The Hormone Link: Recognize the "Link" Between Your Health and Hormones

By Margarita Ochoa-Maya MD

I wrote this book because I came to a crossroad in my life when I felt that what I had set out to do when I decided to become a doctor was no longer in agreement with the current medical practice and the health care institution. Modern health care in the United States is not winning against disease. Health care is extremely expensive and seemingly hard to attainbut there is a reason.

• Language: English
• Publisher: Xlibris US
• Release date: Dec 21, 2016
• ISBN: 9781514420683

Margarita Ochoa-Maya MD

Dr. Margarita Ochoa-Maya, MD Integrative Endocrinologist, Hormone Specialist Originally from Medellin, Colombia, Dr. Ochoa-Maya graduated with honors from Instituto de Ciencias de la Salud, CES, an internationally acclaimed medical school. She came to Massachusetts on an excellence scholarship from Boston University and completed four-year medical school courses. She was then accepted outside the Match to further complete her internal medicine residency at Boston City Hospital/Boston Medical Center, teaching hospitals for Boston University Medical School. She then pursued a fellowship in endocrinology and metabolism at Brigham and Women’s Hospital’s Endocrinology and Hypertension Division, teaching hospital for Harvard Medical School. She also completed a fellowship in medicine at Harvard Medical School. Dr. Ochoa-Maya is board certified in internal medicine and endocrinology and is now pursuing a board certification in obesity medicine with the Obesity Society. She is an international speaker in the field of hormones. Dr. Margarita R. Ochoa-Maya, MD, CDE, has been practicing subspecialty endocrinology since 1995 and has been in private practice since 1999. Her most recent endeavor is the Integrative Endocrinology Practice, Advanced Health and Well-being PC established in 2010. You can see her website at 00000. Dr. Ochoa-Maya is well-known in southern New Hampshire, Massachusetts, as well as along the East Coast through Florida. Dr. Ochoa-Maya also has telemedicine patients around the world and takes pride in her integrative and functional methodology. She blends traditional medicine with contemporary approach. She incorporates the biological aspects of the human body and chronic disease with the concept of constant continuing education, application of psychology, spirituality, and patient education as well as understanding of the importance of the doctor-patient relationship with respect to each unique patient’s circumstances. Dr. Ochoa-Maya’s interests are vast. She specializes in the gender differences in metabolism and obesity. She has designed a medically supervised and optimized weight management program where she helps people across the world. She also specializes in diabetes and the new technology advances in diabetes such as continuous glucose monitoring (CGMS) and insulin pump technology, as well as diabetes’s complications such as cardiovascular disease and hypertension. She is also proficient in women’s health, polycystic ovarian syndrome (PCOS) and infertility, and menopause. She practices integrative thyroid disease management and specializes in thyroid imaging, ultrasound-guided biopsy, and advanced nodule and cancer detection using gene expression classification to improve the diagnosis of thyroid cancer and early intervention. She further specializes in male and female hormone balance and replacement and fully understands bioidentical hormones in a more physiologic approach to hormone replacement and health promotion for both men and women for peak performance. Dr. Ochoa-Maya is an avid blogger and posts interesting topics in hormone health at www.FreedomToHeal.org. She is almost finished with her groundbreaking book named The “Link”: Understand the Relationship between Hormones and Health, soon to be published. If you need to contact Dr. Ochoa-Maya, please e-mail her at [e-mail]. She is on social media: LinkedIn, Facebook, and Twitter, among others. “Knowledge breeds consistency, consistency promotes efficiency, and efficiency contributes to improved patient care!” (Education Services)

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Copyright © 2017 by Margarita Ochoa-Maya, MD.

Library of Congress Control Number:      2015917722

ISBN:      Hardcover      978-1-5144-2069-0

      Softcover      978-1-5144-2070-6

      eBook      978-1-5144-2068-3

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Rev. date: 12/20/2016

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CONTENTS

Dedication and Disclaimer

Preface

Introduction

Why I Decided To Write This Book

Chapter 1     A New Paradigm - Integrative Endocrinology

Hormones And Glands

Chapter 2     The Normal Thyroid

Hypothyroidism, Hyperthyroidism And Thyroid Cancer

Chapter 3     What Is Stress?

Adrenal Hormones And Metabolism

Chapter 4     Hormone Production In Men

Male Hormones (Testosterone, Estrogen, Progesterone)

Chapter 5     Hormonal Journey Of Life

Puberty & Adolescence

Chapter 6     Hormone Imbalances

Pcos And Endometriosis

Chapter 7     Pregnancy And Maternal & Fetal Health

Pre-Eclampsia & Eclampsia

Chapter 8     Breasts And Bras

Common Breast Problems

Chapter 9     Perimenopause

Menopause Phase I, Phase II And Phase III

Chapter 10     Estrogen

Progesterone And Testosterone

Chapter 11     Vaginal Issues

Incontinence

Chapter 12     Skin Basics

Acne

Chapter 13     Sexual Behavior

Sexual Organs

The Hormone Link: Conclusion

About Dr. Margarita Ochoa-Maya, MD

LIST OF FIGURES

Figure 1: Logical Meaning of the Medical Logo

Figure 2: Ideal Principles Of Ideal Health Promotion

Figure 3: Meaningfulness, Progress, Competence and Choices in healthcare

Figure 4: The Different Approaches To Medicine

Figure 5: An Integrative Approach to Well-Being

Figure 6: Subspecialities in the field of Endocrinology

Figure 7: Integrative Endocrinology

Figure 8: My Method

Figure 9: Anterior & Posterior Pituitary

Figure 10: Common Endocrine Hormones

Figure 11: Endocrine Cell

Figure 12: Hormones

Figure 13: How hormones communicate with a target cell

Figure 14: Polar Hormones

Figure 15: Types of Hormones

Figure 16: Non-Polar Hormones

Figure 17: Hormone Mediated Activation

Figure 18: Location of the Pituitary Gland

Figure 19: Main Functions of the Pituitary Gland

Figure 20: The Thyroid Gland

Figure 21: The Thyroid and Parathyroid Glands (view from behind)

Figure 22: Thyroid Hormones Dynamic

Figure 23: Normal Thyroid Function

Figure 24: The thyroid gland: normal and goiter

Figure 25: Image describing the T4 to T3 conversion

Figure 26: Graphic description of hypothyroidism

Figure 28: Graphic description of Hyperthyroidism

Figure 29: Radioactive iodine test

Figure 30: Graphic description of a thyroid nodule

Figure 31: Graphic description of a thyroid nodule and biopsy

Figure 32: Graphic description of a fine-needle aspiration biopsy of the thyroid gland

Figure 33: Decision tree to proceed with the results of a FNA of a thyroid nodule

Figure 34: The different types of thyroid cancer

Figure 35: Different types of Stress

Figure 36: The adrenal gland is located superior to the kidneys

Figure 37: The Two Parts of the Adrenal Gland: What Do We Do?

