February 5: Thyroid; Statins; Testosterone; Progesterone; Lab Review

February 5, 2024


Session Notes

Cholesterol and Statins:

  • Dr. Doug addressed the confusion surrounding cholesterol, referencing historical studies and the evolution of understanding regarding dietary fat and cholesterol.
  • The discussion included the differentiation between HDL and LDL cholesterol, their roles in transporting cholesterol, and the misconceptions about "good" and "bad" cholesterol.
  • Highlights of the importance of looking at cholesterol as one of many risk factors for heart disease, rather than the sole determinant.
  • The pharmaceutical industry's role in developing statins to lower cholesterol was mentioned, along with the relative benefits and risks associated with statin use.
  • Dr. Doug emphasized the need for a comprehensive approach to assessing heart disease risk, including genetic factors, inflammation markers, and other biomarkers.

Lab Review:

  • Dr. Doug reviewed lab results live, providing initial impressions and explaining the significance of various markers.
  • The discussion covered lipid panels, the importance of metabolic health indicators like HDL to triglyceride ratios, and the limitations of total cholesterol as a risk factor.
  • The relevance of LP(a) as a genetic risk factor and other markers like homocysteine and CRP for assessing heart disease risk.
  • The conversation touched on the coronary artery calcium score (CAC) and coronary CT angiogram (CCTA) as diagnostic tools for heart disease.

Hormone Replacement Therapy (HRT):

  • The impact of HRT on cholesterol and overall metabolic health, noting that it generally has a protective effect on cardiovascular health.
  • The conversation also addressed the confusion caused by conflicting advice from different healthcare providers regarding HRT and the interpretation of lab results.

Thyroid Function:

  • Dr. Doug explained the importance of a comprehensive thyroid panel, including TSH, free T3, free T4, and thyroid antibodies, to accurately assess thyroid function.
  • The limitations of relying solely on TSH and free T4 for thyroid assessment were highlighted.

Testosterone and Progesterone Levels:

  • Sex hormone levels, discussing the implications of testosterone supplementation and the importance of balancing estrogen with progesterone, especially for women with a uterus.
  • The potential side effects of testosterone, such as changes in complexion, were mentioned, along with strategies to mitigate these effects.

Questions and Answers:

  • Dr. Doug responded to various questions from participants, including the interpretation of specific lab markers, the role of iodine in thyroid health, and the status of licensing in different states for providing medical services.

The meeting concluded with Dr. Doug addressing individual concerns and reiterating the importance of personalized medical care based on a comprehensive understanding of each patient's unique health profile.



00:00:11.904 --> 00:00:19.343

Dr Doug Lucas: Yeah. So we'll switch to Wednesday at noon, starting next week. So for Valentine's day we can all join each other and talk about


00:00:19.834 --> 00:00:21.493

Dr Doug Lucas: women's health, hormones and bone health.


00:00:24.524 --> 00:00:35.364

Dr Doug Lucas: and then I had told Susan J. That we would review her labs, and then we also had a request for to talk about statins


00:00:35.564 --> 00:00:45.363

Dr Doug Lucas: which are 2 pretty big topics. So I wanna dig into those things and make sure we get through those first, and then we'll take questions from people that are here. Good morning, don


00:00:45.564 --> 00:00:52.873

Dr Doug Lucas:  And And then I'll go through the list because that list is forever growing larger.


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Dr Doug Lucas: So


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Dr Doug Lucas: couple people in chats. Oh.


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Dr Doug Lucas: David, yeah, we'll get to that. I love talking about the Liftmark trial super fun.


00:01:07.174 --> 00:01:24.084

Dr Doug Lucas: awesome and great question about being a lean mass hyper responder. So okay, cool. Well, let's talk about statins first, and then, Susan, I'll I have your labs pulled up, so we will go through your labs. I have not looked at them yet. So you get my first initial impression, and hopefully, I know what I'm looking at.


00:01:24.884 --> 00:01:37.414

Dr Doug Lucas: But let's talk about statins first. So the question that was posed was specifically statins and high cholesterol levels for women. I'm gonna wrap this in, since we also have some men here and a fair number of men in the group.


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Dr Doug Lucas: So I'm gonna kind of wrap this into this whole big


00:01:40.294 --> 00:01:55.583

Dr Doug Lucas: conversation around statins and cholesterol, and it's a really, really confusing topic, and I could probably talk about it literally for an hour, so I'll try to make it less than that. But let me just take a step back, and just talk about cholesterol in general out of the gate.


00:01:56.244 --> 00:02:00.944

Dr Doug Lucas: So, cholesterol, as many of you probably have done a little bit of research on this.


00:02:01.284 --> 00:02:15.643

Dr Doug Lucas: and we hear this word all the time. Right? Good cholesterol, bad cholesterol, the association with heart disease, development of both plaque, which is the the actual stuff in the arteries, and then events which would be heart attack or stroke.


00:02:15.984 --> 00:02:19.604

Dr Doug Lucas:  I think that there is so much


00:02:19.694 --> 00:02:32.793

Dr Doug Lucas: bad evidence and bad research initially, when you go back into like the Ansel Keys era. Right? So this is when his 7 country studies showed an increase in consumption of dietary. Fat


00:02:32.834 --> 00:02:50.434

Dr Doug Lucas: led to or that's not true, was associated with potentially an increase in cardiovascular disease. So the diet heart hypothesis was, really put forward by him, and I forget the year. It was like, I don't know. Forties, thirties, fifties somewhere around there.


00:02:50.804 --> 00:03:00.854

Dr Doug Lucas: And really that study was an association study. He looked at the levels of dietary fat as reported by people in communities


00:03:00.914 --> 00:03:07.264

Dr Doug Lucas: of I think there were 20 something countries in the study initially. And then he published data on 7.


00:03:07.584 --> 00:03:29.143

Dr Doug Lucas: So so whenever somebody does a sub group analysis and publishes data, we have to be aware of potential bias. And so essentially, it turns out, what he did was he picked the 7 countries that supported his hypothesis, published those data, and then, since then, honestly, it hasn't really changed. We've been on a 70 year roller coaster of hatred of dietary fat


00:03:29.194 --> 00:03:48.833

Dr Doug Lucas: in our country. So we were told that dietary fat causes increase in cholesterol. Specifically, at that time cholesterol consumption causes an increase in cholesterol, which is clearly not true. But then also that sort of changed over time to saturated fat causes an increase in cholesterol, which is not always true either, but is true for some people


00:03:48.974 --> 00:04:02.224

Dr Doug Lucas: the pharmaceutical industry really dug into this found ways to lower cholesterol levels in people and did relatively big studies which show that there is some benefit in taking these drug statins.


00:04:02.234 --> 00:04:11.463

Dr Doug Lucas: We'll talk about that benefit. But the things that have changed over the last 70 years also is that we know a whole lot more about cholesterol now than we did then


00:04:11.664 --> 00:04:17.433

Dr Doug Lucas: when they were looking at cholesterol back in the 50 s. All they could do was measure total cholesterol


00:04:17.894 --> 00:04:34.084

Dr Doug Lucas: they couldn't even measure at that time. Ldl versus hdl triglycerides. They had no idea what particles I'll talk about measures of Apo. BLP. Little a. We have all this data. Now that is going to help to break apart the cholesterol story.


00:04:34.334 --> 00:04:42.554

Dr Doug Lucas:  But now, also, we have 2 very different in in disparaging communities on


00:04:42.594 --> 00:05:05.493

Dr Doug Lucas: what the impact of cholesterol is. And so now, if you look on social media, on Youtube, wherever you can see that there are people that say that cholesterol and really, the particles are absolutely the cause of heart disease. And that we have to con control cholesterol under all circumstances. And that means using statins. That means using other drugs as well, and that it's the most important thing you can do to protect your heart health.


00:05:05.554 --> 00:05:08.423

And then you have the opposite opinion, which is


00:05:08.454 --> 00:05:18.633

Dr Doug Lucas: cholesterol doesn't matter as long as you're metabolically well, and that you can have an Ldl of 500, and it's irrelevant as long as you're a one. C. Fasting, insulin, and etc. Are all in good condition.


00:05:18.664 --> 00:05:19.984

So that puts


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Dr Doug Lucas: consumers at a really really challenged perspective. Because now you're being asked to trust your doctors, which are saying


00:05:26.894 --> 00:05:27.924

Dr Doug Lucas: usually


00:05:27.954 --> 00:05:37.033

Dr Doug Lucas: use statins because it's going to lower your risk versus other thought leaders who are saying, Don't worry about it. They're dangerous. They're not going to help you.


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Dr Doug Lucas: So what do we do?


00:05:38.914 --> 00:05:59.093

Dr Doug Lucas: And so, as somebody who's interested in health span trying to help people to live better longer. It puts me in a challenge position, because I'm here to actually sort of work through all of that, and to try to make recommendations that make sense for people, especially for women who have been underserved in this. In the research, most of the research has been done on men.


00:05:59.574 --> 00:06:11.894

Dr Doug Lucas: So what do we do for men? What do we do for women? How do we look at this? So I hope that helped lay the groundwork. So my perspective is that if you look at the research cholesterol does appear to be a risk factor.


00:06:12.044 --> 00:06:17.024

Dr Doug Lucas: it's just not a great risk factor. The problem is is, it's the risk factor that we.


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Dr Doug Lucas: It is the only risk factor, really, that we have a drug for. So in a drug-forward medical model.


00:06:23.374 --> 00:06:30.984

Dr Doug Lucas: it's going to be the risk factor that most doctors talk about. I think it's a little bit dangerous to say that it's not a risk factor at all.


