Women's Health Connection is excited to offer a functional medical program. We feel this is the "way forward" in health care. The approach is therapeutic as well as a highly preventative as a model of care.
Functional medicine refers to a style of medical practice that insists on going back to the science of physiology and biochemistry to help with basic medical problems. Diet, lifestyle, nutritional supplementation, and careful testing of nutritional and hormone imbalances and deficiencies are the foundations of functional medicine. When deficiencies are noted, the goal is to replace only what's missing, and replace it only to the normal range, with the same nutrients and hormones that your body naturally produces.
What does "bio-identical" mean?
The term "bio-identical" is often used to describe hormones and nutrients and substrates identical to those that the body naturally produces. Sometimes they are called "human identical" meaning that they are the forms of these substances that humans produce, and not derived from other animals. Bio-identical substances are sometimes formulated by a compounding pharmacy, although some traditional prescription medications are also bio-identical. Please note that for safety reasons, Women's Health Connection has a policy of only using compounding pharmacies accredited through the Pharmacy Compounding Accreditation Board. Please note that there are currently no Spokane Compounding Pharmacies on this list. We encourage you to have a look at this website regularly and do not take anyone's word for it, if they say they are accredited. While all compounding pharmacies must meet the requirements set by the resident state board of pharmacy, PCAB accreditation denotes a more comprehensive and stringent standard. Dr. Ravasia calls the local compounding pharmacies in Spokane regularly about this, and is anxious to start using them, just as soon as they are PCAB accredited. Being accredited means they are meeting careful safety checks and balances, because pharmacy compounding is a complex process, and otherwise fairly highly prone to human error. The particular compounding pharmacy that we recommend (because they are PCAB accredited AND cost effective) is McGuff Phamacy. Please note that we do not have any financial ties with them, and if you find a more cost effective PCAB accredited compounding pharmacy that you'd like to use, we'd be happy to accommodate. Also, please note that we make no exceptions to using a non-PCAB accredited pharmacy – even though we are asked regularly about this by our patients and even though it would make good business sense. It is a safety issue, in Dr. Ravasia's opinion as Medical Director of this practice.
Being "bio-identical" does not by itself mean that a hormone is "safe" or that large doses are "OK". They are still powerful substances and the principle of using them responsibly is to carefully measure what's missing and what's present in excess and prescribe only what's missing in the amount that it is missing, based on careful testing.
How do you measure hormone and nutritional deficiencies?
Testing for hormones and nutritional deficiencies involves a variety of techniques. Venous blood, saliva, urine, stool and capillary blood are all used. You will learn why we choose to test specific hormone and/or nutritional levels in one body substance or another during this program. Please read Dr. Kenna Stevenson's opinion about testing for hormone levels, much of which I agree with.
What are symptoms of hormone imbalance?
There are many symptoms that can result from hormone deficiencies, excesses and imbalance. The most common ones we hear are hot flashes, nightsweats, weight gain around hips or waist, lack of libido, memory loss (such as difficulty finding the right word, or difficulty remembering why you entered a room), irritability and mood swings, crying easily, anxiety, changes in skin, hair and nails, fatigue and joint pain, insomnia, PMS, salt and sugar cravings, hair loss, palpitations, menstrual irregularities, fibroids, endometriosis, painful breasts, irritable bowel. These are just some. There are others.
Will adjusting and balancing my hormones make these problems go away?
Getting hormones balanced will usually help with these problems. As with any therapy, there are a few people who do not respond. In many cases, hormone balancing can help quite a bit, and help you feel much better, and in some cases, your symptoms will disappear entirely. Of course, it is of utmost importance to rule out disease first of all and then to focus on adjusting hormone levels and nutritional levels for optimal functioning.
My other doctor wants me to take traditional HRT or not to take anything. Is there evidence for bio-identical hormones?
There is evidence and the evidence suggests that they are quite possibly a little safer and a little more efficacious when used responsibly. Unfortunately they are often misused. Please take the time to read a well referenced clinical review article on this topic: The Bio-Identical Hormone Debate: Are Bio-Identical Hormones (Estradiol, Estriol and Progesterone) Safer or More Efficacious than Commonly Used Synthetic Versions in Hormone Replacement Therapy? See also American Heart Association: Hormone Creams May Aid Menopausal Symptoms without Increasing Thrombotic Risk. There are others and we will review them with you.
What is your approach? What's involved?
The first step is to thoroughly assess your symptoms. This starts with completing a questionnaire, reviewing your symptoms in detail with one of our providers, doing a targeting physical exam, updating your annual exam if necessary, making sure that your preventative exam is up to date in terms of PAPs, mammograms, colonoscopy, bone scans and any other recommended preventative exams.
Based on your specific symptoms of hormone imbalance, a set of tests is ordered for you. This often involves a combination of blood tests, salivary testing, possibly urine testing, possibly capillary blood tests, and possibly stool testing, depending on your symptoms. for micronutritional analysis, or detailed cholesterol particle analysis may be ordered as well.