Figure 38: The different layers of the Adrenal gland

Figure 39: Image depicting the process by which the adrenal gland makes adrenal hormones

Figure 40: Image describing the different effects of hormones on the adrenal gland

Figure 41: A common salivary test for adrenal hormone balance

Figure 42:Chronic Stress and Adrenal Hormone Output

Figure 43: Description of the different phases of Adrenal hormone secretion

Figure 44: Male gonad and genital anatomy

Figure 45: Levels of testosterone

Figure 46: Testosterone molecule

Figure 47: Male hormone feedback loop

Figure 48: Testosterone target organ

Figure 49: Age Related Decline in Testosterone Levels in Men

Figure 50: The journey of a woman from childhood to death as seen through the hormonal cycle

Figure 51: The pituitary, the ovaries and the uterus in a woman and how they work together

Figure 52: Visual description of the synchrony between hormones and ovulation

Figure 53: Feedback loop communication system among the pituitary gland and ovaries with growing follicles, the process of ovulation, and function of the corpus luteum

Figure 54: Putting it all together to understand the relationship among the pituitary gland, ovary, hormones, and uterine lining across the menstrual cycle

Figure 55: Ovulation

Figure 56: Signs of ovulation

Figure 57: Conception

Figure 58: The postovulatory infertile phase

Figure 59: Menstruation

Figure 60: Visual description of intrauterine device

Figure 61: Subdermal contraceptive implant

Figure 62: Visual description of a vasectomy

Figure 63: Visual description of a tubal ligation as a form of contraception

Figure 64: Visual description of the Essure procedure

Fg. 65: The different types of PCOS

Figure 66: PCOS Diet

Figure 67: Endometriosis

Figure 68: Causes of infertility by gender

Figure 69: Possible causes of female infertility

Figure 70: Male spermatozoid

Figure 71: Abnormal Spermatozoid Anatomy

Figure 72: In vitro fertilization

Figure 73: Intracytoplasmic sperm injection (ICSI)

Figure 74: Sperm retrieval procedures

Figure 75: Oral Glucose Tolerance Test

Figure 76: Pre-eclampsia

Figure 77: Fetal Monitoring

Figure 78: Thyroid disease and pregnancy

Figure 79: Pregnancy, the thyroid, and the induced thyroid change due to pregnancy

Figure 80: A graph describing thyroid function over time before or after delivery

Figure 81: Breast Anatomy

Figure 82: Normal Breast

Figure 83: Breast cysts

Figure 84: Fibroadenoma of breast

Figure 85: Phases of Hormonal Deficiency

Figure 86: Phases of Menopause

Figure 87: heart disease rate in menopause

Figure 88: Estriol (E3) is the primary estrogen of pregnancy.

Figure 89: Estrogen metabolism in the liver

Figure 90: Estrogen detoxification and elimination

Figure 91: Progesterone

Figure 92: Micro nutrients needed to metabolize estrogen

Figure 93: Side view of the female pelvic muscles

Figure 94: Front view of bladder and pelvic and sphincter muscles

Figure 95: Pelvic floor and bladder front view

Figure 96: Normal skin anatomy

Figure 97: The layers of the epidermis

Figure 98: Visual description of the different types of lesions in acne: Blackhead open comedon

Figure 99: Acne inflammation

Figure 100: Visual description of the hair follicle and the phases of anagen, catagen, and telogen

Figure 101: Components of Libido

Figure 102: Sexual response cycle men and women

Figure 103: Sexual response cycle in women

Dedication

"To my dear husband and children, who have taught me that true love is possible and that with love ANYTHING can be achieved."

Dr. Margarita Ochoa-Maya, MD

Endocrinology and Metabolism

Women’s Health

www.AdvancedHealthNH.com

www.TheHormoneLink.com

www.FreedomToHeal.com

Disclaimer

Although there are many health care experts giving advice on lifestyle and this book is one of them, regardless of the source, it is extremely important to understand that every individual has unique circumstances and medical needs that cannot replace the relationship a person may have with their doctor. It is critical to consult with your health care provider before starting any changes to your health.

I believe that the health care provider should not only be a prescriber of medication but also an advisor and a teacher. In general, people should contact their doctors prior to starting a diet, exercise, or lifestyle program. Also, it is important to consult with your physician prior to taking vitamins, minerals, and other nutritional supplements as they have direct implications on health. It is very important to understand that it is not advisable to manage, increase, or reduce prescribed medications without the prescription and recommendation from the doctor. I recommend that any person deciding to change their lifestyle do so with guidance.

The ideal case is when there is a health care team comprised of both the patient and the doctor, creating a health care collective. Again, consult with your health care provider(s) and work together to enhance your health in a responsible manner.

We have all heard the argument that good science is aligned with orthodoxy, but there are conditions that do not manifest gross clinical signs or symptoms at its inception and therefore precious time is wasted while waiting for the problems to appear. There is excellent deductive evidence, supported by the literature to substantiate preventive medicine. Wellness oriented medical care also uses medical interventions and pharmacologic support when needed.

Dr. Ochoa-Maya disclaims any liability or loss in connection with the advice given in this book. The Link between Hormones and Your Health is for a general broad audience and is mostly focused on lifestyle concepts, not on individualized, personalized, or specific health care advice. In no way should what is written in this book be substituted for medical counseling on an individual basis. This book does not want you to assume that the book is the only diagnostic tool you will need. It is simply another tool designed to help you with providing you with information and support. Please consult with your physician or health care provider before starting a lifestyle program.

