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Night-Time Salivary Cortisol for Cushing’s Disease | Good Hormone Health

March 19, 2025TfriedmanUncategorized
Night-Time Salivary Cortisol for Cushing’s Disease | Good Hormone Health

Night-time salivary cortisol testing is an essential, non-invasive tool that helps detect abnormalities in cortisol levels—particularly useful for diagnosing Cushing’s disease and evaluating diurnal rhythm disorders.

✅ What Is Salivary Cortisol Testing?

Salivary testing is used to assess hormone levels aligned with your body’s circadian rhythm (also called diurnal rhythm). While many hormones don’t correlate well between blood and saliva, cortisol is an exception—saliva levels closely reflect blood levels.

In healthy individuals, cortisol peaks in the early morning, telling the body it’s time to wake up. Cortisol levels typically decline throughout the day, reaching their lowest at night.

⚠️ Why Is Night-Time Cortisol Important in Cushing’s Disease?

In patients with Cushing’s disease, this natural rhythm is disrupted. Elevated night-time cortisol levels are a hallmark of the condition, keeping the body alert when it should be winding down for sleep.

This abnormal pattern is a key diagnostic clue. Night-time salivary cortisol testing provides a practical and reliable method for identifying this irregularity.

🔁 What Is Episodic Cushing’s Syndrome?

Cushing’s isn’t always consistent. Many patients have episodic or periodic Cushing’s, meaning cortisol levels spike unpredictably. Unlike “cyclic Cushing’s,” which implies regular patterns, episodic Cushing’s is harder to catch with a single test.

Dr. Friedman’s 2010 study published in Hormone and Metabolic Research found that 65 out of 66 patients with Cushing’s had at least one normal cortisol test—underscoring the need for multiple tests during “high” episodes.

🧠 How to Recognize a “High Cortisol” Episode

You should aim to test when you’re experiencing symptoms of a cortisol spike. Patients often describe:

  • Wired energy late at night
  • Rapid weight gain or water retention (edema)
  • Acne or flushed skin
  • Insomnia or restless sleep
  • Mood swings, irritability, or euphoria
  • Unusual energy surge after sunset
  • Racing thoughts or fast speech
  • High blood pressure or blood sugar
  • Tasks feel easier, aches and pains diminish

💡 Pro tip: Keep a symptom diary to help identify patterns and improve timing of your tests.

🧪 How to Collect Night-Time Saliva Samples

Collection protocols differ slightly between LabCorp and Quest Diagnostics. Always use the correct Salivette kit from the same lab where your test will be processed.

✅ Preparation (for Both Labs)

  • 🚫 Avoid steroid creams/inhalers 24 hours before
  • 🚫 No food, drink, brushing, or flossing 30–60 minutes before
  • 🕚 Collect sample between 11 PM and 12:30 AM
  • 📝 Label each sample with name, DOB, date, and time
  • ❄️ Store refrigerated or frozen as required

🧴 LabCorp Saliva Collection Steps

  1. Use 4 white-top Salivettes
  2. Roll cotton in mouth for 90+ seconds (until saturated)
  3. Return to vial and seal
  4. Refrigerate or freeze per instructions

Stability:

  • Room Temp: 14 days
  • Fridge: 14 days
  • Frozen: 5 months

🧴 Quest Diagnostics Collection Steps

  1. Use 4 blue-top Salivettes
  2. Keep swab in cheek for 2+ minutes
  3. Return swab and seal container
  4. Refrigerate or freeze per instructions

Stability:

  • Room Temp: 72 hours
  • Fridge: 21 days
  • Frozen: 6 months

📦 Sample Drop-Off

Freeze all samples if needed and drop them off together at your lab’s local pickup station. If questioned, mention the lab’s own instructions allow for freezing.

📋 When Will You Get Results?

Results are typically available 10–14 days after submission. Dr. Friedman will analyze your cortisol levels in relation to your symptoms and guide further testing or treatment.

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Dr. Friedman’s Weight Loss Guide

January 20, 2025TfriedmanUncategorized
Dr. Friedman’s Weight Loss Guide

The Changing Landscape for Compounded GLP-1s

Dr. Friedman only prescribes GLP-1s for established patients who is treating for hormone disorders.

The landscape for compounded weight loss medicines is changing rapidly. The good news is GLP-1s are becoming more available with new oral preparations commercially availability. The prices are going down, Lilly and NovoNordisk have expanded their direct-to-consumer marketing and seem to have reduced their efforts to litigate against compounding pharmacies that supply compounded GLP-1s. More telehealth companies have sprung up to prescribe compounded GLP-1s often at high cost and with little physician supervision. Dr. Friedman thinks the tide is turning in favor of personalized medicine using compounded preparations. Dr. Friedman uses various options summarized below to prescribe GLP-1s and is working with several reliable compounding pharmacies. Some availability depends on the state you live in. Hundreds of Dr. Friedman’s patients have benefited from these compounded GLP-1s which are available in syringes allowing individual dosing that is not possible with the commercial medicines. Compounded GLP-1s do not require insurance pre-authorization and overall are much more affordable. Dr. Friedman does not directly dispense these compounds.