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Dr Doug Lucas: And I understand people like Paul Saladino, Anthony Chaffey, Sean Baker. These doctors who are out there, particularly in the carnivore community, because we're seeing this lean mass hyper responder, which I'll explain in a minute.


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Dr Doug Lucas: We're seeing this phenotype of people whose cholesterol goes way up when they consume a higher dietary, fat and a higher saturated fat diet. and there is some evidence to say that for those people they do not seem to be developing heart disease.


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Dr Doug Lucas: But we only have short-term data 3 to 5 year data.


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And so


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Dr Doug Lucas: I think it's possible that for people that are that have high cholesterol, but otherwise all of their numbers line up, that maybe it's not that big of a deal. but we don't really know the answer to that.


00:07:13.094 --> 00:07:23.753

Dr Doug Lucas: and I think the younger you are, the less disease you have, then maybe it's a risk worth taking. But the challenge I have is that when people have disease, I think that's a very dangerous risk to take.


00:07:23.964 --> 00:07:35.774

Dr Doug Lucas: because if you have disease, I'll talk about how to measure that. If you have disease, you're more likely to continue to develop disease. And if you have a risk factor like cholesterol. Then maybe, you know elevated cholesterol.


00:07:36.134 --> 00:07:41.364

Dr Doug Lucas: Then maybe you should take that into consideration and do something about it.


00:07:41.674 --> 00:07:50.813

Dr Doug Lucas: So the approach that we take is we want to know, does someone have disease? We want to know what are their lipids? Actually say? So let me walk you through that


00:07:51.224 --> 00:08:03.863

Dr Doug Lucas: and hook it to statins, which is what the questions actually about. So when we look at a a blood panel and actually, I wonder, Susan, let me see, we could wrap these 2 questions together.


00:08:06.434 --> 00:08:08.783

Dr Doug Lucas: let me find your lab, Susan.


00:08:14.114 --> 00:08:19.933

Dr Doug Lucas: There they are. I'm assuming you've got some cholesterol numbers in here. Actually.


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Dr Doug Lucas: oh, great! All right, here we go. So we're just gonna do this live. We're gonna wrap these 2 questions together.


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Dr Doug Lucas: But


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Dr Doug Lucas: and so, Susan, are you? You're here right.


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Dr Doug Lucas: See you somewhere.


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Dr Doug Lucas: Where did you go.


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Dr Doug Lucas: Susan? Can you let me know that you can hear me, if that's possible?


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Dr Doug Lucas: Yes, I can hear you. Okay, great alright. And Susan, can you just confirm for me that you're okay with me, showing your labs and talking about your numbers in front of other people. I know I asked you that


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Dr Doug Lucas: all right. So if you look at a


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Dr Doug Lucas: cholesterol panel so you can see here, she has A lipid panels is what most people are. Gonna get


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Dr Doug Lucas: you have total cholesterol. Hdl, Ldl Triglycerides, and they calculate a ratio, and then you have in here you have. Lp, little a. I'll talk about that, and then I don't see another


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Susan Jaye: measure called Apoe B. That we use. But no, they didn't take it.


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Dr Doug Lucas: they didn't do. Apleb, yeah, that's fine. We'll talk about that. Okay. So when you look at these numbers in general, what you can see is that most people again will talk about total cholesterol.


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Dr Doug Lucas: Total cholesterol is a combination of Hdl cholesterol, Ldl, cholesterol, and other things in between. But


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Dr Doug Lucas: the reason why total cholesterol is not a very good measure of risk. Is that total cholesterol includes both Hdl. Or the quote unquote good.


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Dr Doug Lucas: and Ldl. The quote unquote bad. The reason why I'm saying quote unquote is that we know more about Hdl. And Ldl. Now than we used to, and it's not really that Hdl is good, and Ldl is bad, it has to do with the direction that the particles move the cholesterol. So let me explain that


00:10:22.594 --> 00:10:40.003

Dr Doug Lucas: the cholesterol that's in Hdl and Ldl. Is the same cholesterol. There are a few different cholesterol molecules, but there is not an Hdl molecule and an Ldl molecule for the most part. The molecule that's being transported back and forth is the same cholesterol molecule.


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Dr Doug Lucas: Hdl is the molecule being transported from cells outside in the body back to the liver. Ldl is particles transporting the molecules from the liver out into the cells.


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Dr Doug Lucas: so it has to do with the direction of transport more so than the actual cholesterol itself, if that makes sense.


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Dr Doug Lucas: so to say, that Ldl is bad isn't really saying anything from a a risk perspective other than we know that the more Ldl particles you have the actual buses moving the cholesterol around. If you have a lot of them.


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Dr Doug Lucas: you seem to have higher risk. Same thing with Hdl. If you don't have a lot of them, you seem to be at higher risk, but once you reach a certain threshold, that threshold is either 50 or 60 milligrams per decilator like Susan has here, then, having more Hdl. Doesn't actually help. So we know that there's a threshold of good. But having an Hdl. Of 100 or 120 is not better than an Hdl. Of 60, it seems.


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Dr Doug Lucas: but that can be really challenging with total cholesterol, because if your Hdl. Is 60 and something happened, and now your Hdl. Is 100, your total cholesterol would go from one 190 to 230,


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Dr Doug Lucas: and that doesn't impart more risk.


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So total cholesterol is a pretty crappy number. We don't use it at all.


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Dr Doug Lucas: Hdl is important if it's low. but it's not so much that it has to do with the cholesterol. Hdl is really more a measure of metabolic function. and what I mean by metabolic function is glucose sensitivity, insulin sensitivity.


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Dr Doug Lucas: And you can compare that not with total cholesterol as they do here, but actually with triglycerides. So I prefer to look at Hdl and triglyceride together and say, Hey, I want these to be about one to one which Susan has. So congratulations, Susan. It's like, Yeah.


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Dr Doug Lucas: it's likely that you have good metabolic health, because your Hdl and triglycerides are in a one to one ratio. Now, we can actually see that right here, or a one C is 5.2, which is nice and low. I'll talk about what that means in a minute. And then I also saw a fasting insulin in here somewhere.


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Dr Doug Lucas: We'll talk about that later. Oh, here it is, fasting insulin. So fasting insulin is actually pretty darn low at under 1.9. But really we just look at it to be sort of between.


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Dr Doug Lucas: you know, kind of between 2 and 8, 2 and 10. Something like that.


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So nice and low. So yeah, likely. Good insulin sensitivity, good metabolic function there. And you can see that in the cholesterol panel.


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Dr Doug Lucas: Alright. And so then you look at the Ldl Cholesterol and the Ldl cholesterol. And this says, calculated so for those that are very detail oriented, calculated means, they didn't directly measure it. They calculated it based off of the other molecules.


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Dr Doug Lucas: and that can be accurate for some and accurate for others. We prefer direct measurement. But honestly, I don't really care what Ldl is, anyway.


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But if you look at Ldl and you say, Okay, well, it's over a hundred. It's high


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Dr Doug Lucas: by by pharmaceutical standards. Susan is a candidate for Staten.


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Dr Doug Lucas: We'll talk about. Why, that's probably not a good idea.


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Dr Doug Lucas: But this is technically high. However


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Dr Doug Lucas: metabolically, she's well. So then let's look at a couple other markers here. So


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Dr Doug Lucas: LP. Little a. I mentioned the particles before, so the particles again, are the the spheres that carry cholesterol around, and they do that because cholesterol doesn't can't move around in the blood freely because it's not water soluble. It's a fatty substance. So it has to be contained in these spheres. These particles and the particles will move them around. On top of the particles are different proteins. The particles are made up of different proteins.


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Dr Doug Lucas: Lp. Little a. Or this one here lipoprotein, a also known as Lp. Little, a.


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Dr Doug Lucas: LP. Little a. Is a protein that is genetically driven, meaning that we we don't actually know what the genes are, but we know that it is passed down so it's inherited, and either you have it or you don't. It is a binary risk factor. If you are below the threshold, say here 30, then you do not have the risk. So Susan has 4. She does not have the lp. LPA little a risk.


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Dr Doug Lucas: The risk is the association of the development of disease, of disease and events. And so if you don't have the risk, we can say, Well, I'm not as worried about your cholesterol. It's not a strong enough risk factor to say, I'm not worried at all. I see people that don't have Lpa that do develop disease. So it doesn't trump all. But it is a risk factor to consider. So that's great.


00:15:08.394 --> 00:15:19.384

Additionally, we want homocysteine, which is another biomarker that has some inflammatory components under 9, which she is and crp under one which she is. So


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Dr Doug Lucas: when I look at risk factors for developing heart disease.


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Dr Doug Lucas: I actually like how they've done this here cholesterol is one.


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Dr Doug Lucas: But genetic risk is another.


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Dr Doug Lucas: Almost. Cystine is another crp is another


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Dr Doug Lucas: right, and she has none of those.


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Dr Doug Lucas: So is this 112 calculated Ldl, significant?


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Dr Doug Lucas: Probably not.


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Dr Doug Lucas: Probably not. The other marker that we like to get that isn't in here that honestly, wouldn't change my suggestions anyway. But it would be this particle I'm sorry. This protein on the particle called Apo B.


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Dr Doug Lucas: Apo B. Is a protein that lives on all of the Ldl. Containing particles, which is a really confusing statement. But basically any particle that contains Ldl, which includes Ldl particles, idl particles V. Ldl particles.


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Dr Doug Lucas: All of those particles have an Apob on them. So it is a better measure of Ldl cholesterol risk than is the Ldl cholesterol itself.