Preface

I wrote this book because I came to a crossroad in my life when I felt that what I had set out to do when I decided to become a doctor was no longer in agreement with the institution. Modern health care in the United States is not winning against disease. Health care is extremely expensive—but there is a reason. The doctor-patient relationship is being lost by rushing advice and use of excessive prescription medication while cutting back on personal education and the encouragement of self-care.

Humanity is in the search for perfection. Today’s world is filled with images of perfect health, it is easy to lose balance. In our quest for optimal health and the requirements of society and our own internal desires, There is a discrepancy between the ideal and the real as we are bombarded with advertisements, music, arts, and the ideals of society in general. While we see images of thin and beautiful people portrayed as successful, rich, and happy, our society is getting sicker. There is an obesity epidemic that cannot be denied. The use of antidepressants, anxiety medications, and illicit drugs are at an all-time high, translating to a stressed-out and imbalanced society. Our youth appears lost between the use of technology and understanding boundaries, and the difference between being an emerging adult and a responsible adult.

One of the roots of disease and most important signs of lack of balance is obesity. When it comes to managing health, particularly weight and obesity, it is important to look for the underlying cause of the imbalance. Hormones are often overlooked in the diet and health assessments for people. The yo-yo dieters and their frequent frustration with unsuccessful weight loss programs may be due to an overlooked hormonal imbalance. Hormonal imbalance can also be at the root of many other problems, including anxiety, depression, and migraines, along with other disease processes that really interfere with quality of life. Imbalanced hormones can also be at the root of life-threatening diseases such as cardiovascular disease, heart attacks, and strokes via more subtle yet severe problems such as elevated cholesterol and diabetes. The link between hormones and health needs to be explained to people by physicians so that they understand the root of their problems and can seek attention sooner while instituting preventive measures instead of corrective measures that treat the complaint and not the root of the problem.

In the years that I have been involved in patient care as a Harvard-trained physician and international doctor, I have been given the opportunity to meet thousands of people and provide direct care to my patients and their families around the world. I have been able to see firsthand what today’s health care represents, the culture that surrounds the medical practice, and the decline in the doctor-patient relationship. There is a desire for a quick fix for problems that have taken years to present themselves. I have been engaged in giving lectures to fellow doctors and educational sessions to groups of patients and have seen the hunger for information that can be trusted and applied to daily living. I have written articles; and I have actively participated with the online community through several social media outlets including Facebook, Twitter, and my blog: www.FreedomToheal.org. My website is www.AdvancedHealthNH.com

These activities have allowed me to understand that there is a new era in medicine, one that I want to share with my readers. A medical art that is deeply rooted in traditional concepts yet one that embraces the needs of more contemporary patients. Medicine that promotes the integration of healing modalities fosters education and community participation through empowerment and motivation. I want my readers to understand the link between hormones and their health and well-being. With this book, my goal is to simplify the process for patients and invite them to be empowered by knowledge and ask the questions they need answered to improve their health and well-being. I want to promote prevention, self-care, and total well-being with a deep sense of restoring the importance of the doctor-patient relationship.

Contemporary medicine needs to be seen within the light of self-motivation and prevention, centered in close doctor-patient communication. Practical information and easy-to-understand material, which can be clearly understood by the patient, will be the keystone to patient engagement. I am convinced that this method will promote health, prevention of disease, happiness, and total well-being not only for individuals but also for families and communities as a whole. Hormones are the buzz lately. We are bombarded with topics such as hormone replacement therapy, weight loss plans, and other conditions that involve hormones; yet the link between hormones and optimal health is yet to be discussed. In this book, I review the common hormones that rule the communication system in our bodies and discuss the link between hormone health and total integrative health.

Hormone health is complex. There is a scarcity of endocrinologists (doctors who specialize in hormones) and an even greater shortage of doctors willing to explain the link between health and hormones. It goes far beyond the controversial topics of female hormones and menopause. I want to provide you with some information and insight into the relationship between hormones health and happiness.

Discovery consists of seeing what everybody has seen and thinking what nobody has thought—Albert Szent-Györgyi, 1937 (Nobel laureate scientist who isolated vitamin C)

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Introduction

As long as there are people willing to ask questions and ponder the reason for health, we can then pursue the freedom to heal. The understanding of obesity and the hormones that influence it, as well as the application of prevention through knowledge, will help us heal our mind, body, spirit, and soul.

Motivation to change lifestyle for the better does not happen in five minutes. It will be more attainable when people are informed and are driven to change their ways and habits when they see results and feel the improvement in their health. The result of bad habits is barely noticeable until the damage is done.

I have come to understand the importance of health and well-being with optimal quality of life. In order to attain this, here are the key factors that need to be linked and understood:

1. There needs to be a trusting and rewarding doctor-patient relationship in which both patient and doctor are committed to the improvement and prevention of disease and the optimization of health.

2. There needs to be a motivated and educated patient that is willing to work diligently with the doctor’s guidance in making the appropriate changes at the pace that is right for each individual.

3. There needs to be awareness to the connection of our thoughts, feelings, and reactions with what we understand of our genetic, environmental, and biologic/physical environment to be able to understand the root cause of our problems.

4. There needs to be a clear understanding of the hormones that operate and communicate throughout the body and how these systems are often the root of a problem. By dealing with the cause, treatment is more attainable.

5. There needs to be a clear plan in place with a secondary plan to go to when things fail or go off the rails.

When all these factors are linked, optimal health can be attained.

Awareness and total physical, psychological, and spiritual health promotion through motivation will change mankind for the better. It is paramount to have a good relationship with your doctor. Often, the problem of obesity is inherently related to a biological problem. In my practice, I often see the frustration and the desperation of my patients when they have been following a diet they think is healthy and exercising routinely but yet are still gaining weight or feel that their weight loss is not proportional to their efforts. With a good doctor-patient relationship and awareness of the not-so-obvious factors that influence weight, success can be attained.

I am inviting you, as the patient, to get involved. As long as there are people willing to ask questions and seek answers, we can then pursue the freedom to heal. More than ever, there is a need for people to be engaged in their health care. People need to learn about their bodies, how they work, and what diseases they are at risk for based on their genetic and family history. People need to become aware of the effect of stress and the toll today’s toxic environment has on their health and well-being. In this book, I wish to bring some of the good information that’s out there into the conversation about the link among hormones, health, weight, and happiness. I will discuss interesting topics on hormones that relate to the integration of your health and their influence on your weight, as well as how they are contributing to the obesity epidemic of today.

