Thursday, August 18, 2011

Oprah’s Crazy Talk – Bioidentical Hormones – Helpful or Harmful? (Part 1)


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Newsweek just lately took part in tabloid journalism, displaying Oprah on the handle with that headline: CRAZY TALK, Oprah, Wacky Cures, & You. The particular emphasis from the post appeared to be an episode on Suzanne Somers, Oprah, along with bioidentical hormones. The Genie is out with friends from the hormone bottle, customers usually are confused, this health care profession is in its typical funk, as well as on internet land out and about it is undoubtedly a health-improving truth.

One with the authors with the Newsweek posting provides her very own �traditional� e-book on menopause and the different is your m asculine in his first 40s � none features almost any clinical practical experience with the topic and may perform bit more than toss insults along with reference point standard tips involving look at hormones. Newsweek is serious about revenue which is hoping the actual millions of Oprah followers will obtain this magazine.

Traditional health-related people find that extremely annoying, even alarming, of which Suzanne Somers as well as Oprah have generated this sort of massive curiosity about the actual theme connected with bioidentical hormones. After all, the good news is hord of baby-boomer adult females who have not any fascination with getting old any kind of speedier as compared to they want to. Are bioidentical testosterone truly the �juice with youth,� because Suzanne Somers calls them?

The mafia-like FDA includes gotten into your fray, assaulting compounding pharmacies in the bequest involving pharmaceutical competitors. Indeed, the compounding community hasn�t ponied up it's bribery fees for the FDA. The FDA can�t convey to everyone the right way to practice, although many people can easily get a grip of wellbeing states as well as availableness regarding bioidentical hormones.

As some sort of scientific nutritionist I have served adult females with bioidentical testosterone for above twenty years. I feel a new believer in the right utilization of bioidentical hormones, and now have experienced their own power to help initial hand about a lot of occasions. However, you'll find apparent benefits and drawbacks of which any kind of lovely women ought to grasp ahead of using any kind of type associated with bioidentical hormone.

Traditional Western Medicine � Lacking Credibility about Female Hormones

Before pointing available that which is possibly problematic concerning bioidentical testosterone I must show what the heck is wrong with the actual standard group of Western medicine c ritics. Those helping this specific perception system have a recent history connected with getting rid of as well as hurting tens of thousands involving girls making use of their �official� in addition to FDA-sanctioned us going for hormone replacing therapy. In my view, most of these men and women have got little expertise along with should instead often be place trial in the judge regarding law.

And I don�t merely signify Wyeth, a primary the manufacturer with estrogen alternative remedy (ERT) derived from horse urine, whom continues to struggling with 5000 malignancy lawsuits. I�m preaching about the prescribing physicians, who frequently browbeat adult females to tears in the event they will didn�t desire to go on estrogen in addition to progesterone prescriptions � even though selectively case or even downplaying the particular large human body regarding probability data that endured ahead of 2002.

The FDA may also be thrown straight into this part icular group of incompetents, as they definitely authorised horse urine extract as well as sat by way of haplessly watching when women were being wiped out along with hurt � a problem in which proceeds to the current morning in spite of stepped-up FDA warnings.

A major setback for ERT marketing taken place back July involving 2002. Data approaching from your Women�s Health Initiative showed that a mixture off estrogen coming from deer urine and non-bioidentical progesterone amplified the danger involving invasive chest cancer by 26%, shots by 41%, heart attacks through 29%, blot clots by 100%, plus entire cardiovascular system ailment by 22%. Based within the 6 thousand women having these kind of drugs around 2002 (2 billion around sales), the information proposes of which for the duration of one simple year there have been a supplementary 4,800 circumstances of invasive busts cancer, 4,200 heart attacks, 4,800 strokes, plus 10,800 blood clots � such as 4,800 life -threatening maintain clots within the lungs.

Remarkably, Wyeth nonetheless offers 1 thousand pounds worth involving deer urine extract some sort of year, and they also continue to try and spin their estrogen/progesterone drugs when safe. Making matters worse, the marketing these medicines appeared to be influenced by dupery from the very first place.

There ended up only some 1000 women of all ages taking estrogen instruction online 1966. That variety altered dramatically with the release of the actual book Feminine Forever, through Dr. Robert A Wilson, a New York gynecologist. In that book Dr. Wilson attributed all unwanted aspects of aging to a loss of estrogen � when downplaying in addition to wanting to explain away the actual troubling link to cancer.