Compounding Pharmacies that Dr. Friedman works with

Dr. Friedman works with several compounding pharmacies to provide affordable and safe GLP-1 drugs that have improved patients’ health and weight. Dr. Friedman has communicated with representatives from the three compounding pharmacies he works with (University Compounding Pharmacy(UCP)/Anazeo, RedRock and Strive Pharmacy) to determine recommended dosing as described below. Dr. Friedman’s philosophy is that compounded pharmacies are supplying “Tirzepatide” and “Semaglutide” and not “Ozempic”, “Wegovy”, “Zepbound” and “Mounjaro” and that they are supplying customized dosing that are not available with the fixed doses supplied by the pharmaceutical companies. Compounded GLP-1 allow for “microdosing”, in which the GLP-1 does is more physiological and has less side effects. Some compounding pharmacies such as Empower require in person visits, which makes no sense in this era of telemedicine and Dr. Friedman is unable to use them.

Clinic price:

Dr. Friedman has negotiated a clinic price at several compounding pharmacies that is substantially lower cost than pharmacy prices. Patients pay Dr. Friedman using the miscellaneous PayPal payment tab on his appointment tab (https://www.goodhormonehealth.com/appointment-booking/). Square is accepted but less preferred. His office will go over pricing with you by email.

Tirzepatide Vs Semaglutide 

Overall, Dr. Friedman prefers Tirzepatide over Semaglutide as it gives more weight loss and less side effects but is currently available in CA only in the sublingual form. Many patients find sublingual Tirzepatide to be quite affective at appetite suppression and weight loss, while others find it less effective than subcutaneous injections. Dr. Friedman’s top recommendations are in red.

Strive Pharmacy

Strive Pharmacy, which compounds Semaglutide (brand name Ozempic, Wegovy), and Tirzepatide (brand name Mounjaro, Zepbound) is a 503B compounding pharmacy that offers GLP-1RAs to patients at a low price in 45 states including California-see https://catalog.strivepharmacy.com, but note that pricing Dr. Friedman charges will be different. The states they currently do not ship to include AR, IN, MN, SC and TX (Texas requires doctors to have TX license). For Strive pharmacy, patients pay Dr. Friedman directly at a discounted cost, that is lower than if they purchased from Strive. Open bottles are usable for at least 90 days after opening. There are several options available at Strive Pharmacy, with the common 6 options seen in this table (note that the price has decreased recently):

Those in red are popular doses. Other doses are available on request.

Red Rock Pharmacy is a good source of compounded injectable Tirzepatide or Semaglutide to California patients. This is currently the only source of injectable Tirzepatide for California patients. The prices are reasonable, and you pay Dr. Friedman. The caveat is an open bottle is only good for 28 days after opening. Dr. Friedman recommends B12 over glycine, unless you have a sensitivity or contraindication to B12. For all doses, glycine instead of B12 is available for the same price.

Tirzepatide Injections at UCP UCP has recently partnered with AnazoaHealth for compounded Tirzepatide/B12 injections. A 3ml vial of Tirzepatide/B12 at 20 mg/ml lasts 2 months and price includes shipping and syringes. Patients pay Dr. Friedman. They ship to all 50 states. This is a good choice for patients on higher doses of Tirzepatide or in states with less options.

Because the Red Rock Pharmacy is good for low doses and UCP is good for higher doses, one popular choice for California residents is to get one Tirzepatide/B12, 5mg-100 mcg/mL 1 ml vial from Red Rock Pharmacy and take 1 mg (0.2 ml) weekly for 3 weeks, 2 mg (0.4 mL) for 1 week, followed by one

Tirzepatide/B12, 8.5 mg-100 mcg/mL 1 ml vial, and take 2 mg (0.24 ml) weekly for 3 weeks and 2.5 mg weekly the next week. Those can be ordered at once. If the patient is doing well, a new order can be placed for a 20 mg/mL 3 ml vial from UCP and take 3 mg weekly for 2 weeks, 4 mg weekly for 2 weeks, 6 mg weekly for 2 weeks and 8 mg weekly for 2 weeks. The 60 mg bottle can be renewed with a dose of 10 mg weekly.