This book will discuss the most important factors that contribute to optimal health and well-being by introducing you to a new concept of health through the knowledge of hormones and how they influence almost every aspect of the human body. The link between hormones and health is the foundation of well-being, youth, graceful aging, and optimal performance.

Why I Decided To Write This Book

I have always felt a calling for teaching and promoting health education. I decided to write this book because in my daily practice, I have witnessed great success with my patients when I foster and promote the doctor-patient relationship. I help my patients find the answers they are seeking and take the time to explain to them their unique medical problems and the risks involved. I then use motivational tools to empower them to be active participants in their health transformation to optimal wellness, quality of life, and results. I decided to write about it because I know there are millions of people worldwide who want to see the same success in their own quest for optimum health, healing, and happiness.

Women and men alike around the world are very interested in their hormones even if they don’t know it. They want to know what drives their metabolism, their sexuality, and, most importantly, their success in their daily lives. This is all driven by your hormones. The answer is simple: apply healthy habits and ask the right questions to your doctors and health care providers when it comes to maintaining health, preventing illness, or restoring the harmful deficits in health caused by a not-so-good lifestyle. I am a believer that beauty is a sign of health, both inside and outside. It is not just appearance; it is a way of life. With this book, I am hoping to make available to motivated people essential information that will shed light on the biological, psychological, spiritual, and cognitive aspects of our existence and how all that relates to the hormones that provide communication within our body and mind. Understanding of this is essential in helping people change their lifestyle and address their weight problems with the kind of motivation that will help them reach their goals.

Chapter 1 - The Doctor Patient Relationship and the Link to Your Hormones

A NEW PARADIGM - INTEGRATIVE ENDOCRINOLOGY

HORMONES AND GLANDS

What drives the doctor to do well and challenge mainstream mediocre health care? I am concerned that in the near future, we will have computers that will eventually be able to receive a list of complaints a patient may have and, through the use of a preprogrammed algorithm based on population-based medicine, use this to produce a prescription. This is the ultimate degeneration of what I call mainstream health care. In this fast-paced world ruled by big pharmaceutical companies, mainstream health care attempts to connect a tangible chemical known as a drug to the list of complaints a person may have. In time, people will realize that the doctor-patient relationship is what keeps medicine human. There are many other factors that influence disease, such as mental and spiritual health.

PROMOTE SELF-EDUCATION AND INVITE KNOWLEDGE: A NEW PARADIGM TO APPROACH YOUR HEALTH

Today, the leaders of our society and those interested in their health optimization are looking to a new approach to health and well-being. It’s a form of health care that is driven by prevention and wellness. Education and its application when a person is aware of their health care risks because of a genetic predisposition or because of early detection of risk invites the patient, as an informed person, to be more engaged and motivated to get better and prevent disease or further complications. An informed patient seeks information and explanations. We are living in an era of explosive communication channels and social medial and the Internet where new information is available at the reach of the fingertips. This may be confusing and at times dangerous due to the deception of marketing and false promises.

Disease prevention, awareness, and health education promoted by doctors and health care providers are necessary when dealing with patients. By the use of education, the doctor can explain to a patient their specific condition and present examples of how the condition relates to the patient’s unique circumstances. In doing so, it is possible to foster a healthier community and present an alternate solution to reduce the incidence and severity of preventable diseases as well as reduce the accompanying economic burden due to illness in our world today. People will continue to search the Internet to learn about their diseases. Rather than discouraging that, I want to encourage education and questions. These questions need to be answered in order to foster trust with the patient. I believe that this will guarantee that the patient is a motivated partner with their physician to address their health concerns and prevent disease. I also believe that through education, we can then foster the improvement of the health for families and communities.

UNDERSTANDING THE LINK BETWEEN HORMONES AND HEALTH AND TOTAL WELL-BEING

When it comes to more esoteric topics and areas in which there is a great deal of controversy, such as hormones, understanding the basics will allow our patients to be informed and have open conversations with their doctors, in which the risks and the benefits are discussed instead of no discussion at all. This discussion will allow a conversation about the natural events in our human history: menopause, andropause, and other hormonal issues including thyroid disease. Many doctors worry about replacement versus enhancement when it comes to hormones. What is abuse, and what is dangerous? Unfortunately, due to many complex reasons, we will never have an absolute answer. There is no right and no wrong, but surely, the well-intentioned advice of a doctor who is trusted and can illustrate the benefits and the risks is better than a patient making decisions on their own—and possibly causing harm to themselves. Understanding the differences between legal and illegal, FDA approved, and off-label use requires a certain level of expertise. There is evidence based on clinical studies, and there are vanguard anecdotal—yet very popular—manifestos. Some people elect to use hormones at their own risk.

Unfortunately, some people are not informed, and their decision making is clouded by the promise of an immediate effect. An example of this is the use and abuse of hormones by athletes and celebrities who have gone around these safeguards and put their health on the line. This is the reason for this book. I believe that through health literacy, particularly about subjects that are complex and mired in controversy, the reader can understand why searching for the right doctor who will provide the best information based on their unique symptoms and health history is essential to optimum health. Patients should not have to draw their own conclusions, but rather, they should be partners in their health care with a trusted health care provider. I hope to engage the reader to question and seek answers to their questions, engage in candid conversations with their health care providers, and ultimately become responsible owners of their precious bodies.

MY GOAL: TO INTRODUCE A NEW PARADIGM IN INTEGRATIVE ENDOCRINOLOGY

The patient desires to be known as a human being, not merely to be recognized as the outer wrappings for a disease.

—Bernard Lown, The Lost Art of Healing

Medicine has a long history, and it’s one that repeats itself. It is common knowledge that in each discipline of science, new advances, theories, and discoveries adapt slowly, evolving into a new collective set of beliefs and theories, which then become the norm. It usually takes decades to overturn what is perceived as normal as a growing collective thinking emerges after enough evidence mounts to convince people that the old theories are no longer practical or even true.