Dr. Wilson quit his perform along with build a foundation to encourage his or her ideas. He and also his or her wife journeyed about the region supplying seminars plus their book obtained vast media policy within main magazines. The e-book turned one of the firstly label advertising pieces, openly given out to help doctors for a promotional tool.

What was not really recognised at that time seemed to be of which your drug company that will is now Wyeth (Ayerst Laboratories) was money the particular foundation.

Throughout your 1990s I was an outspoken critic connected with ERT � your minority view that has been influenced by essential knowledge the actual medical profession couldn�t apparently grasp.

It was effectively recognized this escalating your woman�s exposure to the woman's personal estrogen, like starting menstruation before grow older 12, greater raise the risk with breast cancer. Anything that releases higher serum concentrations of estrogen sites a woman straight into this risk. It was simple practical this stretching your woman�s exposure to estrogen through ERT ended up being going to place the woman right into a same risk pattern as a result of extended estrogen exposure.

Female malignancy risk, in particular breasts cancer threat linked to estrogen substitution remedies were announced for many years, plus seemed to be broadly analyzed last 1999. This records didn't prevent most health professionals from prescribing and also moving ERT about ladies with menopausal symptoms.

Even worse, the usual dosage of estradiol then seemed to be .625 mgs obtained daily (today it can be .3 mgs). In normal menstruation a lady is shown to be able to .4 mgs associated with estradiol just the summer a short time each month around her ovulation. Thus, this particular Wyeth-promoted prescribing process subjected girls for you to more achieable degrees regarding estrogen when compared with your woman actually manufactured naturally. Furthermore, the particular Wyeth product also contains loads of horse estrones which can be completely out of place for any woman. The FDA twiddled their thumbs.

Adverse files on Wyeth�s hormone drugs persists to be able to stack up, which has a recent study demonstrating that will their particular ERT almost doubles chance to get lung cancer.

Another typical issue with ERT (and birth control pills with the matter) is definitely weight gain, which doesn�t generally happen in order to everyone although comes about so often so it can be a major concern. Doctors applied to see women of all ages that ERT had been good for their heart even although we were holding increasing fifteen excess weight � it simply didn�t total � believability was woefully lacking. Weight gain, especially once menopause, is likewise caused by a heightened risk associated with breast cancer.

I should as well show that this exact risks of beginning command products are generally nevertheless unknown, perhaps though they need happen to be utilised by countless adult females for decades. One recent examine presented wi th a strong American Heart Association conference confirmed that for each decade of birth and labor manage pills there is a 20 � 30 percent raise in peripheral artery little plaques.

It is additionally acknowledged that women possess ten occasions the actual rate of autoimmune condition because males � on account of imbalanced along with excess concentrations associated with estrogen. This is because estrogen (estradiol) inhibits T suppressor cells, giving these folks released inside the actual blood circulation extended and many more almost certainly going to in a harmful way respond to infected tissue. It wasn�t extended before lupus was reportedly attributable to ladies taking deer urine extract. This details may well apply that will almost any autoimmune ailment � in the event researchers bothered to study this issue.

The medical by using ERT, because sent by means of various meds companies, condoned from the FDA, plus adamantly pressed about many l adies by means of doctors, was some sort of distinct violation belonging to the nearly all standard creed of an physician to primary perform zero harm. It is definitely instance with a new lack of data as well as lack of ability to help estimate that obvious result regarding acknowledged principles regarding biochemistry relating to that prescriptions that they prescribe, problems that continues that will problem their particular Big Pharma-sponsored profession.

Any woman seeking to understand how to use bioidentical bodily hormones to guide your ex health and fitness should also understand this history, plus understand that this FDA, medicine companies, as well as the medical profession alone have very bit of credibility as well as beneficial tips to provide during this subject. Thus, the trite phrase to help �consult ones doctor� within the matter associated with female human hormones is a useless waste of your energy and may even even always be dangerous to yo ur health.

Female Hormone 101

I view the actual safe practices challenge adjoining bioidentical laddish behaviour as you regarding purchaser education. There are a quantity of important points almost any female should plainly understand about what her body lands on and also just what exactly that means. Let�s start out at the beginning, with a primary understanding of bodily hormones plus normal health.