Follow-up appointments are made to guide you through what your specific tests show and mean. Because many endocrine systems are involved, you will go through a series of modules to learn more about how the body's endocrine system works and how specific imbalances might be affecting you individually and what you can do about them.
A functional medicine program will be prescribed for you, depending on your symptoms. The cornerstone of effectively managing perimenopausal and menopausal problems nearly always involves the information in the first two sessions, and almost everyone with perimenopausal symptoms can benefit from the education that we provide in these visits, which consist primarily of counseling and coordination of care.
Session #1: Ovarian Hormones: Estrogen, Progesterone and Testosterone
- learn about what each of these hormones does, what normal balance is
- learn about how they are best tested, and what your test results mean for you
- learn lifestyle changes, supplements, nutrients and dietary changes that can help you eliminate excesses
- discuss pros and cons of replacing specific hormones that are missing or deficient in your specific situation.
- learn what other endocrine imbalances might be playing a role in your symptoms.
- learn about why estrogen is a fat storage hormone, and why the adipose (fat) tissue may be the biggest producer of estrogen in your body
- learn other causes for perimenopausal symptoms besides estrogen deficiency – many women with menopausal symptoms have adequate or even excess estrogen levels (Yes, it's a vicious cycle…)
- learn how to decrease levels that are in excess and increase levels of ovarian hormones that are deficient
- learn about why testosterone excess often signals insulin resistance
Session #2: Stress Hormones and the "Cortisol Connection"
- 80% of visits to physicians are due to stress related complaints
- chronic stress can initially cause high levels of cortisol particularly at night, which detracts from your body's ability to make adequate levels of other hormones and causes sleep disturbance and anxiety, abnormal regulation of blood sugar and electrolytes
- chronic stress affects your body's digestive system and ability to eliminate waste
- for some people, chronic stress eventually results in abnormally low cortisol production, particularly during the day, and to difficulty with energy levels and motivation
- inability to cope with stress may also be the result of low cortisol levels, which can be our body's natural response to insulin resistance
- learn about how cortisol and DHEA levels fluctuate throughout the day and what is a normal and an abnormal circadian pattern of these fluctuations
- learn what you can do to help restore normal levels through nutrition, lifestyle change and hormone balancing and what the evidence is for these approaches
Other Sessions, as Needed
The Thyroid: The Master Gland of Energy and Metabolism
- Learn the multiple functions of the thyroid and how best to measure its function
- Learn about storage (T4) and active (T3 ) forms of thyroid hormones
- Sometimes basic initial thyroid testing can be normal, but further testing reveals difficulty changing storage to active thyroid levels, or resistance to thyroid hormone at the receptor levels
- Learn how nutritional deficiencies can affect your body's ability to convert T4 into T3, and the role of nutritional support of the thyroid
- Learn how thyroid hormones affect and are affected by ovarian and adrenal hormones
- Learn about optimal levels of thyroid hormones, within the normal range and how small adjustments within the normal range can help you function at your peak of energy and metabolic efficiency.
Gastro-intestinal Dysfunction: Beyond "Irritable Bowel Syndrome"
- Stress and abnormal cortisol levels affect the GI system, and GI dysfunction stresses the body and affects cortisol levels. Learn how to break the cycle.
- Learn the connection between GI inflammation on chronic fatigue, joint pain, and other inflammatory conditions
- We will review normal GI function, as well as test for subtle and severe GI dysfunction and discuss the roles of healthy gut flora, probiotics and digestive enzymes
- We will rule out parasitic infections, which affect 2-5% of our population and are easily treated
- Learn the importance of subtle and overt food allergies
- Rule out GI disease such as polyps and growths – we will arrange any necessary tests and referrals.
Vitamin D Deficiency
- Vitamin D has many functions beyond protecting your bones
- Food, even fortified, is a very poor source
- Sunlight and a high quality supplements tailored to your levels are much better sources
- Vitamin D helps prevent multiple sclerosis, fatigue, joint pain, a variety of cancers, asthma, depression, and heart disease among others. Please read the medical review from the New England Journal of Medicine: Vitamin D Deficiency.
- Learn how vitamin D functions as a hormone
- Too much vitamin D can be toxic, although that is uncommon – deficiencies are much more common
- Learn what your vitamin D levels are and let us help you get them into, and keep them in, the optimal range
Will my insurance cover my functional medicine program?
To the extent that you have medical symptoms that need evaluation, management, diagnosis and treatment, your office visits and follow-ups are covered like any other visit to the doctor's office, and are subject to copays, coinsurance and deductibles like any other office visit. They are simply more structured than many other follow-up visits.
We will take adequate time at each of your visits to thoroughly understand your problems and counsel you about managing them, and educating you about general principles and your specific situation. These visits are often scheduled for 30 to 45 minutes (sometimes even more time is required). We will not charge the credit card unless you do not show up for your visit, or cancel with less than 24 hours notice, in which case we will charge your card $50. This is to cover our overhead costs for physician time, staff time and general office overhead for an hour of time that was reserved specifically for you. This would not be so much of an issue for shorter visits, but is important when we are holding that much time in the schedule. We appreciate your understanding.