Today we are living in a historic time in health care. Medicine is now in crisis. You know it, I know it, and we all know it. The majority of patients are not satisfied with the care they are given. Both doctors and patients share a dissatisfaction with the system and feel there is not enough time to address the issues at hand. This is largely due to the burden of the economics of health care that demands more patients to be seen in a short period of time allotted. As much as this is extremely important and somewhat unglamorous, it is a reality. In order to successfully navigate health and illness in the twenty-first century, there needs to be a shift in paradigm. We need to start to focus more on education and change the model from one based on illness and disease to a model based on true health and optimal function driven toward prevention and integration. Let us recall the definition of health proposed by the World Health Organization in 1948: Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. We need to come back to this concept and embrace not only the physical health of an individual but also the mental, psychological, and spiritual well-being of each individual, as well as the community as a whole.

We are at the edge of major transformation. We are now looking beyond the typical disease model, delving deeper into prevention, total well-being, and complementary medicine with a goal of optimizing function and asking humanity to support this new way of thinking. It may take some time, but given this crisis, we can take the opportunity to catapult change and improve humanity. The introduction of the anti-aging concept and the notion that health promotion and health education are paired with an emphatic encouragement of exercise, healthy nutrition, and use of micronutrients have opened new doors to the original concept of healing. Slowly but surely, the disparate worlds of traditional and allopathic Western medicine will merge with Eastern medicine and complementary healing modalities. There is a collective hunger for a unifying theory of health and disease based on our dissatisfaction with the current health care system.

There is much medicine and science that we cannot see with our current model of a disease-centered paradigm. In order to do so, we need a more global and integrative approach that considers the person as a whole. The individuality of each person needs to be the center of health, taking into account their genetics and environment. Everyone is unique in his or her biological, psychological, and spiritual health. Each person’s ability to understand his or her world and risk of disease is also unique. The introduction of medical education through a healthy and strong doctor-patient relationship will prove to be the path forward for healing and medicine. Nutrigenomics and molecular biology, among other scientific fields, are certainly making medicine less of an art. But let us not forget the art of medicine and the importance of the doctor-patient relationship and the personal and moral responsibility of each individual. The role of the physician and caregiver in doing no harm is equal to the responsibility that every doctor has in making sure to keep up with research and constant education.

Medicine is an evolving science, and there is much to learn. Society and culture also play a role as more emphasis is needed to promote prevention over treatment of disease. Our current medical model has problems addressing the chronic-disease burden in our society. The medical industry is usually late to make a diagnosis and pays little attention to the importance of engaging the patient in his or her own health care, promoting access to the doctor earlier rather than later in the disease process. As a culture, we have made great efforts and launched international campaigns to promote prevention. But much more can and should be done. As individuals, a good number of people are still behind in making significant positive changes to their lifestyle and environment in order to address symptoms of chronic illness before the disease becomes a reality. Often, poor health is due to certain behaviors driven by the mind and psyche that are possible accomplices in the development of chronic disease.

There are an estimated two hundred million Americans currently burdened with a chronic medical condition. This statistic implies not only the economic burden of health care costs but also our productivity as a society. As a nation, we spend trillions on health care each year. Despite this, we are one of the unhealthiest among the industrialized and developed nations in almost every indicator of health status of a population, such as life expectancy and childhood mortality. More drugs are not necessarily the answer. We need to focus on lifestyle and health education, optimal nutrition, exercise, and, most importantly, doctor-patient communication and trust, which will lead to higher satisfaction for both the patient and the physician, healer or health care provider. Endocrinologists are in the minority among specialists, and usually access to a practicing endocrinologist is limited. Therefore, I have written this book, ultimately, to meet that need while introducing a new concept in integration of the various fields of medicine because hormones are everywhere!

Figure 1: Logical Meaning of the Medical Logo

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THE KEY FACTORS FOR OPTIMAL HEALTH

1. Make the doctor-patient relationship as a foundation for health

2. Understand the link between hormones and weight by first understanding the factors that influence weight, how we define it, and how hormones link to the control and management of some conditions that make a person gain or lose weight

3. Understand the link between female and male hormones and health and well-being

4. Understand the link between the hormones secreted by thyroid and adrenal and gastrointestinal systems, and health and well-being

5. Review the importance of sleep and mood on your energy, weight, and optimal performance

6. Review the different exercise modalities available and be able to choose the right one for you

7. Create a plan that works for you once you know and understand the link between hormones and health and therefore ensure optimal health and total physical, mental, and spiritual well-being

THE DOCTOR-PATIENT RELATIONSHIP AND THE LINK BETWEEN HORMONES: A GUARANTEE TO SUCCESS IN HEALTH

When practicing Integrative endocrinology, as I define it, assimilation of all the healing modalities needs to start with identifying the relationship between the patient and the health care provider. Modern patients are unique. No two are alike. Whenever as a doctor I think I have heard it all, something else finds its way to surprise me either in the positive or in the negative. Yet I always try to focus on the positive. I am amazed by people’s strength, determination, and purpose. I learn from my patients; they inspire me. I listen to my patients’ portrayal of their immense loneliness and despair. I hear of fear and apprehension. Health is definitely not defined by a pill or a procedure. Please don’t get me wrong: The pharmaceutical industry has provided such advanced and lifesaving technologies that are only further magnified by the progress in the technology and research in the field of surgery and other invasive and non-invasive procedures that are used for both diagnosis and treatment. It is important to keep in mind that these are crucial for the overall understanding of health.

When considering the art of medicine and the doctor-patient relationship, the patient is crucial for his or her own healing. If given the right tools, patients are motivated and participate actively in their healing process. Communication is key. It is necessary to have proper understanding of boundaries and the limits of the doctor-patient relationship. What can the patient do? What is the patient willing to do? The difference between the two defines what the patient ultimately does. Similarly, the same questions must be asked of health care providers: What can the doctor do? What will the doctor ultimately decide as the best treatment plan to proceed with, and what options are available? The various limitations imposed by insurance companies and even the government as to what medications, procedures, or doctors are covered or not, coupled with medical and personal socioeconomics and hospital and doctor availability, are all determining factors when it comes to quality of life, well-being, health, disease, or death.

This is daunting and inspires a call for action.

I believe that communication and education allows for a balanced relationship between doctors and patients.