Sublingual Tirzepatide at UCP- is good choice for patients who don’t want a shot. Its effectiveness is more variable as some patients do well and lose weight and others find it ineffective. Patients pay UCP. Tirzepatide injections have been discontinued but they have sublingual (under the tongue) Tirzepatide (10 mg/mL). Recent information from UCP have recommended daily dosing for optimal weight loss. Recommended dose is 0.5 mL (5 mg) under the tongue daily. After 4 weeks, increase to 1mL (10 mg daily which is the final recommended dose. The price for the starter dose of 10 mL (lasts 20 days) is $180. The 30 mL vial which lasts about 2 months is $250 and a 60 mL vial that lasts about 3 months is $450. Patients pay UCP directly. It needs to be refrigerated and can be used for 90 days after opening the bottle. It comes with a syringe that can withdraw the liquid from the vial and put under the tongue, where it should

Zepbound Glass Vials For those patients who want a non-compounded FDA-approved preparation, Zepbound Glass Vials from Lilly Direct are an option, with the costs for different doses listed on the website. The cost for the 4 of the 10 mg vials is $499 for the first vial and $499 if renewed within 45 days or $699 if renewed after 45 days. Patients need to register on LillyDirect.lilly.com and purchase syringes for a small fee. Each vial is 0.5 ml, so the concentration is 2 mg/0.1 ml. Although the company discourages using the vial for multi-dosing (it doesn’t contain a preservative), one option would be to inject 1 mg (0.05 mL) weekly for 2 weeks, 2 mg (0.1 mL) weekly for 2 weeks, then 4 mg (0.2 ml) weekly. The box of 4 vials would last about 10 weeks. Dr. Friedman’s staff would send it to LillyDirect Self Pay Pharmacy Solutions.

Oral daily Wegovy- Oral daily Wegovy just became FDA-approved and is commercially available from Novo Nordisk. Commercial insurances are unlikely to cover it and MediCare and MediCal do not cover it. For cash-pay, the cost is $199/month for the 0.25 mg dose and $349/month for the 0.5 mg (it will be $199/month until March 31, 2026), 1 mg, 1.7 mg and 2.4 mg dose. Patients should sign up at wegovyprosavings.com and Dr. Friedman will e-prescribe it at NovoCare pharmacy.

Foundayo (orforglipron) is an oral daily GLP-1 analog related to semaglutide (prices should be compared to that of compounded semaglutide) that is available for self-pay through LillyDirect at https://www.lilly.com/lillydirect/medicines/foundayo. It can be taken with or without food. The price of the starting dose of 0.8 mg is $149/month, the 2.5 mg dose is $199/month, the 5.5 mg and 9 mg dose is $299/month and the 14.5 mg and 17.2 mg doses is $349 per month, or $299 per month if you refill within 45 days.

The Medicare GLP-1 Bridge program runs from July 1, 2026 until December 31, 2027. It allows eligible Medicare Part D beneficiaries to get specific weight-loss drugs for a $50 monthly copay. Covered drugs include Wegovy®, Zepbound® (KwikPen® only), and Foundayo®.

You must have Medicare Part D drug coverage. You cannot get a GLP-1 drug covered through your current Part D plan.

  • Diagnosis: You must need the medication for weight loss and cannot have type 2 diabetes, moderate-to-severe sleep apnea, or fatty liver disease.
  • Weight/Health Requirements: You must be 18 or older and meet specific BMI and health risk criteria: BMI ≥ 35: No additional conditions required.
  • BMI ≥ 30: Must also have heart failure, uncontrolled high blood pressure, or chronic kidney disease.
  • BMI ≥ 27: Must also have prediabetes or a history of heart attack, stroke, or blocked arteries.

Our office will complete the preauth for patients who qualify for a $50 processing fee. Please pay using the miscellaneous fees tab at https://www.goodhormonehealth.com/appointment-booking/. More information is available at https://www.cms.gov/medicare/coverage/prescription-drug-coverage/medicare-glp-1-bridge/information-pharmacies

What about Retatrutide? Retatrutide is an experimental triple-agonist weight-loss and diabetes drug developed by Eli Lilly that targets GLP-1, GIP, and glucagon receptors. In Phase 3 clinical trials, it produced unprecedented average weight reductions of up to 24% to 30% of body weight. Some providers are prescribing it even though it is not yet FDA-approved and probably won’t be FDA Approved until 2027. Due to safety concerns, Dr, Friedman only prescribes compounded GLP1s (Tirzepatide and Semaglutide ) that are FDA-approved.

Is Glycine/B12 helpful in compounded GLP-1s?

 B12 may afford advantages: it has been studied for ameliorating nausea triggered by GLP-1 RAs. B12 may also optimize metabolic functioning, making it an adjunct in weight management goals. The glycine may help prevent loss of lean muscle mass in the context of caloric restriction.

What about loss of muscle mass with compounded GLP-1s?

Loss of muscle mass may occur on GLP-1s. Dr. Friedman does not recommend GLP-1s in patients with low muscle mass to begin with. He recommends making usre you have adequate protein intake, including plant-based protein. He also recommends increasing exercise, especially using the large muscles in arms and legs. He also recommends measuring a bioavailable and total testosterone lab every 3 months and going on compounded testosterone cream if bioavailable testosterone is less than 2.5 ng/dL. Because of the different options for compounded GLP-1s, Dr. Friedman is advising his patients to make a 10-minute followup appointment to discuss options. Compounding pharmacies do not give automatic refills; if you are on GLP-1s, make a 10 min appointment to discuss refills at least every 3 months. It is helpful to get labs before your appointment, including a bioavailable and total testosterone. For more information, please read about compounded GLP-1s, and listen to listen Dr. Friedman’s original GoodHormoneHealth Webinar on November 17, 2024 on compounded Tirzepatide vs Semaglutide for patients with endocrine problems https://www.youtube.com/watch?v=u9VbPDsJcPE,
https://www.facebook.com/goodhormonehealth, https://www.goodhormonehealth.com/webinars or on your podcast channel. Dr. Friedman discussed the updated situation for compounded GLP-1s at his most recent GoodHormoneHealth Webinar on Sunday March 23, 2025 at 6:00 PM after his talk on “How can Blue Zones and Maimonides’ principles be applied to lead a healthy life for patients with endocrine problems?” It is available on YouTube at or https://youtu.be/6q_zxNqu2uc