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Dr Doug Lucas: It would probably be somewhere right around the threshold of 90,


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Dr Doug Lucas: which again is again going to change our recommendations. The only time that's relevant is when we're worried about somebody that has elevated Ldl cholesterol.


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Dr Doug Lucas: and then we can see if they have a lot of particles or not a lot of particles. It's going to tell us more about that particle risk, because it's going to tell us about particle size. There are tests out there like, and nmr, and


00:16:43.434 --> 00:16:52.423

Dr Doug Lucas: something that measure particle size. But knowing the particle size doesn't actually help us any. It hasn't really borne out in literature to help


00:16:52.774 --> 00:17:01.243

Dr Doug Lucas: make decisions. So we don't get that test anymore. So that's that. So then let's talk about The Staten used then. So


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Dr Doug Lucas: our stratification goes like this, we get those labs. And then we say, Okay, you know, are you genetically at risk? You have a family history. You know how old are you if we're worried about your cholesterol, and we wanna know what's happening in your arteries. We can test for that. So there's 2 main tests that we do. Well, there's there's 3 that are available with 2 that we do.


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Dr Doug Lucas: So, the 2 that we do, one would be called a corner artery. Calcium score. The coronary arteries are the arteries that feed the blood to your heart.


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Dr Doug Lucas: The coronary arteries will develop plaque, and when that plaque ruptures and causes a heart attack, this is the bad thing we want to avoid.


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Dr Doug Lucas: So we you can get a coronary artery calcium score which looks for calcification of those arteries. This is an okay test. It's not a great test, but it's an inexpensive test with low radiation low risk. So we we get that test as a screening tool. Now for all of our patients that are over 50 coming into the practice.


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Dr Doug Lucas: If it's anything other than 0,


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Dr Doug Lucas: then we know that you have disease, and we know that you have been developing disease over time. Susan, have you had a coronary artery. Calcium score.


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Susan Jaye: Yes, I had when it was 0. But I've been listening to this guy before Brewer Prev Med, and he's talking that some people have higher calcium scores. It doesn't. I don't know. His philosophy is, it's not as bad as it seems. Yeah. So let me.


00:18:26.664 --> 00:18:33.843

Dr Doug Lucas: yeah. So like, I said, great segue. So it is an Ok. Test. It's not a great test. And here's why


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Dr Doug Lucas: the calcified plaque generally is more stable plaque.


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Dr Doug Lucas: So if it's if you had plaque, and it was inflamed, and you had this kind of nasty area and your artery, it was at risk for rupture. But then your body heals it, and it gets calcified over time. That's actually a stable plaque, and those plaques are less likely to rupture. So, Susan, what he's saying is absolutely right.


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Dr Doug Lucas: The other problem with a Cac score is that the Cac score doesn't catch soft plaque


00:19:03.824 --> 00:19:23.903

Dr Doug Lucas: which would make sense but the soft plaque is the plaque that's more likely to rupture, and you can have a 0 Cax score and have significant soft plaque burden which will put you at risk for for having an event. So we see people, especially athletes. That'll get a you know. They'll they'll turn 50. They'll get a Cax score. It'll be 0, and they'll have a heart attack the next day.


00:19:24.054 --> 00:19:28.864

Dr Doug Lucas: These things happen. So it's not a great test. So that's why there's another test.


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So when somebody comes in with a 0.


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Dr Doug Lucas: My next question is, okay, is that enough information? Are we happy with that? Or do you want to go to the next level, which is to get a Ccta.


00:19:39.384 --> 00:19:52.934

Dr Doug Lucas: Ccta. Stands for coronary Ct. Angiogram. So same coronary arteries, same Ct. But angiogram means that they actually put dye in your arteries, and they run the Ct. With the dye running through the arteries.


00:19:52.964 --> 00:20:02.894

Dr Doug Lucas: and then you can get a picture of what's going on in those arteries, so it'll tell you, stenosis. It'll tell you about narrowing of the arteries. It'll tell you about both soft and calcified plaque.


00:20:03.574 --> 00:20:07.413

Dr Doug Lucas: So we use the Ccta for people that want to know more.


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Dr Doug Lucas: I've gone through this myself. It's a really really cool study. The Ccta itself will tell you about stenosis to some extent, but it's more like mild, moderate, severe. If you really want to know about the plaque, then you need to take the next step, which is to get what's called a clearly clearly uses the same data from the Ccta, but then runs it through an AI algorithm.


00:20:29.954 --> 00:20:49.013

Dr Doug Lucas: and it will spit out this 3D representation of your arteries, and it is awesome. So we like to do this when we can. The challenge is, it's more expensive. There's more radiation, exposure and Iv contrast danger kidneys every time you do it. So not something that I would do on a regular basis.


00:20:49.034 --> 00:21:01.693

Dr Doug Lucas: but as a screening tool. If we're trying to decide. Statin. No statin drug, no drug. How aggressive are we with reducing dietary, fat, etc. Then might be worth to do once, maybe worth doing over time, but like


00:21:02.064 --> 00:21:05.144

Dr Doug Lucas: every 2 years, 3 years, 5 years, I don't know.


00:21:05.264 --> 00:21:16.643

Dr Doug Lucas: We don't really know enough about that right now. So, but that's the next test, and that will tell you about soft plaque. It'll tell you about unstable soft plaque. So it's a really good test to do for people that are considered to be at risk.


00:21:16.754 --> 00:21:21.024

Dr Doug Lucas: The third test is the carotids we see, like the Ligate carotid ultrasounds.


00:21:21.424 --> 00:21:37.183

Dr Doug Lucas: And that test will tell you about disease. It'll tell you about thickening. It'll tell you about plaque, but we don't know as much about what's going on in the carotid versus what's going on in the coronary arteries. So the carotids, if you have disease here that can lead to strokes. So that's a big deal.


00:21:37.214 --> 00:21:50.673

Dr Doug Lucas: It's kind of a different conversation, though, because the the all of the trials on statins and the other drugs are looking at heart attacks not necessarily stroke. So we don't have the same correlation between interventions and outcomes.


00:21:50.824 --> 00:21:54.823

So we're really interested more about the coronary arteries, which is why we have to use a Ct.


00:21:55.344 --> 00:21:58.614

Dr Doug Lucas: so then, depending on the results of that. Then we'll come up with a plan.


00:21:58.654 --> 00:22:07.553

Dr Doug Lucas: So I'll give you a couple of examples. So let's just use Susan, for example. So she has high Ldl, all of her other biomarkers look good. Her kaak is 0.


00:22:07.674 --> 00:22:10.553

I would probably be comfortable just saying, Hey, you know what?


00:22:10.594 --> 00:22:28.903

Dr Doug Lucas: Let's just give this some time. Let's optimize everything else, because these numbers seem to be looking pretty good. I don't know that we need to go down this pathway any further unless she was like, Oh, well, in my family, you know my my mom and dad both died of a heart attack, and my sister had a heart attack at 45. But then we're getting a ccta. Okay?


00:22:29.224 --> 00:22:36.713

Dr Doug Lucas: If she wants to know more, then we just get the information and then we get the information. Then we move on from there. But my guess is, the Ccta. Would look good.


00:22:36.944 --> 00:22:38.404

Dr Doug Lucas: Actually, just I look


00:22:38.484 --> 00:22:52.693

Susan Jaye: sorry I had a I had a what do you call it? What you just mentioned? I had a duplex carotid ultrasound. And


00:22:52.704 --> 00:23:01.613

Susan Jaye: I didn't send it in because I didn't realize you were. Gonna get that involved with all this. But it says, here findings


00:23:01.994 --> 00:23:03.984

Susan Jaye: anti-grade rape


00:23:04.474 --> 00:23:16.713

Susan Jaye: artery flow right. Cert. PSV. 66 cm. Right Subclavian artery waveform demonstrates a multi


00:23:16.774 --> 00:23:25.123

Susan Jaye: flow pattern. And then here, right mild, right intimole thickening at elevenmm.


00:23:26.214 --> 00:23:29.824

Dr Doug Lucas: And so the question, then, Susan is like, Well, what does that mean?


00:23:29.884 --> 00:23:32.013

Dr Doug Lucas: Okay, so it's a little bit thicker.


00:23:32.424 --> 00:23:40.594

Dr Doug Lucas: But how does that relate to disease and events? And that's why people like to do, Karate is because they're easy. There's no radiation with ultrasound. But


00:23:40.674 --> 00:23:50.543

Dr Doug Lucas: but what do you do with it? So unless it's it shows very severe disease. It's not really very helpful. So I don't order that task for that reason. but it doesn't sound bad.


00:23:50.614 --> 00:23:57.423

Susan Jaye: that's all I can say. Is there a test called CMIT. Or C,


00:23:57.503 --> 00:23:58.543

Susan Jaye: a.


00:23:58.554 --> 00:24:01.963

Dr Doug Lucas: CI, Mt, yeah. Crowded intimal.


00:24:02.144 --> 00:24:03.224

Susan Jaye: Something


00:24:03.374 --> 00:24:07.113

Dr Doug Lucas: crowded me, anyway. Yes, see? Mit it might be.


00:24:07.253 --> 00:24:09.943

Dr Doug Lucas: But yeah, it has to do with the thickness of the the wall.


00:24:10.444 --> 00:24:13.763

Susan Jaye: Got it? Okay, thank you. Yep.


00:24:13.864 --> 00:24:24.484

Dr Doug Lucas: so anyway, it so a Ccta would tell us more. But otherwise I'm not that excited about using statins on Susan, because I don't think that she likely has disease.