—Dr. Margarita Ochoa-Maya

WHAT DOES A DOCTOR REPRESENT?

Do you know your doctor? You deserve to know the education and training your health care professional received. Equally important is knowing the years of experience in the field and their bedside manner—all factors that will allow you to decide who the right doctor for you is. Trust is paramount in the doctor-patient relationship, and I suggest you do a little research on the doctor you choose to trust with your health. Below is a table that includes the approximate length of graduate-level education and the amount of time spent in residency and/or fellowship, plus the total patient care hours required in the field in order to start practicing.

In today’s health care environment, physicians and patients alike are getting caught between their lifestyle and chronic illness. Increasing age and life expectancy against an impersonal insurance industry—and now with government health care options that are inefficient—makes health care decisions daunting. Add to that a declining economy and burned-out physicians, and it is clear why change is needed. However, in order to make a change, it is vital to understand the world physicians are living in today. It is also necessary to understand the expectations placed on the physician and the role a patient should have when it comes to his or her own health and well-being. This will foster a healthy doctor-patient relationship and ensure better health overall.

What are physicians? Who are they? And what is expected from them?

In order to know if our expectations are founded and reasonable, one should consider who physicians are and what makes them operate and behave as they do. Once you understand what it means to be a doctor and what the professional and personal expectation is of them, you can then optimize your doctor-patient relationship. If you know a physician personally, if you work for one, if you are married to one, or are in some way related to one, you may also find this information useful in understanding this person. Physicians perform one of the most valuable personal services in the world. They care for our fellow humans and their bodies in the most intimate of ways. We place our lives in their hands and trust they have our best interest at heart. When people get sick, doctors try to figure out why this happened. They examine people, listen to their complaints as they describe their health problems, and perform tests to see what is possibly going wrong. They give people medicine and other kinds of treatment. They may also give advice about diet, exercise, and sleep.

TABLE: DESCRIPTION OF THE LENGTH OF STUDIES IN THE DIFFERENT FIELDS OF HUMAN HEALTH CARE

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*This is a guide for informational purposes and may not be used as a limitation or expansion of the lawful scope of practice applicable to practitioners (American Medical Association).

Becoming a doctor requires more training than most other jobs. It is not easy to get into medical school. You have to do very well in school and college and on medical school entrance tests. To become a doctor, you should study biology, chemistry, physics, math, and English and sometimes even art. The standard medical school curriculum for the first two years are spent in labs and classrooms, covering topics such as anatomy, biochemistry, physiology, pharmacology, psychology, microbiology, pathology, medical ethics, and laws governing medicine. Students also learn to take good medical histories, examine patients, and diagnose illnesses. In the last 2 years of schooling, students work with patients and doctors in clinical settings. During years three and four, medical students work with patients under the supervision and guidance of experienced physicians who are serving an academic role and go through rotations or visits at hospitals, clinics, or other medical institutions. They learn acute, chronic, preventive, and rehabilitation work. They also learn to ask patients the right questions and to properly examine them. They learn how to tell what sickness or ailment a patient has. They also rotate through subspecialty clinics in the fields of internal medicine, family practice, pediatrics, obstetrics and gynecology, psychiatry, and surgery. By doing this, the prospective physician gains experience in the diagnosis and treatment of illness. They develop their ability to see things that otherwise might be ignored or overlooked. This is what I did in medical school. I am very proud of my education.

It usually takes at least 11 years to become a doctor: 4 years of college, 4 years of medical school, and 3 years working in a hospital. For some specialties, doctors may have to work in a hospital for up to 14 to 16 years before they are fully trained. Once graduated, most doctors work long hours at all times of the day and night. Sometimes doctors have to rush to the hospital to deal with emergencies. FACT: In 2008, about 3 out of 10 physicians worked more than 60 hours a week.

A physician is a health care provider who practices the profession of medicine, which is concerned with promoting, maintaining, or restoring human health through the study, diagnosis, and treatment of disease, injury, and other physical and mental impairments. It is important to note that the art of prevention is also crucial to the healing process. There is a variety of qualifications and degrees that health care providers may have, but both the role of the healer and the meaning of the word itself changes around the world, even though there are some common elements. General practitioners assume responsibility for the provision of continuing and comprehensive medical care to individuals, families, and communities. Family and general practitioners are often the first doctors patients go to when they get sick. These doctors treat common problems, for the most part. They also send patients to other doctors, called specialists, in order to work as a team. Specialists are experts in specific types of health problems. Specialists may focus their practice on certain disease categories, types of patients, or methods of treatment. For example, internists focus on problems with internal organs. Pediatricians care for children and babies. Surgeons perform operations, like fixing broken bones or transplanting organs. Endocrinologists, like in my case, study hormones.

This is just a brief description of the hard work it takes to become a doctor. The practice of medicine requires both a detailed knowledge of the academic disciplines (such as anatomy and physiology) underlying diseases and their treatment (the science of medicine) and also a decent competence in its applied practice (the art or craft of medicine). This art is obtained through experience and mentoring. Another vital aspect of the practice of medicine is ethics. This integral part of medicine requires that physicians show consideration, compassion, and benevolence for their patients in a universal way.

Actually, I believe that a doctor really must want to be a doctor and have a burning desire to help people. Keep in mind that people who usually visit the doctor are sick and feeling unhealthy and most likely will be grumpy and may not be on their best behavior. You have to know how to talk to sick people. And you should be able to make decisions and handle emergencies relatively quickly. This takes a lot of courage, perseverance, and confidence. Physicians make people healthier, or so we think. Who has the last word? Physicians give advice and give prescriptions. Only when we believe and trust and follow physician or health care providers’ recommendations can we as people become truly healthy.

Physicians held about 661,400 jobs in 2008. Today, more doctors are working as partners or as part of a group. And the number of jobs for physicians is expected to grow much faster than the average for all occupations through the year 2018. This is partly because the population is growing and getting older and sicker, so there will be a need for more health care providers. New machines and tools are letting doctors diagnose and treat more health problems sooner and detecting diseases even when no complaints have yet been felt by the patient. Interestingly, and sadly, there is a higher concentration of physicians in urban areas, but there are not many in rural and low-income areas. These areas do not have enough practitioners.