https://www.goodhormonehealth.com/webinars/ or

https://www.facebook.com/goodhormonehealth

Protect access to compounded medications — make your voice heard. Sign the Petition!

For more information go to Dr. Friedman’s website https://www.goodhormonehealth.com or contact his office at mail@goodhormonehealth.com.

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T4/T3 Combination

January 16, 2025TfriedmanUncategorized
T4/T3 Combination

Understanding Thyroid Hormones: T4 and T3

The thyroid makes two hormones, T4 which has a long half-life meaning it can be given once a day. T4 gets converted to T3 which is the active form of the hormone and has a short-half life, meaning it has to be given frequently. Most patients with hypothyroidism are treated with levothyroxine (L-T4), which is T4. There are many brands of levothyroxine that include Tirosint, Synthroid, Unithroid, and Levoxyl. As the thyroid makes both T4 and T3, doctors that give only L-T4 hope the L-T4 goes into “overdrive” to make up for the lack of T3 replacement and converts to T3. However, multiple studies have found that about 15-20% of patients on L-T4 replacement with a normal TSH level still have hypothyroid symptoms. Are you one of them?

Challenges with T4-Only Therapy

However, two very important recent articles suggested that about 15% of patients with hypothyroidism do not convert T4 to T3 properly and should be on a T4/T3 combination or on desiccated thyroid extract (DTE) that contains T4 and T3. I wish to highlight these papers as they are very interesting and important studies.

Study on T4 to T3 Conversion: The UK Research

One study came from the United Kingdom that looked at the prevalence of the gene that converts the T4 to T3. This is called the type 2 deiodinase. In this study, 15% of the population had an alteration in the gene that converts T4 to T3, the alteration is called a polymorphism. This polymorphism means the DNA is changed so that this enzyme works less effectively. The patients with this polymorphism required higher T4 dosing and had more psychological problems than those that did not have the deiodinase polymorphism. They did not examine whether these patients would benefit from T4/T3 combination and also did not actually measure the enzyme, they only looked at the gene coding for this enzyme.

Italian Study on Free T4 and T3 Levels

Another very intriguing article came out from Italy that initially examined patients that had a thyroid nodule but were not on a thyroid medicine and did not have any other problems with their thyroid. Examining several thousand of these healthy patients, they were able to establish normal values for free T4, free T3, and TSH in this Italian population. Once these normal values were obtained, the researchers then took patients that had their thyroid completely removed for thyroid cancer, but did not get any other procedures done to the thyroid such as radioactive iodine. The patients with the thyroid cancer who had the thyroid removed were then placed on T4 or levothyroxine therapy and their free T4, free T3, and TSH were measured. All the patients had a normal TSH and that was the criteria for being in the study. However, approximately 15% of the people had a low serum free T3 that was below the range previously established. An additional 5% of the patients had a free T4 above the range that was established. This shows that about 15% of the people do not convert the T4 to T3 properly. This was based on serum T3 levels and is a very good indication that these 15% of the people would need T3 in addition to T4 to get both levels in a normal range. This study suggested that measuring serum free T3 is quite helpful in patients that are treated with T4 for hypothyroidism, an evaluation that is not normally done. This paper did not measure reverse T3, which some Dr. Friedman also uses to determine that the T4 to T3 conversion does not occur and actually this paper suggested that the measurement of serum free T3 itself can be used to determine which patients need T4/T3 combination treatment.

Implications for Hypothyroidism Treatment

These 2 intriguing papers challenge the idea that all patients with hypothyroidism should be treated with T4. Dr. Friedman uses different thyroid medicines to treat patients with hypothyroidism including T4/T3 combinations, and desiccated thyroid that contains T4 and T3. Dr. Friedman interprets this data that the majority of hypothyroid patients do fine on T4 alone, include the patients he treats at Los Angeles County Department of Health Services. Approximately 15% of the population does need T4/T3 combination to have an optimal effect on the thyroid. Dr. Friedman feels these patients are the vocal minority who are not doing well on T4 treatment and would benefit from seeing a thyroid specialist like Dr. Friedman.

A Personalized Approach to Thyroid Health

For more information about Dr. Friedman’s practice or to schedule an appointment, go to www.goodhormonehealth.com.

