’t try this on your own! It’s too easy to self-medicate with the wrong hormones or the wrong amounts and cause even more imbalance which will make the symptoms even worse.

Laboratory Testing

You will need laboratory testing of several hormone levels: progesterone, estrogen, testosterone, DHEA, thyroid, lipoprotein(a), and possibly growth hormone. Salivary hormone testing has many advantages over the blood testing method.

First, blood consists almost entirely of non-bioavailable hormones. These are form of the hormones in your body that are bound up by binding proteins, such as sex hormone binding globulin (SHBG), cortisol binding globulin (CBG), and albumin.

Measuring these bound-up hormones gives a very inaccurate idea of what is effectively going on at the tissue levels. Saliva on the other hand contains only bio-available, unbound hormones. So analyzing the hormone content of a saliva specimen gives a far more accurate result.

Treating Sex Hormone Deficiency

Once your lab results come back to you or your doctor, he or she will determine if there are any imbalances that need correcting. Again, this is a complex matter that needs the input of an experienced medical provider. Also, all of the sex hormones require a physician’s prescription for proper replacement.

Talk to your doctor about bioidentical hormone replacement, as this is recommended over synthetic hormone replacement therapy (HRT). Studies have concluded that synthetic HRT, with either estrogen alone or estrogen and synthetic progestin, is associated with an increased risk of stroke, coronary heart disease, breast cancer, and pulmonary embolism.

Evidence based research demonstrates the safety and efficacy of bioidentical HRT. And, doctors who have used this approach report that these hormones are much better tolerated than conventional HRT.

Whereas half of all women starting on conventional HRT discontinue it within a year because of unwanted side effects, compliance among women taking bioidentical hormones, which are tailor-made for each woman, is excellent.

Remember, effective hormone therapy is not a one-size-fits-all solution, and replacement therapy will involve prescription bioidentical hormones that can be administered only by your doctor. Laboratory testing is a key component of the therapy protocol and key markers have to be watched by your doctor to make sure the proper balance is being maintained.

The End Result

Men and women who work closely with their physician and get sagging hormone levels back in balance usually experience remarkable results in terms of how they feel. Energy, brain function, libido, restful sleep, and much more can be vastly improved.

So don’t let hormone imbalances keep you from experiencing a full recovery from your clinical depression. This step certainly requires some extra work on your part plus the partnership of a caring physician, but the end results will likely be well worth it!

Now, if you’ve worked and made sure that your adrenal, thyroid, and sex hormone function are all up to par, then it’s time to look at the next major underlying cause of clinical depression—an imbalance in neurotransmitters.

The post Strategy #1: Hormone Function Problems appeared first on University Health News.