There were more internal medicine physicians in the United States in 2010 than any other specialty, according to the 2012 Physician Specialty Data Book prepared by the Center for Workforce Studies at the Association of American Medical Colleges. The primary data sources include the American Medical Association 2011 Physician Masterfile, population estimates from the U.S. Census Bureau, and the AAMC/AMA National Graduate Medical Education Census.

The top 5 specialties with the largest number of active physicians in 2010 were:

1. Internal medicine: 109,048

2. Family medicine/general practice: 106,549

3. Pediatrics: 55,509

4. Obstetrics and gynecology: 40,377

5. Anesthesiology: 40,123

CHANGES IN THE HEALTH CARE ENVIRONEMENT

The environment for practicing medicine has changed dramatically over the past few decades. The commoditizing of physicians and their work frequently causes a dehumanization of the doctor and the doctor-patient relationship and the connections between physicians and other support staff. Due to the training, practice culture, constraints, liabilities, and pressures placed on physicians today, they often cannot practice the kind of personalized relationship-enhancing medicine that would benefit both patient and caregiver. By understanding doctors, you can then know how to relate to them and how to best support them in their critical role as your health care provider while at the same time benefit from a great doctor-patient relationship.

Over the years, I have learned to categorize things in order to better understand them.

A DOCTOR WEARS SEVERAL HATS:

1. The academic hat: This is when a doctor should be informed about the facts of medicine, follow the scientific method, review the literature, and be up-to-date with the constant flow of information. Knowledge about new drugs, new techniques, new methods, as well as the procedures by which these facts came to be, is essential.

2. The medical-legal hat: This is when a doctor needs to make sure that there has been due diligence in following the protocol. It is where the Hippocratic Oath is of paramount importance: Do no harm. This hat is what makes doctors nervous about breaking the mold and what drives the FDA to be so powerful. This is also important in order to protect people from drugs, procedures, and methods that could potentially be detrimental to their health in the short or long term.

3. The socioeconomic hat: As you well know, health care is very expensive. Technology and the marvels of research and discovery have led us to be able to do things in health care never imagined. But they also have come with a cost. It is important to know where the limits are and to understand the resources that are available to help overcome this growing issue in health care.

4. The caring (empathic) doctor-patient relationship hat: This is extremely important. People want to know that their doctor cares about them as an individual and not just a number. Unfortunately, doctors today are portrayed as some uncaring, money-hungry people more focused on the report card than the patient. If patients feel like numbers, it’s in large part because doctors are being forced to think of themselves as numbers in the modern health care industry. There is a system protocol known as RVU, or relative value unit, which is part of the reimbursement process.

Always remember the doctor is human and has feelings and emotions too. Emotions lead to beliefs, and beliefs lead to actions. When a physician finds balance among all these requirements with one encompassing bedside manner, he or she can achieve professional greatness.

ON CLINICAL JUDGMENT AND THE DOCTOR VISIT

Clinical judgment is the interpretation of a fact based on clinical reasoning. Medicine itself is an art. It is the art of applying clinical science and the facts that have been demonstrated by the scientific method and juxtaposed with clinical experience and empirical studies to construct a tentative account of the condition at hand. A physician looks at the patient’s history along with the presenting physical signs and symptoms and uses clinical judgment based on the facts that have been collected and learned over the years. Medicine is uncertain. What we know today may easily be very wrong tomorrow. We see it every day when mistakes are made, medicines recalled, etc. Assuming medicine is strictly a science without recognizing the vital role of clinical judgment can have serious consequences and adverse side effects.

In today’s health care environment, a physician will on average interrupt a patient describing her symptoms within 18 seconds. In that short time, many doctors decide on the likely diagnosis and best treatment. These clinical decisions may be correct, particularly if the condition to be treated is common and straightforward. Yet when the complaints are vague and difficult to ascertain, this practice of quick judgment can be wrong—and have catastrophic consequences. It is only human to understand that doctors can make mistakes and should avoid snap judgments. They should embrace uncertainty and communicate openly with their patient and their colleagues.

WHAT HAPPENED TO GOOD OLD-FASHIONED DOCTORING?

Are the wheels coming off medicine in the new era? Have we reached the end of the road, or is it just a turning point or a crossroad? Are doctors uncertain? What does it mean be a doctor today? What has happened to the good old-fashioned doctoring when doctors and patients knew each other and belonged to a community? A time when both doctor and patient worked together to find the cause of the problem and worked together to fix it?

Most people rely on chemicals also known as prescriptions, but have they forgotten the importance of behavior change and prevention? Did you know that some doctors are poets and pastors or storytellers in their spare time? The majority of doctors are nice, gentle people who want to admit to their own vulnerabilities. They want to be advocates for their patients. They see themselves as teachers, writers, biographers—human beings who would like to bring an understanding of the arts into their dealings with human suffering.

When doctors make mistakes, it is not pretty. It may even be a life-or-death situation. This is what makes the difference between a good doctor and a great one. Please, after reading this, take a moment to think of your doctor as a human being and take a long look at yourself and see where in the wheel of life—and in your journey—you can take the wheel and become a partner with your doctor. It’s my belief that this is an essential step in restoring one’s own spiritual, psychological, cognitive, and biologic health. Befriend a physician and pursue and protect that doctor-patient relationship.

THE DOCTOR AND THE PATIENT: A PARTNERSHIP IN HEALTH

While medical science has limits, hope does not. If a patient is ready to be helped, even a little, and grateful for the marginal, it enhances the doctor’s commitment to fostering a relationship between equals. Only such a relationship, bonded by understanding and respect, can deepen into a true healing partnership.

—Lown

The doctor-patient relationship is a partnership. A patient must have confidence in the competence of their doctor and must be comfortable enough to confide in them. Research confirms that the health of the doctor-patient relationship is the best predictor of whether the patient will follow a doctor’s instructions and advice and actually reap the benefits of the intervention. Physicians should have a professional rapport with patients, uphold a patients’ dignity, and respect their privacy. Most medical schools and universities teach medical students from the beginning, even before they set foot in hospitals, the importance of this relationship as it is the foundation of contemporary medical ethics and the first key element in healing. It is a fact: the doctor-patient relationship is central to the practice of medicine and is essential for the delivery of high-quality health care in the diagnosis and treatment of disease. For most physicians, the establishment of good rapport with a patient is important. Some medical specialties, such as psychiatry and family medicine, emphasize the doctor-patient relationship more than others, such as pathology or radiology.