00:24:24.773 --> 00:24:33.753

Dr Doug Lucas: So then let's talk about statins in general. So statins are a controversial drug. However, they are one of the most prescribed drugs in the world, because


00:24:34.314 --> 00:24:42.513

Dr Doug Lucas: coronary artery disease, heart attacks will kill the majority of adults right? So whatever we can do to prevent that is probably a good thing.


00:24:42.654 --> 00:24:55.194

Dr Doug Lucas: but it's always a risk benefit equation. So statins have been studied obviously extensively, you actually can't even do a drug trial without a statin on board. If it's for heart disease, because they are the standard of care.


00:24:55.684 --> 00:25:01.683

Dr Doug Lucas: The challenge with Staten trials is that they report relative risk.


00:25:01.864 --> 00:25:12.973

changes rather than absolute risk changes just like most drug trials do, because they want to make it sound impressive. So you look at the trials in in the drugs, and they say, you know, 50% reduction in in heart attack.


00:25:13.184 --> 00:25:24.923

Dr Doug Lucas: But if you look at the absolute reduction, it was usually less than 1% over the course of these trials. So how significant is that clinically, and is it worth the potential risk? So what's the risk?


00:25:25.074 --> 00:25:38.654

Dr Doug Lucas: The risk is that statins block cholesterol development in the liver. So the body's probably doing that for a reason, although I've heard some arguments to say that that's vestigial. And we maybe we don't need that anymore. Don't know that that's true.


00:25:38.964 --> 00:25:48.944

Dr Doug Lucas: But they block cholesterol production. There's some concerns about association of statin drugs with diabetes, with dementia we know that it


00:25:49.374 --> 00:25:55.874

Dr Doug Lucas: utilizes magnesium strongly. So you have to increase magnesium. It depletes things like Co. Q. 10.


00:25:55.914 --> 00:25:59.224

So there's just a lot of things that I don't love about statins.


00:25:59.264 --> 00:26:09.604

Dr Doug Lucas: But what I would say about statins is that yes, they lower cholesterol. But I don't know that that's actually the reason why they prevent disease. I think it's because they're anti-inflammatory, and they're plaque stabilizing.


00:26:09.744 --> 00:26:27.404

Dr Doug Lucas: So if somebody has significant disease, it's probably not unreasonable to say, Hey, let's go on a low dose statin to stabilize that plaque. The problem I have with doing this for women. that in all the drug trials. It seemed like there was more impact for men than for women, and I don't know if it's because


00:26:27.864 --> 00:26:33.053

generally will develop disease a decade later than men because of their estrogen levels.


00:26:33.324 --> 00:26:42.644

Dr Doug Lucas: So I don't really know what to think about that other than it doesn't seem like statins are as effective for women as for men. But if you have significant disease.


00:26:42.714 --> 00:26:46.114

Dr Doug Lucas: if you're if you're imminently at risk of


00:26:46.304 --> 00:26:51.643

Dr Doug Lucas: having a heart attack, then I would be on a statin regardless of sex, if that makes sense.


00:26:52.234 --> 00:27:11.864

Dr Doug Lucas: So that's kind of the pathway we go down. There are some other drugs like Pcs. Canine inhibitors like Rapatha, which will drop Apob or Ldl cholesterol almost to 0. We consider those for people that are very high risk. And that's another drug to consider, either in addition to a statin or off label without a statin.


00:27:12.344 --> 00:27:13.703

Dr Doug Lucas: It's another thing that we do.


00:27:13.944 --> 00:27:20.763

Dr Doug Lucas: So that was a whole lot of cholesterol any questions on that before I move on to the rest of Susan's labs.


00:27:21.644 --> 00:27:30.803

Susan Jaye: Just a quick question going back to the HRT. So how do you feel about people on HRT.


00:27:31.104 --> 00:27:37.074

Susan Jaye: With, you know my my measurements? Or do you have any comments in general about that


00:27:37.224 --> 00:27:40.484

Susan Jaye: regarding cholesterol? Yeah.


00:27:40.814 --> 00:27:44.174

Dr Doug Lucas: bill that brings up 2 interesting points. So first of all.


00:27:44.414 --> 00:28:02.084

Dr Doug Lucas: HRT. Has a variable impact on cholesterol. If we're doing HRT. The way that we recommend it, which is topical estrogen, topical, testosterone, and oral progesterone. There's usually not much of an impact on cholesterol. And if there is an impact, it's good meaning that Hdl generally will go up and Ldl will go down.


00:28:03.034 --> 00:28:32.464

Dr Doug Lucas: But we find that in general it's gonna improve metabolic health. It's gonna improve insulin sensitivity. It's gonna decrease inflammation. So overall, we find that the impact from a cardiovascular perspective is protective particularly in those first 10 years after menopause. So I don't think there's gonna be a negative impact there. But that also brings up Susan and something I didn't mention, which is, what about dietary change. And I get this question a lot. So people say, well, I wanna change my diet to lower my cholesterol.


00:28:32.864 --> 00:28:35.643

Dr Doug Lucas: So I have a oh, no, I think I already did it.


00:28:35.784 --> 00:28:38.083

Dr Doug Lucas: I did a short video


00:28:38.114 --> 00:28:45.543

Dr Doug Lucas: on this end of one study that came out recently. Maybe you guys saw the headlines that Oreo cookies reduce cholesterol. Anybody see that?


00:28:46.254 --> 00:28:47.624

Susan Jaye: Yeah.


00:28:47.944 --> 00:29:11.044

Dr Doug Lucas: So here's the thing about diets that reduce cholesterol is if they reduce cholesterol, but make everything else worse. Not worth it right? And so if you look in the, you know, go just look at the headlines, you'll see, you know, claims of diets that reduce cholesterol. They're generally gonna be lower dietary fat. So this is where the low fat craze really does show a potential benefit for heart disease.


00:29:11.214 --> 00:29:13.793

Dr Doug Lucas: but always as measured through cholesterol.


00:29:13.824 --> 00:29:24.273

Dr Doug Lucas: And, as I just said, cholesterol is not a great risk factor for heart disease. So if it improves your cholesterol, but it makes you pre-diabetic or diabetic. Is that worth it?


00:29:24.444 --> 00:29:25.634

Dr Doug Lucas: Definitely? Not


00:29:25.974 --> 00:29:30.113

Dr Doug Lucas:  If you can tolerate the carbohydrate load.


00:29:30.614 --> 00:29:39.983

Dr Doug Lucas: maybe it's a good idea as long as everything else checks out, and you're getting all your nutrients. But where this really comes to conflict for me is that if you're going to eat a higher


00:29:40.384 --> 00:29:45.434

Dr Doug Lucas: protein diet, I shouldn't say higher. If you're going to eat an adequate protein diet


00:29:45.854 --> 00:30:06.764

Dr Doug Lucas: and you're gonna get it from animal sources, you're likely gonna get more dietary fat. So we see people that will increase their cholesterol levels as a result of eating the way that I'm recommending. And that's when this question of the lean mass hyper responder comes in. So people that have that impact. And I'm one of those people, too. If your cholesterol goes up when you eat more dietary fat.


00:30:06.814 --> 00:30:18.233

Dr Doug Lucas: Is that good, or is that bad? Should you eat less dietary fat to reduce your cholesterol? Or should you eat the the diet that supports your muscle, mass and metabolism.


00:30:18.374 --> 00:30:19.994

Dr Doug Lucas: I would say the latter.


00:30:20.234 --> 00:30:27.154

We know that plant-based diets. If you reduce it down and you eat only plants a lot of times, you'll see significant reductions in cholesterol.


00:30:27.324 --> 00:30:34.603

Dr Doug Lucas: But what we see is that other factors get worse. A when C goes up insulin goes up so for me. That's that's not a trade that I'm willing to make.


00:30:35.524 --> 00:30:36.484

Dr Doug Lucas: That makes sense.


00:30:37.324 --> 00:30:43.304

Cathy: I will say, the yeah. I was, Cathy. I have a question when you're done there.


00:30:43.484 --> 00:30:50.693

Dr Doug Lucas: Yeah. So I just gonna say that one little caveat to that is at 1 one big error that I see


00:30:50.714 --> 00:31:05.233

Dr Doug Lucas: is people that will look at somebody like me, for example, or these other guys like Anthony Chaffee, Sean Baker, etc. And they'll say, cool. Well, I'm gonna eat a high dietary fat diet. But I'm also gonna eat a high carbohydrate diet, and that is a big no-no.


00:31:05.284 --> 00:31:12.144

Dr Doug Lucas: You have to choose. You can't do both if you do both. That is the standard American diet, and that will cause heart disease without a doubt.


00:31:12.834 --> 00:31:13.844

Dr Doug Lucas: Yeah, Kathy.


00:31:13.954 --> 00:31:26.653

Cathy: are you familiar with lifeline screening $139 for 4 tests, which is carded cara, rotted artery plaque, which is an ultrasound


00:31:26.784 --> 00:31:28.164

Cathy: heart rhythm.


00:31:28.254 --> 00:31:54.104

Dr Doug Lucas: abnorm abdominal, aortic aneurysm and peripheral arterial disease. Yeah. Yeah. And that's a cool study. The price points great. And so that's gonna look at your carotid arteries like we just talked about. It's gonna look at your abdominal aorta, which is something that can also get diseased. And it's good to know. Because if you have an aneurysm of your aorta, that's something that definitely you wanna consider potentially intervention for cause. That'll kill you quickly


00:31:54.134 --> 00:31:57.453

Dr Doug Lucas: and then peripheral artery disease is really important.