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Supplements to Lower TPO Antibodies

January 16, 2025TfriedmanUncategorized
Supplements to Lower TPO Antibodies

There are some supplements that can be used to lower the TPO antibody. Selenium at 200 mcg a day (can be purchased at Trader Joes or online) can lower the TPO antibody as can Myo-Inositol plus from Omnibiotics, 2000 mg/50 mg once a day that can be purchased on Amazon. These supplements are helpful in those with a positive TPO antibody and a high normal or slightly elevated TSH, in patients who don’t want to take thyroid medicine. They are probably not helpful in those with a high TSH who definitely need thyroid medicine.

For more information on Dr. Friedman’s endocrinology practice, please go to www.goodhormonehealth.com.

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Glucocorticoids & Sleep: Impact on Your Hormone Health | Good Hormone Health

January 16, 2025TfriedmanUncategorized
Glucocorticoids & Sleep: Impact on Your Hormone Health | Good Hormone Health

Dr. Friedman, when he was a fellow at the NIH in the 1990s, published a paper in the Journal of Clinical Endocrinology and Metabolism on the timing of giving glucocorticoids to patients with Addison disease. This paper involved sleep studies, and Dr. Friedman and colleagues found that a small dose of hydrocortisone given at bedtime helped the patients with Addison disease go into deep sleep while if the glucocorticoids were withheld for 1-1/2 days, the patient did not go into deep sleep. It is commonly known that excess glucocorticoids give trouble sleeping, but this paper showed that glucocorticoid insufficiency is also associated with poor sleep and that it is beneficial to give a small amount (2.5 mg) of glucocorticoids at bedtime. Almost all of Dr. Friedman’s patients sleep better with this low dose.

Contact Dr. Friedman Today

If you have any questions about Dr. Friedman’s practice or want to make an appointment, please to go his website www.goodhormonehealth.com.

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Anti-Thyroglobulin Antibodies and Hashimoto’s

January 14, 2025TfriedmanUncategorized
Anti-Thyroglobulin Antibodies and Hashimoto’s

There is some confusion about the role of anti-thyroglobulin antibodies in diagnosing Hashimoto’s. A large study using a national database called the NHANES database showed that only the TPO antibodies correlated with hypothyroidism and not anti-thyroglobulin antibodies.

The confusion seems to come that before the TPO antibody was identified, doctors used a test called an anti-microsomal antibody that was not as specific for Hashimoto’s as the TPO antibody. When that was the only test available for Hashimoto’s, an anti-thyroglobulin antibody was helpful because it could be used in complement with the anti-microsomal antibody to diagnose Hashimoto’s. However, now that the TPO antibody is standardized and is a very sensitive and specific test for Hashimoto’s hypothyroidism, there is no reason to get a anti-thyroglobulin antibody unless the person has thyroid cancer, in which it is a useful test.

For more information on Dr. Friedman’s endocrinology practice, please go to www.goodhormonehealth.com.

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In Memoriam

December 10, 2024TfriedmanUncategorized

Dr. Friedman’s patient Dr. Madonna Ramp tragically passed away on November 12, 2024. She had adrenal insufficiency and was hospitalized for the last 5 months of her life.
Madonna is the fourth patient of Dr. Friedman who tragically passed away who had adrenal insufficiency.

Dr. Friedman was interviewed by Yahoo about the passing of TikTok star Taylor Rousseau Grigg who also died of Addison’s disease. Dr. Friedman doesn’t know the details of the deaths of either Taylor or Madonna but feels there is a lack of understanding by doctors of how to treat Addison’s/adrenal insufficiency and both patients and doctors don’t take it seriously  Dr. Friedman heard about Madonna’s death from his patient Erin who said “Patients with adrenal insufficiency need to be taken seriously”. Below is her obituary. Feel free to donate to Listening Ear Crisis Center in East Lansing, MI.

 

Dr. Madonna Nicole Ramp, 43, passed away on November 12, 2024, in Las Vegas, NV after a long battle with multiple illnesses. 

Madonna was born on April 14, 1981, in Jackson, MI to Daniel Ramp and Madonna Chapin. She attended St. John’s Elementary School, J.C.M.S., and Lumen Christi while living in Jackson. During her years in school, she was active with many different sports, clubs, and youth groups. She ultimately moved to Paw Paw, MI before her senior year of high school, and graduated from Paw Paw High School. 

After graduation, Madonna attended Michigan State University and was part of the Honors College. While attending MSU, Madonna continued her track record of being very active within her community. One of her most beloved experiences from her time at MSU was working at the Listening Ear Crisis Center. She supported numerous people through very difficult times while volunteering and always felt a sense of pride knowing she was helping provide others with someone to speak with when they needed it the most. She continued working her way up through the center and eventually ran the recruitment, selection, and training programs.

Due to her drive to help others, Madonna joined Teach for America after earning her Bachelor of Arts in Humanities. She moved to Miami, FL to work as a Special Education, Reading, and English Language Arts teacher in an inner city high school. She loved her work there; especially seeing the growth her students made! Even though she moved to Austin, TX from Miami, she didn’t leave the education world. There she expanded her role of educator outside of the classroom. She recruited, selected, trained, or mentored thousands of teachers nationwide in full- and part-time roles with traditional public school districts as well as non-profit organizations such as The New Teacher Project. She also worked as a Teaching Ambassador Classroom Fellow with the U.S. Department of Education.