The quality of the patient-physician relationship is important to both parties. Key elements that promote a healthy relationship are:

• Mutual respect

• Adequate time

• Fundamental knowledge and admiration

• Trust

• Shared values and perspectives about disease and life

With a good doctor-patient relationship, the amount and quality of information about the patient’s complaints and/or disease is adequately communicated in both directions. This enhances the accuracy of diagnosis and increases the patient’s knowledge about the disease, with opportunities for prevention of further problems. When such a relationship is compromised, the physician’s ability to make a full evaluation is limited, and the patient is more likely to sense this. This interaction may sometimes even promote mistrust and further division in the relationship by his behavior, and inevitably, distrust and judgment will interfere with the proposed treatment. This, in turn, can cause decreased compliance and willingness to actually follow medical advice. This is particularly complicated in the treatment of hormonal disorders. It is a field in which many studies are surrounded by controversy, and contemporary and valid differences in medical opinion that support both sides contribute to confusion. Many patients rely on word of mouth; others seek a second opinion from another physician or may even choose to find another doctor.

A majority of patients only go to the doctor when they are sick. Suffering and illness further complicate matters as a patient may feel unable to relieve their own pain. This fear and helplessness could result in a state of desperation and dependency on the physician. The physician may be viewed as superior to the patient because the physician has the knowledge and credentials and the ability to prescribe and therefore has the last authoritative word.

The word patient is derived from the Latin pate, which means to suffer.

Every physician should at least be aware of these disparities and these potential weaknesses of the ego in order to optimize communication with the patient. Another dilemma is the method of treatment. On occasion, the treatment may not be pleasant. As an example, think of insulin and finger stick testing for an adult diabetic. This approach may be even more problematic for a patient than the problem itself, creating a disagreement between the physician and the patient. In such cases, the physician needs solid strategies for presenting unfavorable treatment options in a way that minimizes strain on the doctor-patient relationship while guaranteeing the patient’s overall physical health and best interests. This is not an easy task.

ON FORMAL OR CASUAL DOCTOR-PATIENT RELATIONSHIPS

There may be differences in opinion between doctors and patients as to how formal or casual the doctor-patient relationship should be. For instance, according to a Scottish study, most patients don’t want to call the doctor by his or her first name. In this same study, patients confirmed that they would rather be addressed by their first name more often than is currently the case. In this study, most of the patients (223 patients) liked being called by their first name, 175 patients did not mind, and only 77 disliked it. Most of the patients that disliked it were over 65.

With your doctor and healer, there needs to be boundaries. Yes, up front, I disclose that there are exceptions. But what I love most in my profession is the ability to promise my patients their right to privacy. And thus, I prefer a formal relationship with a wonderful, trusting, and friendly undertone, always abiding by the ethics of understanding that we are going to be completely honest and in a relationship of knowledge, mentoring, and guidance that is unique to us. In this kind of relationship, the doctor and the patient cannot be just friends. This relationship is deeper—hopefully, in a deeper psychological and spiritual way.

HOW TO STUDY AND UNDERSTAND THE DOCTOR-PATIENT RELATIONSHIP

One of the pioneers in the study of the doctor-patient relationship is Dr. Michael Balint. He has studied psychoanalysis and was a leading physician in this field in the 1930s. He held a top position in his field in England and was the president of the British Psychoanalytical Society. He also published a book called The Doctor, His Patient and the Illness. Dr. Balint was influential in setting up groups (now known as Balint groups) for medical doctors to discuss psychodynamic factors in relation to patients. Such seminars provided opportunities for physicians to discuss with one another and with him aspects of their work with patients for whom they had previously felt ill equipped. Since his death, the continuance of this work has been assured by the formation of the Balint Society.

ETHICS AND THE DOCTOR-PATIENT RELATIONSHIP

In different societies, periods, and cultures, different values may be assigned different priorities. In the last 30 years, medical care in the Western world has increasingly emphasized patient autonomy in decision making. Ethical goals of the doctor-patient relationship have three key components:

a. Do no wrong or non-maleficence.

b. Do good or beneficence.

c. Consider patient and physician autonomy and justice.

SOCIAL POWER AND THE DOCTOR-PATIENT RELATIONSHIP

The relationship and process can also be analyzed in terms of social power relationships. Physicians have been accorded gradually higher status and respect over the last century, and they have been entrusted with control of access to prescription medicines as a public health measure. This represents a concentration of power and carries both advantages and disadvantages and, in particular, to patients with conditions such as pain. A further twist has occurred in the last 25 years as costs of medical care have risen, and a third party (an insurance company or government agency) now often insists upon a share of decision-making power, reducing freedom of choice of health care providers, affecting patients in many ways.

Michel Foucault (October 15, 1926–June 25, 1984) was a French philosopher, social theorist, and historian of ideas. Foucault studied psychology and philosophy and is best known for his critical studies of social institutions—most notably psychiatry, medicine, the human sciences, and the prison system—as well as for his work on the history of human sexuality. His writings on power, knowledge, and discourse have been widely influential in academic circles. He questions common concepts, like justice or equality, and asks where these concepts originated and to whom they benefit. He wrote several books, two of which I would like to mention:

• The Birth of the Clinic: An Archaeology of Medical Perception (Naissance de la clinique: une archéologie du regard médical) was published in 1963 in France and translated to English in 1973. This book traces the development of the medical profession, specifically the institution of the clinique (translated as clinic, but here largely referring to teaching hospitals).

• Discipline and Punish (Surveiller et Punir). In this book, he discusses the micropower structures that have developed in Western societies since the eighteenth century, with a special focus on prisons and schools. This book was translated into English in 1977. He discusses a new more subtle form of power: disciplinary punishment that gives professionals (psychologists, program directors, parole officers, etc.) power over the prisoner and most notably in that the prisoner’s length of stay depends on the professionals’ judgment. Foucault suggests that a carceral continuum runs through modern society, from the maximum security prison, through secure accommodation, probation, social workers, police, and teachers, to our everyday working and domestic lives. All are connected by supervision (surveillance, application of norms of acceptable behavior) of some humans