00:31:57.564 --> 00:32:06.263

Dr Doug Lucas: But if you don't have symptoms, you know, what is it, it's not likely to show much, so it's good to know I would put that in something to do, you know, on a


00:32:06.754 --> 00:32:16.134

Dr Doug Lucas: you know, whatever one year 5 year 10 year, depending on symptoms. Timeframe. Again, the price point is good and there's no downside, because it's all done through ultrasound.


00:32:16.344 --> 00:32:22.464

Cathy: Yeah. So is that similar to the coronary artery calcium score.


00:32:24.074 --> 00:32:27.074

Dr Doug Lucas: It won't give you information on the coronary arteries directly.


00:32:27.374 --> 00:32:29.274

Cathy: Okay, but it is helpful.


00:32:29.414 --> 00:32:38.353

Dr Doug Lucas: It is helpful. I mean, you could assume that if all those markers look bad, then probably your your heart arteries look bad, too. but if they look reasonable it doesn't actually help you.


00:32:38.504 --> 00:32:46.033

Cathy: Okay? And my other thing is my labs. My Hdl is one. One. And my triglycerides are 45.


00:32:46.424 --> 00:32:53.073

Dr Doug Lucas: Yeah, and that's that's great. Although, like I said, we don't really know, you know, if once Hdl goes above 60,


00:32:53.264 --> 00:32:55.834

Dr Doug Lucas: it doesn't show any potential benefit.


00:32:55.874 --> 00:33:04.613

Dr Doug Lucas: So it's great and when we see numbers of 100 or higher it almost. There's some evidence to say that that actually could potentially be worse than low.


00:33:05.014 --> 00:33:23.054

Dr Doug Lucas: But I wouldn't. I wouldn't worry about that, because again, you're right at that 100 mark. So I would just say genetically, you have high hdl, that's great. We don't. It's not any better necessarily than having it at 60. But if your triglycerides are around 50 or lower than that's really low, so you still beat that one to one, or even, you know, point 5 ish


00:33:23.094 --> 00:33:26.674

Dr Doug Lucas: ratio. So I think that's great. That shows option.


00:33:26.734 --> 00:33:28.564

Cathy: Thank you. Yeah.


00:33:29.074 --> 00:33:30.284

Dr Doug Lucas: yes, Lorna.


00:33:31.184 --> 00:33:42.444

Lorna Nichols: Well, I you haven't had a chance to look at. I know Kentucky is the slowest state so far, maybe behind Minnesota. It's been so frustrating because


00:33:42.564 --> 00:33:53.683

Lorna Nichols: you you ordered the lab work, and I've got it, and there's some really scary shit in here, and I'm sitting with it going


00:33:53.694 --> 00:33:57.623

Lorna Nichols: and specifically on the stuff that we're talking about.


00:33:57.754 --> 00:34:14.783

Lorna Nichols: And I'm wondering what my next move should be, you know, even doing it on my own. You know I've had the corn coronary artery scan done, and it was 0. You know I've got the high Apo a 183 Apo B.


00:34:14.804 --> 00:34:17.223

Lorna Nichols: Is 105


00:34:17.424 --> 00:34:23.374

Lorna Nichols: I've got I. The c-reactive protein cardiac was 3.0 1,


00:34:24.864 --> 00:34:36.994

Lorna Nichols: and my triglycerides are 79 hdl. 74. So that's for that one on one ratio. I guess the Ldl is 1 28.


00:34:38.384 --> 00:34:42.334

Lorna Nichols: So now my Homocysteine was


00:34:42.344 --> 00:34:45.643

Lorna Nichols: 7.2. So that's less than 9.


00:34:45.764 --> 00:34:46.754

Lorna Nichols: Yeah.


00:34:47.754 --> 00:34:52.544

Lorna Nichols: can you? Can you tell me any next move I should make?


00:34:52.914 --> 00:34:57.353

Dr Doug Lucas: Yeah, and how long ago did we do that lab panel? And have we repeated it?


00:34:57.404 --> 00:35:04.313

Lorna Nichols: This has been pretty. This was the first to the end of December, the very end of December 20 seventh.


00:35:05.314 --> 00:35:23.974

Dr Doug Lucas: Yeah. So that when you, when you list out those numbers like that, your Ldl. Is just slightly elevated, but your hdl Triglycerides look great, so I'm not that worried about the Ldl. Except that your crp is elevated and your Lp. Little a. Was elevated right. So so you have the genetic risk and you have some inflammation.


00:35:24.144 --> 00:35:30.704

Dr Doug Lucas: The problem with inflammation from a crp perspective is that we don't know if it was inflammation for the


00:35:31.144 --> 00:35:35.214

minute that you took that lab. Or is this inflammation that's present chronically.


00:35:35.284 --> 00:35:50.403

Dr Doug Lucas: and the only way to know that is to continue to repeat, crp over and over again. but generally our approach is when we see it one time, then we have people take whole forms of vitamin c and potentially glutathione, because we don't know why you have inflammation, but we know that we can bring it down


00:35:51.154 --> 00:35:52.914

through those avenues.


00:35:53.034 --> 00:36:13.763

Dr Doug Lucas: And those are good for most people, anyway. So that's something that we could potentially add to you. In the meantime, if you're worried about that crp. But remember to that cardiovascular disease is a disease of decades. So I know this delay in Kentucky is super annoying, and you're not alone. There's some other people in other States that are sort of in the same like, like just waiting.


00:36:13.844 --> 00:36:22.273

Dr Doug Lucas: waiting, waiting, waiting. But this is a disease of decades that a a month, or even a year. Delay isn't gonna make an impact


00:36:22.304 --> 00:36:23.373

Dr Doug Lucas: for the most part.


00:36:23.604 --> 00:36:31.213

Lorna Nichols: Well, that's encouraging. Thank you. So I will look into the taking those supplements. I just want to comment. One more thing. I've had


00:36:31.754 --> 00:36:37.743

Lorna Nichols: c reactive protein done in the past like every twice a year. But it wasn't


00:36:38.114 --> 00:36:42.354

Lorna Nichols: cardiac. It was just c-reactive protein. Is that a different test?


00:36:43.014 --> 00:36:48.243

Dr Doug Lucas: So they're they're labeled differently. So usually, if you look at the reference range


00:36:48.904 --> 00:37:05.223

Dr Doug Lucas: and the reference range either says one to 3 or less than one. But you know that it's the high sensitivity Crp. Sometimes they'll call it cardiac, sometimes they'll call it other things. So it's just different different labs or changes over time. But basically crp that if the reference range goes up to 10, it's a different crp.


00:37:06.504 --> 00:37:08.854

Lorna Nichols: Okay, so


00:37:10.164 --> 00:37:25.373

Lorna Nichols: if if you can give me 1 s. I've got that test right here. And I wanna see what the range was. Yeah, take a look at that, Lorna. Take your time and and let us know what those numbers are. I'm gonna pull up Susan's so that we can run through those. Okay.


00:37:26.424 --> 00:37:30.143

Lorna Nichols: It was less than one, and the range was 0 to 10


00:37:30.594 --> 00:37:38.103

Dr Doug Lucas: 0 to 10. So that's that's not high sensitivity, so that not high sensitivity crp. But again, if it's less than one.


00:37:38.234 --> 00:37:39.963

Dr Doug Lucas: then that's probably good.


00:37:40.344 --> 00:37:42.614

Lorna Nichols: Thank you. Thank you.


00:37:43.474 --> 00:37:57.683

Dr Doug Lucas: All right. So let's run through the rest of Susan's labs. And again, Susan, this is my attempt just to give people an idea of what we're looking at. I can't tell you exactly what to do, but you got a bunch of stuff here. So let's look at it.


00:37:58.814 --> 00:38:00.154

Dr Doug Lucas: Alright, so


00:38:00.914 --> 00:38:18.033

Dr Doug Lucas:  so we have an ntx, so ntx is the urine form of ctx, which is the the blood value that we generally use to look at bone breakdown. So Ntx preceded Ctx. It was out and more available first.


00:38:18.064 --> 00:38:23.124

I'm not that familiar with the reference ranges on Ntx. But if we look at


00:38:23.894 --> 00:38:41.894

Dr Doug Lucas: they give you a reference range for preman apostle females, which is funny because they know your age, Susan. So clearly, you're not pre-manip puzzle. And the Preman Apostle range is 4 to 64, and you are well within that range. So that's probably a good sign that it's not that high. But again, I don't have that much.


00:38:42.374 --> 00:38:50.733

Dr Doug Lucas: That much history with this one. I also see to you that your creatinine was low, and I don't know if that impacts this value or not.


00:38:50.754 --> 00:39:00.093

Dr Doug Lucas: So this is why we use CTX over NTX, but my, my guess is that it probably looks okay. I just don't know how. Okay, if that makes sense.


00:39:00.754 --> 00:39:08.413

Dr Doug Lucas: the basic metabolic panel or Bmp is going to tell you about glucose, which, again, based on your other metabolic numbers, this glucose looks great.


00:39:08.814 --> 00:39:11.104

Dr Doug Lucas: Your urine labs look.


00:39:11.464 --> 00:39:19.694

and your kidney lambs rather. The metabolites almost always look normal. So people get really worked up about these. But the body keeps these


00:39:20.024 --> 00:39:32.654

Dr Doug Lucas: electrolytes in really, really tight control. So generally, these are going to look great. And even if they don't look great, then that's usually related to dehydration, not because there's actually deficiency that we can tell. There.