Madonna not only loved teaching others, she also loved learning and strived to get better at her craft. She worked to earn a National Board Certification as an Exceptional Needs Specialist. In 2012, Madonna earned a Master of Arts in Education Leadership from Columbia’s Teacher College. From there, she went on to earn a Doctorate of Education Leadership from Harvard on May 23, 2018. 

To say Madonna was a free spirit would be an understatement. She loved moving to the beat of her own drum and trying to push the envelope to get others to think critically. Elvis, music, dancing, poetry, and catching up with her loved ones were some of the most important things to her! She also valued moving and growing, so no one person or place could tie her down for long!

Madonna was a valued member of many communities! She came from a large family and built an even larger family throughout the world! She is preceded in death by her father, Daniel, and her mother, Madonna. She is survived by her step-mother, Peggy Ramp, siblings, many aunts, uncles, cousins, nieces, nephews, and an immeasurable number of people who loved her.

While Madonna is no longer physically on Earth, the legacy she left behind will live on! She loved being in service to others, so in lieu of flowers, please make a donation to the Listening Ear Crisis Center in East Lansing, MI, or another charity of your choice, in her name.

May her memory be a blessing.

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Fludrocortisone for Adrenal Insufficiency Treatment | Good Hormone Health

November 25, 2024TfriedmanPosts
Fludrocortisone for Adrenal Insufficiency Treatment | Good Hormone Health

Understanding Adrenal Hormones

The adrenals make 2 important hormones, cortisol (a glucocorticoid) and aldosterone (a mineralocorticoid). Patients with adrenal insufficiency from an adrenal cause such as an adrenalectomy or Addison’s disease require replacement of both hormones, Although the natural mineralocorticoid is aldosterone, we give fludrocortisone or Florinef as a replacement. Florinef is the brand name and is no longer available. The glucocorticoid and mineralocorticoid axes are 2 different axes and in patients with Addison’s disease or who had an adrenalectomy, both hormones (cortisol and fludrocortisone) need to be replaced. Patients with pituitary cause of low cortisol usually do not mineralocorticoid replacement, although patients with low blood pressure and symptoms such as dizziness on standing and salt craving may benefit from fludrocortisone replacement.

Differences in Glucocorticoid and Mineralocorticoid Replacement

The symptoms of glucocorticoid insufficiency include nauseousness, vomiting, diarrhea, abdominal pain, joint pain, muscle pain, weight loss, and low energy and fatigue. Patients with mineralocorticoid insufficiency have low blood pressure, dizziness on standing, palpitations, salt craving, lightheadedness, low blood pressure, and a high pulse, and they often feel like they have brain fog because they do not get enough blood to the brain. They may do worse after exercising as exercise causes more blood to go to the muscles and less towards their brain. It is important to distinguish when the symptoms are due to not enough cortisol or not enough aldosterone, or both.

Symptoms of Adrenal Insufficiency

Dr. Friedman has been treating patients with adrenal insufficiency for about 40 years, and he notices most patients treated by outside Endocrinologists are over-replaced on glucocorticoids or cortisol and under-replaced on mineralocorticoids or fludrocortisone. A patient on too little fludrocortisone often is often symptomatic, and the typical doctor will often give him more glucocorticoid and they might feel a little bit better, but then they start getting cushingoid symptoms including weight gain and central obesity and increased chance of infection and increased chance of getting diabetes. This is because they should have been getting more fludrocortisone instead of more hydrocortisone.

Measuring Fludrocortisone Effectiveness

There is a very accurate test to determine whether the patient is getting enough fludrocortisone if they have primary adrenal insufficiency, and that test is the plasma renin activity (PRA) test. Dr. Friedman uses LabCorp and Quest which measures plasma renin activity while some labs use a direct renin assay. The laboratory director at LabCorp discussed with Dr. Friedman that the plasma renin activity test is more accurate than the direct renin level. The plasma renin activity should be collected in a chilled blood sample and kept cold and spun immediately. Otherwise, it will be falsely low. Unfortunately many labs don’t do that, but a high PRA does mean the patient is not on enough fludrocortisone.

What Plasma Renin Values Mean

A high plasma renin activity indicates not enough mineralocorticoids, and a low plasma renin activity indicates too much, and therefore the dose of fludrocortisone should be adjusted to normalize the plasma renin activity. This is much more accurate than looking at electrolytes, such as potassium, which are a later change and usually are not that affected by too much or too little fludrocortisone, unless severe. 

Substantial mineralocorticoid excess can lead to low potassium, but usually this does not happen too frequently, and therefore Dr. Friedman recommends the plasma renin activity and not electrolytes to be measured routinely until the Florinef dose is stabilized and the patient’s plasma renin activity is normal. Potassium levels can still be monitored. 