In the initial a couple of days of this menstrual cycle your human brain emits a hormone signal identified as FSH (follicle stimulating hormone), which in turn vacations for a ovaries and also ripens a good egg. As your egg ripens it releases estradiol, a questionnaire connected with estrogen necessary to get regular reproductive function. As estradiol quantities rise in your maintain it data in your mind in which an ovum is ripe. Once your head understands this specific it changes to help a good androgen signal called LH (luteinizing hormone) , which in turn fuels the release of the egg. For your second half of your own menstrual period this follicle that's houses your egg currently makes progesterone (from what exactly is labeled your corpus luteum). Progesterone assists attach protein into the wall of this uterus if you turn into pregnant. Estradiol is selecting the particular proliferation regarding muscle which creates this possible.

If about to catch with child subsequently progesterone production stops, in turn commencing the particular sheathing of the protein build-up heli-copter flight walls of this uterus � that is certainly ones menstrual cycle.

Your menstrual cycle is definitely energy intense. You have to decide to put a steak dinner�s worth involving protein against that walls of your respective uterus every day. If a person don�t eat adequate protein, mainly that week in advance of your menstrual cycle, subsequently the body will require separately muscle proteins and in some cases the neurotransmitter proteins this maintain your mood elevated. A insufficient nutritional protein will be easiest natural reason behind an undesirable mood regarding PMS.

In inclusion to protein alternative foodstuff most commonly incomplete with the eating habits connected with virtually any lovely women having any good PMS are fruit, vegetables, and also necessary fatty acids. The increased the actual poor quality food and also suscrose content material connected with your ex diet, the greater very likely you will find to get problems. As strain and/or physical requires increase, complications multiply plus health weak spots turn into more important.

Anorexia in addition to abnormal training are generally two issues around young women this reflect substandard protein food intake for the actual menstrual cycle, commonly ending throughout not any cycles, erratic cycles, or perhaps missed out cycles.

On the opposite hand, to be a lady gains weight and then that performance involving hormone signals, which includes signs to help your ex ovaries, usually are a lesser amount of effective and many more at risk intended for troubles developing.

Other basic eating routine includes B vitamins, calcium, magnesium, and iron. B nutritional vitamin supplements are generally needed to assist protein for you to operate correctly, in addition to to assist balanced out stress. Calcium as well as magnesium will be critical for your pain-free menstrual cycle, and also in conjunction with efa's their own deficiency may be the most typical cause for menstrual cramps. Iron is normally deficient throughout women who have little if any red meat, who work out your lot, or maybe who may have heavy menstrual cycles. A deficit of iron bars could result in fatigue that is certainly irritated as the menstrual spiral progresses allowing it to manufacture every sign connected with hypothyroid, including excess fat gain.

A purpose which shows health and wellbeing is definitely since your menstrual routine will come and is going each and every calendar month with a minimal volume of difficulty or maybe distraction. Your menstrual period obtains an increased demand intended for nutrition than any various other technique in your body, since this really is just about all about success in the individual race. It is a monthly analyze of the best way well an individual did ALL MONTH LONG managing your present health.

If you are approaching menopause and you also use a long-term history connected with challenging menstrual cycles, you have far more possibility associated with the make use of estrogen in order to curb or modulate unpleasant symptoms. You may also be more inclined to acquire more sizzling flashes.

What is definitely Estrogen Dominance?

Any female of menstrual age, like ladies who're pre-menopausal, must do everything within their strength to r educe this signs and symptoms of estrogen dominance. This is essential for decreasing this possibility with any kind of women malignancy as well as autoimmune disease.

The signs and symptoms of excessive estrogen are generally every with the following: hefty menstrual cycles, surplus clotting with menstrual cycle, abnormal bleeding/spotting in between cycles, breast inflammation as well as tenderness, fibrocystic breasts, endometriosis, substance retention, or head aches with cycle.

Oftentimes women of all ages which includes a background with estrogen dominance end up by using a new partial or complete hysterectomy. Gall bladder problems can be typical, while extra estrogen super-concentrates cholesterol into their gall bladder inducing sludge and stones. Cellulite will be often made worse simply by surplus estrogen in addition to now and again estrogen dominance troubles stands out as the reason behind cellulite.