00:39:33.264 --> 00:39:42.943

Dr Doug Lucas: Ctx, you actually have 2. So you have ctx and ntx in the future. Just get ctx. So your ctx is 537, and our range is.


00:39:43.004 --> 00:39:58.324

Susan Jaye: and we kind of say, like 200 to 600, which is a really big range but it really has more to do with the Np. And do you have A. And P. In here, Susan? I don't think he tested it, and also Dr. Lucas, I had


00:39:58.404 --> 00:40:10.343

Susan Jaye: 6. Well, I went on prolia because I had a vertable fracture, and I couldn't stand it, and I went off of it, and my CAC. Tx. Was up to 800.


00:40:10.434 --> 00:40:26.664

Susan Jaye: And then I went on, HRT. And now it's 5, 37  so I don't know if I should. you know if it. I think it's helping. But II don't know what number I should get down to.


00:40:27.144 --> 00:40:32.664

Dr Doug Lucas: Yeah, it depends on your P. One. And P, because here's what we're finding. So what we're keeping track of this and we have.


00:40:33.534 --> 00:40:37.434

Dr Doug Lucas: I don't know how many dozens of patients that we have follow up data on at this point.


00:40:37.444 --> 00:40:43.484

Susan Jaye: but what we're seeing is that ctx and p. Onemp. Rarely will go opposite directions.


00:40:43.524 --> 00:40:52.333

Dr Doug Lucas: meaning that in in my head I want p. One, and P, which is the bone building biomarker to go up. I want Ctx, which is the bone breakdown marker to go down.


00:40:52.364 --> 00:40:56.433

Dr Doug Lucas: but that's not how it works in general, they're going to go up and down together.


00:40:56.794 --> 00:41:13.443

Dr Doug Lucas: And so what we wanna know is, how much is one going up versus the other, and that's why we use the ratio that we've talked about before. So you really need to know. And P. And doctors don't like to order it, because insurance companies don't like to pay for it. They don't want you to get stuck with a really stupid, expensive lab test.


00:41:13.714 --> 00:41:32.504

Dr Doug Lucas: That's why we use cash instead of insurance for labs, because we can then negotiate and dictate those prices, and they're predictable, even though we end up paying our lab panel is some stupid like $850 for cash. But if you were to pay the insurance prices for those things, it would be like a $10,000 lab panel


00:41:32.684 --> 00:41:37.944

Dr Doug Lucas: as the insurance idiocy that our healthcare system place


00:41:38.334 --> 00:41:56.663

Dr Doug Lucas: so the through cash for us. I don't know how much it is. It's not cheap, but if you were to end up paying the insurance rates for it, it could be $1,000. I mean, I've I've seen that happen, and people that have that try to sort of ride that fence of ordering them through insurance. But then making the patients pay the balance


00:41:56.774 --> 00:41:57.734

Dr Doug Lucas: finger burnt.


00:41:58.024 --> 00:42:13.034

Susan Jaye: Let's say that I did have it just for argument's sake, for everyone here, everyone here. What? Even if it if it was high, low what are some of the things you would do when you're treating somebody.


00:42:13.474 --> 00:42:26.994

Susan Jaye: you know, with that I mean how that I mean. Is it valid enough that you could actually tweak what you're doing to help them. Oh, totally, absolutely right. So you mentioned that you're on hrt, so you know 1 one of the things we would do, and you have some.


00:42:27.034 --> 00:42:48.403

Dr Doug Lucas: You have some labs here, so we'll look at your your levels. Although there might be saliva. But so we would look at your estrogen levels to make sure you're getting adequate. So I see a lot of women that'll be on estrogen. But they're on the lowest dose possible, and the lowest dose possible might be good for recei for relieving some of the symptoms of menopause, but likely wouldn't get you to serum levels that are gonna help your bones, your heart, and your brain.


00:42:48.474 --> 00:43:12.684

Dr Doug Lucas: And so that's that's a huge one. But then all of the other components. So all the lifestyle, the nutrition, the protein, the resistance training, all the potential supplements for bone health. They all have an impact on Ctx and and P. So when we see people that aren't getting better. Then we go back and look at the program and say, Okay, well, what are we missing? You know, what could we potentially add? What are we doing that isn't working from a lifestyle perspective. What could we change?


00:43:12.684 --> 00:43:24.293

Susan Jaye: So we have to look at all of those things. But we're learning more and more about which things seem to be consistent for ctx, and which things seem to see. Look seem to be consistent for. And P. Does that make sense.


00:43:24.514 --> 00:43:37.603

Dr Doug Lucas: Yeah. other biomarkers here. So the parathyroid hormone. So we get this the first time, and then we generally don't check it again. After that we're just looking for parathyroid tumors, and we've only seen


00:43:37.634 --> 00:43:55.013

Dr Doug Lucas: I've seen one in a patient, and I'll be honest. I actually missed it because her values were normal. But they were normal, high, and they were trending up. So we didn't have the long term data. But she did actually end up getting diagnosed with a parathyroid tumor and had it removed. And now she's doing great. I actually just heard from her this morning.


00:43:55.254 --> 00:43:57.884

Dr Doug Lucas: So she has. She had a great story to tell


00:43:59.764 --> 00:44:18.674

Dr Doug Lucas: thyroid. I wanna know more, so we'll see if you have more. But tsh! Is thyroid, stimulating hormone. Tsh! Is what most doctors will get, and they sort of get this test, which is tsh and free. T. 4, because that generally will make them feel good cause they're getting more than tsh, but here's the problem which is


00:44:19.064 --> 00:44:24.584

Dr Doug Lucas: free. T. 4 doesn't really tell us a lot, because we also need to know what the free T. 3 is.


00:44:24.644 --> 00:44:31.273

Dr Doug Lucas: So our panel is tsh, total. T. 3. Total, t. 4. Free, t. 3. Free, t. 4. Reverse t. 3.


00:44:31.304 --> 00:44:42.763

Dr Doug Lucas: And then antibodies against the thyroid. You need to know all of those things, to know what's happening in the thyroid. This doesn't really tell me much, and then you also need to know symptoms. But this is


00:44:42.774 --> 00:44:48.354

Dr Doug Lucas: higher than I'd like to see it. I like to see. Tsh! Between one and 2. But again tsh! Alone doesn't really help me.


00:44:51.164 --> 00:45:20.674

Susan Jaye:  Is your 24 h calcium. This is another test we used to get. We actually don't get it anymore unless we're worried about parathyroid tumors or other secondary causes of osteoporosis. It's a pain in the butt, as you noted. I'm sure Susan took urine for 24 h in a bucket, so people don't like to do that test, Doctor Lucas. If you open the bio, if you open the bio station, she did test the T. 3 and T. 4,


00:45:20.734 --> 00:45:33.783

Susan Jaye: the one I went. Yeah, I went to a bone metabolism specialist, and you just read his report. And when she read this report she said he she went, and she tested the antibodies and everything.


00:45:33.814 --> 00:45:36.543

Susan Jaye: She was really not happy.


00:45:36.714 --> 00:45:38.613

Susan Jaye: We'll get there. Okay.


00:45:38.814 --> 00:45:52.414

Dr Doug Lucas: This is an Ekg which I am not a not an Ekg guy. Oh, I put that there because at the bottom, right? Yup, yup, yup.


00:45:52.644 --> 00:45:53.464

Dr Doug Lucas: yeah.


00:45:53.914 --> 00:45:58.493

Dr Doug Lucas: it's funny. I tell I this is what I can tell by looking at the Ekg. Yep, you're live.


00:45:59.654 --> 00:46:00.714

Dr Doug Lucas: It's all got


00:46:01.554 --> 00:46:11.473

Dr Doug Lucas: they used to hand me when I back when I was operating that the pre-out nurses would hand me the Ekg to for for to clear patients for surgery. Now


00:46:11.634 --> 00:46:25.973

Dr Doug Lucas: give this to the anesthesiologist. I don't know what this means. Alright Cvc is just gonna tell us about blood levels, red blood cell levels. Playlet levels all looks fine. As long as we're not looking for infectious stuff


00:46:27.254 --> 00:46:35.674

Dr Doug Lucas: breakdown of your white cells. There's some value in here when it comes to looking at potentially gut health and different kinds of infections.


00:46:35.714 --> 00:46:39.064

Dr Doug Lucas: And we generally looking at percentages. All these look. Okay.


00:46:39.964 --> 00:46:54.203

Dr Doug Lucas:  gfr kidney labs again. All of your electrolytes are all gonna look normal unless there's something off your liver. Enzymes. Look really nice Susan.


00:46:56.414 --> 00:46:59.773

Dr Doug Lucas:  where I looked at this part of this.


00:46:59.854 --> 00:47:02.523

Dr Doug Lucas: there's the free T, 3, free. T, 4 again.


00:47:03.534 --> 00:47:04.494

Dr Doug Lucas: And then.


00:47:05.264 --> 00:47:15.163

Dr Doug Lucas: yeah, here we go so free. T 3 is. It's low, I mean, it's still within the reference range. But here's what. So for people that don't know what these mean.


00:47:15.524 --> 00:47:21.934

Dr Doug Lucas: So T. 3 is the active form of thyroid hormone. whereas T. 4 is the storage form.


00:47:22.594 --> 00:47:28.224

Dr Doug Lucas: so you can have high t. 4 and low t. 3, and still be hypothyroid.


00:47:28.264 --> 00:47:31.353

Dr Doug Lucas: and if you had high T. 4, your Tsh. Would likely be normal.