Our experience is that lab tests for hormones and nutritional levels are usually covered when medical indications are present. We have yet to see them denied when medical indications are present, and we will determine if they are when we initially evaluate you.
High Quality Supplements
Along with lifestyle changes, prescription medications, and prescription hormones, we may recommendnutriceutical supplements and foods classified as “Medical Food” by the FDA, We caution that not all supplements are created equally.
Many people are unaware that not all of the vitamins and nutritional supplements available over the counter at health food stores, pharmacies, supplement stores, grocery stores and large well known chains such as Walmart and Costco,are safe. Although cheap, they may be untested, ineffective and sometimes even dangerous.
- LA Times Questions the quality of herbs. Monmaney T Labels' potency claims often inaccurate, analysis finds. Los Angeles Times, August 31, 1998
- Lactobacillus products mislabeled and contaminated. Hughes, et al. Microbiologic characteristics of Lactobacillus products used for the colonization of the vagina. Obstet Gynecol 1990;75; 244
- Herbs seriously contaminated with heavy metals and pathogens. Bateman, J. Possible toxicity of herbal remedies. Scottish Med J 1998l 4:7-15
- Twelve Supplements You Should Avoid: The FDA's Dirty Dozen, Consumer Reports, Sept 2010
- Nutrient interactions inhibit mineral absorption from multiple vitamin-mineral supplements. Shils et al. Modern Nutrition in Health and Disease, Vol 1, 8th ed. Philadelphia: Lea and Febiger; 1997, pp 216-217.
- Calcium supplements contaminated with lead. Bourgoin B et al. Lead Content in 70 Brands of Dietary calcium Supplements. Amer J Pub Hlth. August 1993, vol. 83, no. 8.
For these reasons, the Medical Director of Women's Health Connection, Dr. Ravasia, feels strongly that the nutritional supplement industry should be more strongly FDA regulated, that nutriceutical standards should be the same as pharmaceuticals, and that these (sometimes very potent) supplements should be medically monitored.
However, the reality is, they are not, and you don't know what your are getting. You are at the mercy of business people with no or little health care background, looking for the best price point, when you purchase supplements over the counter.
For all of these reasons, Dr. Ravasia recommends advises extreme caution when purchasing products over the counter. Because she does not wish to “throw the baby out with the bath water”, and thinks that high quality supplements based on careful scientific research have a strong role to play in your health, she has carefully researched and visited many labs and manufacturing plants and facilities of several nutritional supplement companies, looking for ones that meet the following criteria:
- Certified for GMP quality and using only GRAS certified ingredients
- Scientific ingredient selection and formulas, based on published scientific evidence, specific for that formula
- Comprehensive safety reviews at each level of development, manufacture, processing
- Human Clinical Evaluations, available in peer reviewed medical literature, to be sure what you are taking reaches the bloodstream in adequate amounts, does not interact with medications or other nutrients, and has the desired effects
- Leading scientific staff and facilities that would meet and exceed the standards for pharmaceutical manufacturing - no shortcuts
She has fortunately found a few such nutritional supplement companies, albeit not many, that meet all of these high standards, and a few others that come very close. The companies that meet or get very close to these standards do not wholesale to stores and chains, partly because they produce potent products that they believe need to be medically supervised, and partly because they cannot manufacture at this level of quality and still meet the price point expected by most retailers to be competitive in the over the counter market.
All of which means that the supplements we recommend are not found over the counter and not readily available by internet, for better or worse. We have made them available through our clinic, under careful supervision. We are confident in their safety and efficacy, after thoroughly researching the options. We are not aware, yet, of any insurance coverage for these products, however, we can give you receipts for possible tax and FLEX plan purposes. Please refer to our policies as there is a small fee associated with extra forms and letters.
Cost of Prescriptions for Compounded Hormones
Many insurance companies handle prescriptions for compounded hormones the same way they do any other prescriptions. Your pharmacist can tell you more. None of the PCAB accredited compounding pharmacists that Dr. Ravasia is aware of will bill insurance on your behalf. Some non-accredited pharmacies will, but they are non-accredited, so we do not use them. As well, often the insurance companies who bill insurance charge in addition a dispensing fee that is as high, or higher than, the total cost for the same amount from the accredited compounding pharmacy.
How do I get started?
Call our office at 465-8885 and ask to book an initial visit to assess your symptoms and concerns. Expect a complete exam at your initial visit, unless you've recently had one completed with us or another provider in the last few months. Please fill out the attached paper work ahead of time and bring it with you. If you have not been to our clinic before, there will be about 20 minutes of administrative paperwork to complete ahead of time as well, so please arrive a little early. Please try to bring previous medical records with you or arrange to have them sent to us.
We are very excited about this program and confident that you will derive some important and beneficial knowledge and health benefits from it. We look forward to seeing you for your first visit.