The following will be a r eport on the actual primary topics that create or bring about estrogen dominance, besides the simple dietary insufficiencies listed in the last section. Many women include difficulties overall these areas.

1) Extra pounds of fat.

Fat tissues produce a further sort associated with estrogen identified as estrone. Think of estrone as a load that will get a grip of blood concentrations of estradiol. In other words, estradiol could be converted into estrone to help �store it� in addition to estrone could be converted to help estradiol in order to �make it active.� Having a new back technique in order to sustain quantities of required estradiol regarding reproductive requirements is definitely vital.

Remember, females employ a naturally greater number regarding unwanted weight than adult males in an attempt to have the offered electrical power to help supply a baby � a survival necessity. Fat serves several contracts with this huge plan. Gaining more excess fat messes this specific up, not alone producing increased sums involving estrogen, nonetheless hormones in general develop into tolerant to normalcy communication together with every single other. This pieces upward a very inflammatory plus pro-carcinogenic health-risk situation.

Problems along with excessive quantities belonging to the fat-hormone leptin drastically worsen ovarian purpose and can help to make female hormone purpose miserable (such since causing polycystic ovarian syndrome). Losing weight in a very wholesome way, when overweight, can be critical intended for usual woman hormone function.

2) Estrogen-like chemicals.

Estrogen-like compounds pose a grave pressure that will woman along with male health. Bisphenol A out of plastics will be one example, many of the pesticides used on food is another, and Monsanto�s PCBs are nevertheless another. These seem to take in into fat along with interact along with estrogen r eceptors. They in all likelihood enjoy a considerable factor while in the previous attack associated with menstruation in younger women, plus they certainly pose a life threatening women cancer malignancy probability � especially throughout ladies using genetic susceptibility.

Compounds that will guard a person's liver as well as assist anyone apparent these types of toxins are actually general eating tips only regarding safeguards � because our govt features no guts to generate almost any big company clean way up their enviromentally friendly trash. Nutrients for instance Milk thistle extract, chlorella, in addition to R-alpha lipoic acidity tend to be top rated choices, when could be the nutritional consumption of an wide range of vegetables. The higher an individual�s compound sensitivity, a lot more very likely you will find to be reactions to toxins along with adverse girl hormonal interactions.

3) The fail for you to apparent estrogen � digestive problems.

Estrogen quantities high core spiral and are then cleared from your blood vessels by your current liver. Your liver binds estradiol to help yet another compound, a procedure generally known as conjugation. This package is then sent by way of your own bile, through a person's gall bladder, in to your own the disgestive system tract, and with luck , out. A major issue develops while it comes with an overgrowth of unfriendly bacteria inside your gut � normally mirrored by symptoms involving gas, bloating, constipation, irritable bowel, etc. In this specific scenario that microbes might �eat� the actual conjugation bond, triggering estradiol for being unveiled in your the disgestive system pathway also to re-enter your own common circulation.

This issue is usually a common way to obtain surplus estrogen. It is almost often taking place in the event of inappropriate estradiol-drive tissue proliferation including endometriosis, while well when cy st enhancement � of course most cancers risk. Extra eating and also supplemental sheets along with acidophilus are fundamental steps to help. Digestive problems may well have your more substantial strategy regarding improvement � and solving them is vital for you to women hormonal health

4) Pregnancy.

Even a proper maternity can easily act like a jolt to help hormone balance. While a few women locate their menstrual rounds actually work better immediately after pregnancy, a great deal more may very well discover indications associated with estrogen extra have finally began whilst some people did not exist prior that will pregnancy.

In essence, the particular regime demands of having a baby really are a kind of tension to metabolism, thyroid function, and also womans hormones. The common final result is a deficiency of progesterone, referred to next. However, entire lively along with metabolic restore pursuing pregnancy is obviously a great idea, to ensure maternity is just not observed seeing that your time frame as soon as a person's wellbeing began to help decline (a common finding for most women). This is in many cases a serious challenge as adult females aim to juggle the involves with children, working, sleeping adequate hours, and sustaining good self-care routines like exercise.

5) The shortage with progesterone � an excessive amount stress.

One perform regarding progesterone is like a normal managing substance to help estradiol. The precursor chemical substances intended for progesterone development are also employed to generate adrenal laddish behaviour of which resist stress. If tension can be too high, and also a person is definitely too malnourished, progesterone could be altered in to stress-fighting hormones. Unfortunately, this results in estradiol ranges huge as a result of relative shortage connected with progesterone.