00:47:31.794 --> 00:47:46.113

Dr Doug Lucas: And so this is why tsh is not a great measure for thyroid function. We need to know what's happening with free. The argument is free. T. 3 moves up and down relatively, rapidly throughout the day. So it's not a great measure, either, and that's why symptoms are so important.


00:47:46.144 --> 00:48:05.743

Dr Doug Lucas: But when I look at these, this biomarker free, T. 3 looks pretty pretty good. I like to see it over 3 but it would be for me really more based off of symptoms at this point, and and this is something I would likely recommend starting out with supporting it with a a supplement versus replacement, unless someone had over symptoms.


00:48:05.744 --> 00:48:17.433

Dr Doug Lucas: The other thing we're looking at here is the thyroglobulin and tpo antibodies. These are going to be looking at whether or not the immune system is reacting against the thyroid. And you don't have that, Susan. I think that looks good.


00:48:18.114 --> 00:48:33.703

Susan Jaye: Dr. Lucas, what supplement would you recommend for the we have a bunch of different ones? Yeah, so that we have a whole. We have this like ridiculously long list of supplements. The ones that we've been using are via the company apex energetics


00:48:33.834 --> 00:48:42.394

Dr Doug Lucas: and apex energetics has again, they have, like 5 different products. The one that I think that would meet these criteria is the one called Thyraxis.


00:48:42.654 --> 00:48:48.954

and then the challenge there is dosing. So dosing for these is between one and 6 caps a day. So


00:48:49.154 --> 00:48:57.714

Dr Doug Lucas: that's a big ring. But starting low and then going up, and we do see some people that get better on those, not everybody. I don't. I'm not in love with


00:48:57.724 --> 00:49:17.553

Dr Doug Lucas: thyroid supplements. I feel like there's the thyroid is really more likely a symptom of other things. You know sex hormone, dysfunction, strassen dysfunction, gut dysfunction, etc., than it is a primary problem. So we generally will kind of focus on those things would armour thyroid, be a product for this.


00:49:17.654 --> 00:49:26.963

Dr Doug Lucas: so armor thyroid is desiccated, thyroid and desiccated. Thyroid is a commercial or compound of preparation.


00:49:27.294 --> 00:49:55.104

Dr Doug Lucas: And so I would consider that replacement. It is replacement. So I wouldn't use that out of the gate, and unless you're already on it, are you already on it, Susan? No. A doctor gave me 30 mg. S. And I woke up at 40'clock in the morning, and I thought I was gonna have a heart attack. Yeah. And and that's the thing with thyroid is that. And this is why we would recommend supplementation rather than replacement out of the gate, which is


00:49:55.184 --> 00:50:11.173

Dr Doug Lucas: it. People are really sensitive to thyroid, and I find, especially the older we get, the more sensitive we are, so I would have recommended that same dose if we were gonna try it, but would have had the conversation to say, Look, if you feel symptoms of hyperthyroid, which is what you just experienced.


00:50:11.184 --> 00:50:22.853

Dr Doug Lucas: Then stop it, and it's just not for you. Now, some people do, you know you can. Even you can compound like 15 milligrams. You can compound 10 milligrams, and you can do whatever you want. But my guess is that you probably just don't need it.


00:50:23.254 --> 00:50:51.973

Dr Doug Lucas: Be my guest there, it wouldn't. It's not wrong to try it, because it doesn't short circuit anything but depending on symptoms. I just don't think you need it.  other things of interest in here. So you get into your sex hormones and and serum. So your DHEA. Is really low, even though it's in the reference range. But when you see reference ranges like this, it goes up to 400 and down to almost 0. You know that that reference range doesn't really help you doesn't tell you anything.


00:50:52.004 --> 00:51:03.333

Dr Doug Lucas: And so we like to see women. If we're gonna be building muscle and bone over 200 for Dha if they can tolerate it, and that generally for a postman, a plausible woman is gonna require some kind of supplementation


00:51:03.694 --> 00:51:14.373

Dr Doug Lucas: testosterone levels. So this is a really interesting case. So your test, your total testosterone is in the fifties now is testosterone part of your bhrt. Susan.


00:51:14.744 --> 00:51:29.493

Susan Jaye: Yes, but they did. They combined it with 10 mgs. Of DH ga, and I'm taking very low doses. But my complexion just going in the


00:51:29.724 --> 00:51:46.063

Dr Doug Lucas: yeah. And that's the potential side effect of testosterone. So so you're an example of somebody who has. If you look at your serum marker, it's actually pretty good right? So your total testosterone is over 50, which looks like well, it's in the upper, you know, probably upper third of the reference range.


00:51:46.444 --> 00:51:55.674

Dr Doug Lucas: which actually is not unreasonable, except that your free testosterone is is still pretty low. Now, these are quite. This is done through quest, I think.


00:51:56.664 --> 00:52:15.563

Dr Doug Lucas: Yeah. And so the they have different reference ranges than Lab core. So when I'm looking something else, yeah, so it's I have to look. I have to look at these reference ranges to see if this makes sense, it looks low to me. But looking at this reference range, I'd have to look more into this to see how low this really is.


00:52:15.764 --> 00:52:37.473

Dr Doug Lucas: The reason why you could have potentially low, free T is that your SHBG. Which is the sex hormone binding globulin. Your SHBG. Is pretty high and you can see that they have different again, very broad reference range here. But this binding globulin when it's higher, will bind up most of your testosterone, and you won't have much free.


00:52:37.534 --> 00:52:47.074

Dr Doug Lucas: You need the free testosterone to have an impact. But the thing that they don't measure here, which we don't really measure really in women either is DHT. Or dihyrot testosterone.


00:52:47.424 --> 00:53:09.814

Dr Doug Lucas: And so dihydro testosterone is the breakdown product of testosterone in the skin and in the periphery. And that's why your complexions going to crap is because you're breaking down testosterone. And D ht, that can be blocked through supplementation. Typically, you're gonna see this marketed to men for prostate health. But things like saw Paul Meadow


00:53:09.904 --> 00:53:18.324

Dr Doug Lucas: pumpkin pumpkin extract, I think. But if you look at products specifically like,


00:53:18.694 --> 00:53:40.264

Dr Doug Lucas: prostate health products, you'll see that they have that in it. And they're they're attempting to block D Ht, in the periphery which can be done. Other things that can be done. There is sporon lactone, which is a mild diuretic potassium sparing diuretic, and we also use that. It's a pharmaceutical but low doses can block the the conversion of testosterone dhc, as well.


00:53:40.634 --> 00:53:42.313

Susan Jaye: thank you. That makes sense.


00:53:43.464 --> 00:53:59.123

Dr Doug Lucas: And yeah, looking at this. So this number, this is another we don't use. But this, if you look at this bio available testosterone. It's actually in the upper again, kinda third or quartile, which. So you might actually have adequate testosterone. I just don't know cause I'm not familiar with these labs.


00:53:59.414 --> 00:54:09.423

Dr Doug Lucas: What this actually means on Lab core. We go way over the recommended range, but I don't know what. I don't know where this range came from. So I'd have to know more about that, and how it relates to to lab core


00:54:11.784 --> 00:54:15.214

Dr Doug Lucas: Estradiol levels are


00:54:15.614 --> 00:54:22.963

Dr Doug Lucas: super-duper, low. And so this is where. So we don't. We don't really worry about estrone. I'm more interested in Estradiol.


00:54:23.054 --> 00:54:31.273

Dr Doug Lucas: The range of estradial that you need to get to in BHRT. Is really around 60 picograms per mol.


00:54:31.364 --> 00:54:59.514

Dr Doug Lucas: Clearly your way off of that. Well, if you look at the saliva test, they say I have too much. S. Estrogen ready to just quit, because so did the same doctor ordered the saliva and the serum tests. Yes, yeah. So I think that's a mistake, because saliva tells you something totally different. It's like we order. We order your metabolites and serum. But I don't.


00:54:59.534 --> 00:55:04.073

Dr Doug Lucas: I don't use the urine metabolites for dose adjustments.


00:55:04.334 --> 00:55:12.694

Dr Doug Lucas: If you're going to order saliva and blood, and you're going to dose based off of both, then it's going to be contradicting recommendations, it doesn't work.


00:55:12.704 --> 00:55:22.853

Dr Doug Lucas: Saliva is is not sensitive, and there there's plenty of case. Press a day where doctors use saliva to dose hormones and mess people up, and they got sued and they lost.


00:55:22.894 --> 00:55:27.154

Dr Doug Lucas: So so I don't like saliva. We don't use saliva for anything other than cortisol.


00:55:27.164 --> 00:55:34.274

Susan Jaye: Well, I've been to 2 functional medicine doctors in the last month, and I am ready to just


00:55:34.544 --> 00:55:36.783

Susan Jaye: throw the towel in, because


00:55:36.794 --> 00:55:53.803

Susan Jaye: the other thing that's happening is if you go down the next one, or you look at the progesterone. They they're telling me not to. I have a uterus. They're telling me not to take the one, doctor says. Take the progesterone 1 25 every night.


00:55:53.804 --> 00:56:03.723

Susan Jaye: and the other doctor says, don't take it because you're because the saliva test is more accurate, and you don't. You have too much estrogen.


00:56:03.724 --> 00:56:27.823

Susan Jaye: So I'm between the rock and a hard place be because II don't know what to do, and the and the progesterone that now they give me slow release, Progesterone. So if I take it at night, and I take it, say at 11 at night or 10 at night, and then I get up the next day and I take the saliva test. It says the progesterone is at 9 55. It's high


00:56:28.114 --> 00:56:36.723

Susan Jaye: on the on the saliva test. So now, am I really gonna go without Progesterone? If I have a uterus? No.