Measuring Plasma Renin Activity by Position

Dr. Friedman has looked at measuring standing or lying down plasma renin activity and feels that the sitting value is accurate and does aim for a value in the middle or upper part of the range. However, if a patient is still having symptoms of mineralocorticoid insufficiency and the value is in the middle of the range, he might increase the dose a little bit. Remember that fludrocortisone is much better tolerated than hydrocortisone. When patients are cutting down on their glucocorticoids, they need more mineralocorticoid requirement, and Dr. Friedman will often add extra Florinef as he is trying to taper a patient down who is on too much glucocorticoids.

Optimizing Fludrocortisone and Hydrocortisone Dosing

It is known that the glucocorticoid, hydrocortisone, has to be given in divided doses because it has a short half-life. Dr. Friedman has also researched that fludrocortisone has a pretty short half-life and also should be given twice a day. Most doctors just give it once a day, although Dr. Friedman experience is that patients do better if the dose is split up to twice a day, with the first dose first thing in the morning and the second dose in the mid-afternoon. Patients will often need more fludrocortisone in the summer when it is hot and they are sweating and less in the winter.

Seeking Expert Care for Adrenal Insufficiency

If you have adrenal insufficiency and want an expert to treat you, please contact Dr. Friedman via his website at goodhormonehealth.com.

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Treatment Options for Hypothyroidism

November 22, 2024TfriedmanUncategorized
Treatment Options for Hypothyroidism

Treatment Options for Hypothyroidism

Dr. Friedman prescribes various different treatments for hypothyroidism. A traditional treatment is to give a preparation of levothyroxine, such as Synthroid, Tirosint, Levoxyl, or Unithroid. This can be given once a day because the T4 in it has a long half-life, which means it stays in your body for a long time. However, Dr. Friedman also uses combination therapy that would include T4 plus T3, which is also called Cytomel. He also prescribes natural desiccated thyroid (NDT), which comes from pig thyroid and has T4 and T3 in it. Brands of NDT that Dr. Friedman prescribes include Armour thyroid, NP thyroid and Adthyza. The T3, either when given alone or when given in NDT, has a short half-life, which means that it disappears form the body in a couple hours.

How Often Does Your T3 or Desiccated Thyroid Need to Be Taken?

Therefore, if you take your desiccated thyroid, or your T3 preparation, once a day in the morning, it is gone by the late afternoon and is certainly gone by the next morning. This will give you a period of hypothyroidism right after the morning dose and more importantly, hypothyroidism in the evening and next morning, and most people will feel worse on this. Many providers who are not experts on proper prescribing of T3 or DTE overlook this. To overcome this problem, the T3, or the desiccated thyroid, needs to be given twice a day. The second dose is given in the mid-to-late afternoon so that the T3 will be around in the evening, and some of it will still be around in the next morning in time for the next dose. A good time to take the second dose is about 3 PM about an hour apart from food. Some people may need to set an alarm to remind them to take the afternoon dose.

Contact Dr. Friedman Today

If you would like more information about thyroid hormone replacement, please do not hesitate to make an appointment or visit Dr. Friedman’s website at goodhormonehealth.com.

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Do I Need a Thyroidectomy After a Cancer Diagnosis? | Good Hormone Health

November 22, 2024TfriedmanUncategorized
Do I Need a Thyroidectomy After a Cancer Diagnosis? | Good Hormone Health

Thyroid Cancer

Thyroid cancer is quite common but very few people die from it or have a shortened lifespan because of it. In other words, don’t worry. Many people have a thyroid nodule found in their neck area. Sometimes you the patient notices a lump, sometimes the doctor finds it, and sometimes (especially more recently) it shows up on other studies such as when CT scans or MRIs are done.

Thyroid Function Tests If You Have A Thyroid Nodule

If a thyroid nodule is found, the first thing you should do is have your doctor determine your thyroid hormone status by measuring thyroid function tests, especially a TSH level. If you are hyperthyroid and have a suppressed TSH, the nodule could be what is called a hot nodule, in that it makes too much thyroid hormone, which can often be treated with either medicines or radioactive iodine. Hypothyroidism in which the TSH is high, may be part of a Hashimoto gland. If your TSH is high, you should get a TPO antibody measured, and you could be treated with thyroid medicines for it. However, most commonly, you are what is called euthyroid or have normal thyroid tests. In that case, the next step is to have a thyroid ultrasound done.

Thyroid Ultrasound

The thyroid ultrasound is crucial to determine who needs to get a thyroid biopsy and who can just watch their nodule. In addition to the maximal size of the thyroid nodule, the ultrasound should state different characteristics of the nodule including echogenicity (lumpiness) and whether the nodule is solid or cystic or a mixture. It will also describe the shape of the nodule.

Key Characteristics Assessed in Thyroid Ultrasound

The radiologist then gives a score called a TI- RADS which goes from 1 (looks very benign) to 5 (looks like it might be cancer). If the TI-RADS score is 3 and the nodule is bigger than 2.5 centimeter, or the score is 4 and the nodule is bigger than 1.5 centimeter or the or the score is 5 and the nodule is bigger than 1 centimeter, then Dr. Friedman would recommend a fine-needle aspirate (also called a biopsy).