By helping adrenal health and handling wo rry better, progesterone will be spared this fate. Almost each and every lovely women witnesses that in case she's experienced an even more nerve-racking and also in physical form hard month, next signs regarding PMS or even menopausal warm flashes are likely to be worse. Basic diet pertaining to adrenals comprises better diet protein, B vitamin supplements � mainly pantethine, nutritional C, Q10, in addition to essential fatty acids similar to DHA.

Bioidentical Progesterone Can Help

Over the past some decades the employment of bioidentical progesterone cream is a famous health option to help you girls beat difficulties regarding estrogen prominence as well as symptoms regarding menopause, an approach built popular by John Lee, M.D. In arrangement to help maximize the chance in which these kinds of an method could possibly be people to your account it will be important to recognise your general wellness (are you estrogen major as well as why), together with your dose as well as style of progesterone for you to use.

Bioidentical progesterone enters in OTC creams, by way of compounding pharmacies, along with by simply traditional prescription.

There can also be non-bioidentical sorts of progesterone drugs that happen to be really hazardous plus shouldn't be used. It have been exhibited this non-bioidentical progesterone grows danger regarding cancer, whereas bioidentical progesterone has the opposite influence and it is protective.

Progesterone drugs just like Wyeth�s Provera (medroxyprogesterone acetate), that is implicated in the Women�s Health Initiative study in conjunction with horse urine extract, appear to be making sure that drug providers could patent one thing in order to sell, not really as it is good for your health. Provera is just not bioidentical, it is regarding remarkably dangerous side effects which include virtually every symptom involving estrogen excess!

The OTC creams have been available regarding several decades � along with I individually include used these folks together with many women. Bioidentical progesterone is actually synthesized out of rough outdoors yam. It can be originating from a healthy source. It is actually artificial and bioidentical, this means ?t had been changed on the precursor molecules with outdoors yam in to the impossible to tell apart progesterone hormone since your human body produces. Most OTC solutions incorporate 20 mgs of progesterone for every tsp.

These goods slip suitable grey regulating area where that FDA can be concerned. The FDA lets these individuals available on the market as aesthetic humidity creams. Companies offering all of them can't express that the progesterone (or estrogen in the event that with a strong estrogen-containing cream) is consumed or features every impact on a woman�s health. Otherwise, your FDA could view in which corporation when selling a good unapprov ed drug. In alternative words, the FDA permits that treatment items that you can buy but doesn�t need you to definitely understand how make use of them. This will be of course as good as definitely not getting in the marketplace by any means � and there is actually genuine matter the actual FDA could opposite it has the decades-long plan � which would likely always be detrimental to the health of several women of all ages exactly who be dependent about these kinds of creams intended for recognizable wellness benefits.

While studies on progesterone creams show them to get less dangerous than drugs, their results with quenching menopausal symptoms is upward inside the air. A amount of studies assistance benefits, and the like do not. This happens because studies tend not to individual women matching for their overall fitness along with level of estrogen dominance, health and fitness history, etc. In other words, the resource of countless estrogen dominance problems is actually not just a lack regarding progesterone and also a lovely women will be much better away from dealing with such a difficulty as well as at the very least implementing this whilst together seeking several progesterone. Progesterone will in no way be a �one stop solution.�

As sometimes appears from the last section on estrogen dominance, any kind of female could possibly be possessing many reasons why you are estrogen excess. These signs can have a monthly severeness � just how bad are generally they? They will likely have a development � how much time have that they been recently proceeding on? Simply giving progesterone may perhaps or maybe may not really work. The greatest technique can be improving any obvious issues that could be causing estrogen excess. The by using progesterone could well be component of an adrenal, thyroid, in addition to pressure assist protocol, possibly not a common factor getting done. Many times, women would find they will don�t have any progesterone any time their adrenal function, thyroid function, and also tension calls for are usually in greater shape.

Another essential to help this harmless using bioidentical hormones should be to employ an quantity that is certainly at or even down below what exactly your body could ordinarily produce. For example, through the second fifty percent of your menstrual spiral your current ovaries generate about 25 mgs of progesterone a day.