00:56:36.944 --> 00:56:37.884

Dr Doug Lucas: no, you're not


00:56:38.684 --> 00:56:53.693

Dr Doug Lucas: so. And this is why you just don't use saliva and your and your problem is solved. But so so again, the saliva is measuring. It's measuring breakdown products and depending on


00:56:54.454 --> 00:57:06.564

Dr Doug Lucas: how your body metabolizes it. The timing, I don't know why, would be that high, but we're more interested what's happening in blood. And honestly, I think it's hard to catch either way. So if you look at Progesterone


00:57:06.944 --> 00:57:08.114

and here


00:57:08.124 --> 00:57:13.204

Dr Doug Lucas: of course, postmenopausal women, that reference range for Progesterone goes to 0 because


00:57:13.244 --> 00:57:23.673

Dr Doug Lucas: you don't wanna make any. So this doesn't actually help. Generally, if you really wanted to balance this out with estrogen, you'd wanna see this, like, you know, between 3 and 5.


00:57:23.674 --> 00:57:44.704

Dr Doug Lucas: But the thing is is we're really using it to balance estrogen. You want it there at night. It's gonna go away during the day, because that's how we're dosing it. And so I don't actually care. I just want to give you the the amount that we know will balance estrogen. And if we're getting your estrogen levels between 40 and 60 picograms per Ml. And serum.


00:57:44.704 --> 00:57:59.764

Dr Doug Lucas: Then you need between 150 and 250 milligrams of oral progesterone to balance that out. If you don't take Progesterone, you are at risk, and you will likely see endometrial hyperplasia. You'll see breakthrough bleeding, and it puts you at risk for endometrial cancer. So not a good idea.


00:57:59.904 --> 00:58:09.074

Dr Doug Lucas: So you definitely need progesterone plus. It helps with sleep. And there are receptors for progesterone on osteoblasts. So all good reasons to take Progesterone.


00:58:10.194 --> 00:58:20.014

Dr Doug Lucas: So it just sounds to me like you are experiencing the reason why I am happy to announce that I have found a partner to help me create a company to do just what you're looking for.


00:58:20.104 --> 00:58:26.713

Dr Doug Lucas: So we're going to. I shouldn't be saying this, but we're going to start a women's


00:58:27.263 --> 00:58:41.294

Dr Doug Lucas: biodenic hormone replacement nationwide Telehealth company. I don't know the timeframe yet. We just started talking about it, but I'm working with a partner who just sold off his Trt company. And he's looking for a new project, because this happens


00:58:41.404 --> 00:58:42.544

Dr Doug Lucas: all the time


00:58:42.664 --> 00:58:54.814

Dr Doug Lucas: we get thousands and thousands of comments on Youtube. And so many of them are on this topic. I can't find somebody to do it. My Obgiza says this, my functional doctor does this. My natural path does this.


00:58:54.884 --> 00:59:16.684

Dr Doug Lucas: and it's it is. It's a nightmare. And so for somebody to have somebody that has the same interests that you do, Susan, to prescribe would be very powerful. So we're gonna create that I don't know. I can't give you a timeframe on when that's gonna be available. But it's coming, so don't give up. You're 71. I might be dead.


00:59:18.593 --> 00:59:19.694

Susan Jaye: We all are.


00:59:19.763 --> 00:59:40.373

Dr Doug Lucas: We all? We all face that risk, Susan. Tomorrow's guaranteed for no one but I would say, keep going. I like your testosterone levels. If you're on 125 milligrams of Progesterone and your estrogen levels are this low? You do not have too much estrogen. I guarantee you that


00:59:40.564 --> 01:00:07.084

Susan Jaye: So I would just keep going, and then we will come in to rescue you hopefully sooner rather than later. Well, the well one doctor that I saw last week I showed him that there was some fluid in my uterus which the which the gynecologist says wasn't there before the HRT. And you commented on that before, and said, it's not such a big deal, and then the the doctor said, Well, if you start to bleed, call me


01:00:07.124 --> 01:00:10.704

Susan Jaye: so so, anyway.


01:00:10.764 --> 01:00:28.903

Susan Jaye: The thing is. At this point I'm so confused. I called the Women's International Pharmacy. I'm I'm basically just asking the the second functional medicine doctor. Can you give me a prescription? For? He took me off. He wants to do a pap smear


01:00:28.904 --> 01:00:45.833

Susan Jaye: and look and see what's going on with that before he'll put me back on Pogesteron. So he took me off Progesterone, and then he put me on like every 3 nights the estrogen, and every 2 nights the testosterone


01:00:46.674 --> 01:00:53.324

Susan Jaye: they that's what he want. They want me to do that, both doctors. I showed him what the first doctor said. He said he agrees with it.


01:00:53.514 --> 01:01:01.913

Susan Jaye: so the first one wants to keep me on Progesterone, and the second one wants me off until it can take a pap smear to see what's goin on.


01:01:02.484 --> 01:01:04.444

Dr Doug Lucas: What's he? What's he looking for?


01:01:05.444 --> 01:01:06.894

Susan Jaye: But anyway.


01:01:06.934 --> 01:01:18.343

Dr Doug Lucas: I don't know. Medical school, see cancer cells or something. Sure. Yeah. Cervical cancer, which


01:01:19.634 --> 01:01:21.324

Dr Doug Lucas: which you should be doing anyway.


01:01:21.564 --> 01:01:29.344

Dr Doug Lucas: So anyway, well, that's the end of our time. So, Susan, again, I would just reiterate.


01:01:29.844 --> 01:01:34.533

Dr Doug Lucas: you need to find a good provider. I do have another provider we have. We don't.


01:01:34.614 --> 01:01:48.053

Dr Doug Lucas: We stopped pushing it because it it was clunky, and it doesn't really make sense. But I can refer you to a company that can do VHRT. The way that you want it done, and the way that I recommend it done, they just look funny because they are


01:01:48.224 --> 01:02:03.904

Dr Doug Lucas: their treatment at men and specifically at athletes. So it looks very like awkward for our audience, which is why we don't have it on Hsn anymore. But if you wanna send I think Julie is here. If you wanna send Julie an email.


01:02:04.304 --> 01:02:06.794

Julie, are you


01:02:06.954 --> 01:02:08.593

Dr Doug Lucas: there? Can you hear me?


01:02:10.234 --> 01:02:18.043

Susan Jaye: Is that that Merck company? MI tried to look them up. They're hard to call.


01:02:18.354 --> 01:02:20.784

Dr Doug Lucas: Yeah, they're not a call kind of company.


01:02:20.904 --> 01:02:33.514

Julie Optimal Human Health: They're an email. They're an email kind of company. Oh, Hi, Julie, yeah, great. So, Susan, if you wanna drop Julie an email, she just put it in the chat Julie Wallace at? Oh, hmdcom, do you have that?


01:02:33.914 --> 01:02:37.174

Susan Jaye: I'm on the chat. Let me look


01:02:37.924 --> 01:02:51.534

Dr Doug Lucas: oh, here, let me click on it. Yeah. So. Ca, copy that down. Send her. She can get you the link, and you just fill out a form, and they they'll do. They'll do it the way that I recommend they do it. And if they don't let me know


01:02:51.934 --> 01:02:55.874

Dr Doug Lucas: But like I said, we're just gonna create our own company. I just can't give you a timeline yet?


01:02:55.944 --> 01:03:07.963

Dr Doug Lucas: And then a couple other quick things. Then I got to bounce to another meeting. Lorna, why don't, Lorna? We can look at your numbers next time. You are a patient. I just can't see you yet, because Kentucky's so slow.


01:03:08.564 --> 01:03:22.474

Dr Doug Lucas: And then don I haven't read that book, but I've read similar books. She was asking about using lifestyle interventions for finding and treating the root cause of Hashimoto's and yes, Hashimoto's is in general, a lifestyle usually a gut health problem.


01:03:23.294 --> 01:03:31.954

Dr Doug Lucas: And then how does iodine affect the thyroid randomly? Is what it seems like? Seems like there is an argument around iodine


01:03:32.174 --> 01:03:47.734

Dr Doug Lucas: deficiency versus iodine overload. Some people like Doctor Christensen. Christian got his book right here, Kristensen somewhere. He's a natural path, but he's gone extensively into low thyroid, and feels like we all have too much iodine.


01:03:48.084 --> 01:03:51.914

Dr Doug Lucas: and then lots of other providers will say that we are all iodine deficient.


01:03:52.094 --> 01:04:10.963

Dr Doug Lucas: So iodine is hard to test, for it's one of those minerals that's challenging to test for we used to use iodine for everybody, and we found that about half of our patients got worse, about half got better. So I feel like it's probably that some people do. Some people don't. We generally don't give it anymore. Unless we can prove deficiency.


01:04:11.434 --> 01:04:15.994

Dr Doug Lucas: and so I don't know how to answer that question other than seems random.


01:04:16.194 --> 01:04:28.003

Dr Doug Lucas: Kim asked about Washington. Yeah, I think we're still waiting on Washington, Kim, but I think that it's my other, my other meeting. But I think that


01:04:28.314 --> 01:04:33.903

Dr Doug Lucas: it's Washington's imminent. I mean, they're all imminent. It's just they're everything's submitted. They're just slow.


01:04:34.764 --> 01:04:46.797

Dr Doug Lucas: So alright, guys. So next week on Wednesday at noon. Great questions. We'll get to and tell you what. And, David, let me talk about lift more. Next time we'll talk about that specifically.