If the TI-RADS score is less than these cut-offs, the nodule can be followed, usually with an ultrasound in a year. Thus, all patients with a thyroid nodule should get an ultrasound that helps determine the next course. Thyroid nodules with a higher TI-RADS score are more likely to be malignant, and in those cases the patient may need to get the total thyroid removed. Also, the ultrasounds look at lymph nodes, and if there are lymph nodes present, that would be more of a concern and more of an indication for a total thyroidectomy at the time of surgery.

Thyroid Biopsy

If the ultrasound suggests a biopsy, it should be done by a specialist who has many years of experience doing thyroid biopsies (Dr. Friedman does not do this procedure). The person who does the biopsy is often a radiologist, endocrinologist, or pathologist, and they put some numbing medicine on you before putting a needle into the nodule. The biopsy is done while you are lying down. Often, they put the needle in several times to get multiple samples to make sure they get tissue from the thyroid nodule. This sample gets sent off to the laboratory, where they determine whether it is cancer, possible cancer or not.

Types and Treatment for Different Types of Thyroid Cancer

There are several different types of thyroid cancer. The most common one by far is called papillary thyroid carcinoma, which occurs in at least 90% of the cases. The next most common is called follicular carcinoma, and then rarely it could be medullary carcinoma or anaplastic carcinoma, or thyroid lymphomas.

Diagnosing Thyroid Cancer

The pathologist will easily be able to tell about papillary thyroid carcinoma, anaplastic thyroid cancer, lymphomas, and medullary carcinoma. However, in terms of some papillary thyroid carcinomas and most follicular carcinomas (see below), sometimes it comes back clearly cancer, sometimes it comes back clearly non-cancer, sometimes it comes back not enough tissue to make a determination. If it comes back thyroid carcinoma, it depends on the size of the nodule and whether lymph nodes are involved.

When Surgery Is Not Needed

If the nodule is smaller than a centimeter, then surgery is not needed. Let me repeat that. Even if you have thyroid cancer, if your nodule is less than a centimeter, it is not recommended to undergo surgery. Some experts even suggest not removing it if it is less than 2 cm, but Dr. Friedman will probably recommend removal of those 1-2 cm. Of course, if you feel more comfortable having the thyroid nodule removed, you could have it removed. But in general, Dr. Friedman does not recommend surgery for these small thyroid carcinomas because they are very unlikely to affect people’s life.

Treatment for Nodules Between 1 and 3 cm

If the thyroid nodule is between 1 and 3 cm, and there are no lymph nodes involved, then Dr. Friedman usually recommends just having that half of the thyroid gland removed, which is called a hemithyroidectomy. This allows you to preserve thyroid function, and you will usually not need to take thyroid medicine. If the nodule is greater than 3 cm, a total thyroidectomy is usually recommended.

The Importance of Ultrasound in Treatment Decisions

Dr. Friedman also recommends that the ultrasound look carefully to see if there are any lymph nodes. If there are lymph nodes, then most likely a total thyroidectomy is needed, but if there are no lymph nodes and the nodule is between 1 and 3 cm, just taking out the site of the tumor is the recommended procedure.

Follicular Lesions

The problem that often occurs is that follicular thyroid cancers are very hard to tell on biopsy if they are cancer or not. It is rarely determined that it is follicular cancer. They often come back as follicular tumors that look like cancer, and that it would be recommended that the thyroid be removed even though there is only about a 30% chance they are malignant. There is also a category that is quite common, called follicular lesion of unknown significance (FLUS); these are most likely benign and often occur in thyroid glands that have Hashimoto’s. If this pathology comes back, then Dr. Friedman recommends checking the TPO antibody, and if the TPO antibody is positive, then could just watch it and repeat the biopsy in a year. These lesions can also be sent off for molecular testing. The patients who have smaller follicular lesion could also get a hemithyroidectomy (half your thyroid removed).

Total vs Partial Thyroidectomy

Although many other doctors recommend a total thyroidectomy for the papillary thyroid carcinomas and the follicular carcinomas, Dr. Friedman does only recommend taking out half of your thyroid. Usually, people who have the total thyroid removed have more hypothyroid symptoms than people who have hypothyroidism from Hashimoto. For these reasons, Dr. Friedman likes to keep the thyroid in place.

Balance

Dr. Friedman wants to balance the downsides of having aggressive surgery but also wants to make sure the thyroid cancer does not give people problems and spread. It is very rare for thyroid cancers to spread, but a balance between doing the right amount of surgery is what is needed in these cases. In general, thyroid experts including Dr. Friedman are recommending less aggressive treatments than 20 years ago.

If you are have thyroid cancer and want to take advantage of Dr. Friedman’s expertise in this area, please do not hesitate to make an appointment by visiting his website at goodhormonehealth.com.

*Photo by Ed Uthman

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