It seriously isn't known exactly how a lot progesterone can be consumed through the skin color creams; however, it's likely to get below half. One review applying 40 mgs connected with progesterone cream on a daily basis found in which blood vessels degrees never increased by higher than normal production, although being great at lowering the actual signs regarding menopause. Another analyze exhibited in which 80 mgs of ointment each day raised continue concentrations just like a 2 hundred mg common pill with the approved drug.

There usually are three fundamental menstrual situations for every woman implementing progesterone; a) she's obtaining regular cycles, b) she is don't owning cycles, c) she is throughout limbo land rather than understands if or perhaps if your following cycle could come.

Progesterone ointment intended for repeatedly menstruating women of any grow older can be a miracle. It is exceedingly beneficial intended for any kind of indication involving PMS or estrogen dominance � specially horrible menstrual headaches. 40 mg regarding progesterone ointment has shown being protecting alongside surplus estrogen exposure. As such, it is continually worth some sort of try for any female who will be having difficulties. In this knowledge it can be probably be with help additional as compared with 75% with the time, specially whenever made use of within a course with regard to overall fitness improvement.

Most women of all ages utilize tsp daily through daytime 14 on the thirty days (day a single may be the first day time of your own period), until morning 28 (or the particular morning your current time period starts). Some women of all ages locate it useful to attend tsp per day out of days 21 years of age � 28, to support together with uncooperative symptoms.

It is relatively easy in order to assess in the event that this sort of a great method is helpful and also not. The most usual part effect is usually obtaining a headaches (rather when compared with becoming eliminate of one). Other ladies realize that that simply just doesn�t assist or may even manage to intensify symptoms. In this sort of cases, this progesterone definitely isn�t working, and so don�t apply it.

Common sense informs you that if this helps, and you tend to be applying a dose that is certainly at or perhaps under just what your whole body the natural way produces, then you've observed a harmless servi ce technique regarding hormonal balance. If of which isn�t happening, even if you have a very research laboratory rating together with decreased progesterone or every one of the symptoms with estrogen dominance, you may need to uncover an alternative solution. Don�t embark on four week period after four week period performing anything in which isn�t helping.

During menopause, specially to support reduce popular flashes and also help mood, it's typical to test to be able to tsp connected with progesterone every day. Once again, the following either helps or not. If an individual can�t notify a large benefit, free of any unfavorable edge impact symptoms, next I wouldn�t employ it. It can be a lot more typical of which progesterone is extra very helpful when compared with not � nevertheless in the event for reasons uknown that isn�t working next leave to one thing else.

Women using unreliable menstrual cycles throughout menopause will frequently apply pr ogesterone for you to strengthen disposition plus help scorching flashes, they usually commonly utilize it each and every day. In many circumstances the body may perhaps be attempting to function some sort of menstrual cycle, also , you may possibly be feeling bloated as well as as being a period can be endeavoring to come but it surely simply isn�t happening. This is a indicator provide ending the actual progesterone for a few days, which could usually make it possible for your menstrual cycle to be able to occur.

Many women of all ages also work with progesterone within a healthy bone support program, because progesterone will help switch on the osteoblasts of which create bone. A analysis regarding postmenopausal women possesses found of which in females with osteoporosis the employment of progesterone prevented further bone loss. However, girls likewise having soy negated the particular effective results involving progesterone (soy is also anti-thyroid).

You are finished with a new laboratory analyze that will determine a person's progesterone in case you are following the recommendations I include spelled out earlier mentioned therefore you will be trying to keep your own technique hormone with a natural degree of one's body�s production and also you are generally watching whether them is helping. Ideally, you ought to become at the same time working away at improving upon any medical issues generally and not influenced by progesterone to correct ones problems.

Summary

Progesterone is essentially the most very popularly used bioidentical hormone, by using about three decades people inside the United States. In order to have the most profit by applying hormone you must know the topic regarding estrogen prominence and just what exactly components might be adding for you to just about any problem you might be having. It is properly advised to operate on these kind of issues, coupled with every make use of with progesterone. It can be best to help utilize every bioidentical hormone from or perhaps below how much your body naturally produces. Higher levels are generally capricious and as unnatural as hormone drugs.

The following element of the article makes clear laddish behaviour and aging within better detail, such as perils connected with development hormone, DHEA, in addition to testosterone. The safe and sound use of estriol is explained, the sole variety connected with estrogen substitution adult females will need to consider.


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