What Are Liver Enzymes?
Liver Enzymes are made by cells throughout the body but are found in highest concentrations in liver cells. These enzymes are found inside liver cells, so when the concentration is elevated in the blood, usually indicates liver cells (hepatocytes) are inflamed, damaged for dying. Below is a list of the four common liver enzymes that are routinely tested on an annual basis or monitored due to certain medications, such as Statin drugs and acetaminophen.

Liver Enzymes: 

Alanine transaminase (ALT) / Serum Glutamic-Pyruvic Transaminase (SGPT) 
Aspartate transaminase (AST) / Serum Glutamic-Oxaloacetic Transaminase (SGOT) 
Alkaline phosphatase (ALP)
Gamma-glutamyl transpeptidase (GGT)

Liver Enzyme Reference Range: (Quest Diagnostics)

Liver Enzyme Test

Male
Female

AST

10 – 40 U/L
10 – 35 U/L

ALT

9 – 46 U/L

6 – 29 U/L

ALP
40 – 115 U/L

33 – 130 U/L

GGT

3 – 95 U/L

3 – 70 U/L

 
What Does Slightly Elevated Liver Enzymes Mean?
Something we have consistently observed with our patients over the past ten years is slightly elevated liver enzymes. Specifically, a slight elevation to AST and ALT.   

For example, on a routine Comprehensive Metabolic Panel (CMP), a woman will have an AST level of 54 U/L and an ALT level of 47 U/L. Both enzymes are slightly outside the normal range, but this often gets blown off by the primary care physician because the liver enzyme levels are not high enough to indicate major a concern. However, if the enzymes levels were in the hundreds, then the doctor would do some follow-up testing for some liver disease like Hepatitis.

Does progesterone make you tired? It is a lot more complicated than a yes or no answer.  In this episode, we are going to explain this question in full detail.

We are going to talk about:

Types of progesterone replacement: creams, capsules, sublingual, troche
Why progesterone is used to balance hormones
When you usually take progesterone
How much progesterone is a typical dose for treatment

Progesterone is a common type of hormone replacement and is an excellent treatment for many of the symptoms associated with hormone imbalances that occur during Premenstrual Syndrome (PMS), perimenopause and menopause.

We are also going to talk about how progesterone can help with symptoms of hormone imbalance.  One of the most common symptoms is insomnia. Progesterone is fantastic for sleep.  It is particularly helpful for helping women both fall asleep and stay asleep throughout the night.  

Many women complain of waking multiple times during the night or are awake for hours in the middle of the night.  We are going to talk about how progesterone can help with healthy sleep.

We are also going to talk about what forms and doses of progesterone help the most with sleep, mood, and energy.  How some forms of progesterone do not affect energy or sleep quality, and other forms of progesterone can make you tired or sleepy.

Why progesterone is used to balance hormones:
Many of the symptoms associated with PMS, perimenopause, and menopause are related to an imbalance or a decline of progesterone.

Types of progesterone:
Of the different dosage forms of progesterone, we prefer to use bioidentical progesterone sustained release capsule with our patients. We have found this form to provide the most consistent results with our patients. In some cases, we might use a transdermal cream, but it depends on the situation.  We rarely use sublingual tablets or progesterone troches.

Capsules (either immediate or sustained release) 
Transdermal cream
Sublingual tablet
Troche

How much progesterone is a typical dose for treatment?

A common starting dose for women in menopause is 100 mg progesterone sustained release (SR) capsule. This amount can be increased or decreased depending on the response.  For menstruating women, the dose can be as low as 25 mg and go up from there.  

When you usually take progester

It may not always be obvious, but hormones have a significant influence on how we feel and our behavior on a daily basis. It is not something that is given enough thought to in medicine; however, it is something we pay a great deal of attention to because we understand the connections.  

Hormones dictate everything from eating to sleeping and just about anything else in between.  When hormones are balanced, then our behavior normal. If hormones are not balanced, then emotions and behavior will suffer. For example, if someone is under heavy stress, cortisol will rise. Over time, the rise in cortisol can negatively impact the sleep process, resulting in chronic insomnia.

Below are a few more examples of behaviors/emotions that are influenced by hormones:

Sleep
Hunger / appetite / food cravings
Sex Drive (libido)
Addiction
Motivation/drive/ambition
Focus/concentration
Anxiety/depression
Irritability
Emotional/weepy
Sad/melancholy
Grumpy

The relationship between hormones and behavior is a very complicated topic and one we will dive deeper on in the future. For now, hopefully, this gives you a bit more insight into how hormones influence our behavior. If you think that your hormones are having a negative impact on your behavior, please send us an email to [email protected].
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Triiodothyronine also is known as T3 is the active form of thyroid hormone.  T4 also known as thyroxine is made in the thyroid gland.  T4 is then sent peripherally through the system, and mainly the liver will convert T4 to T3.  You can have all the T4 in your body, but if your T3 is low, then you will have symptoms of low thyroid.    
If suspecting a case of low thyroid, thyroid disease, hypo or hyperthyroid your conventional doctor is going to run a TSH blood test.  The TSH (Thyroid Stimulating Hormone) is a signal from the brain monitoring thyroid disease and the thyroid levels in the body.  
To put it simple:  

If the thyroid levels are high, then the TSH is low.  
If your thyroid levels are low, then TSH is high.

As mentioned above the thyroid mainly makes T4, which is released into the blood and will travel in the body and be converted to the active form of thyroid, T3.  Approximately 60% of this conversion occurs in the liver, about 20% is converted by gut flora and about 20% is converted by peripheral tissues, such as muscle.  

As we have always talked about before, your primary care doctor is looking for a ‘disease.’  If you have a ‘disease,’ your GP, internist, or endocrinologist can save your life.  In the case of thyroid, your conventional doctor is going to run a TSH and perhaps a T4.  That is because they are looking for thyroid disease, not low levels of T3.   
Many people with Low T3 get missed by their doctor because their TSH is in the normal range.  They are told, “you are fine,” even though they do not feel fine.     

How do you know if you have Low T3?  You can do a blood test for Free T3.  Free T3 is the bio-available thyroid hormone ready for use.  In checking for Low T3, you want to check the free T3 levels, not the Total T3 levels. Total T3 levels in the blood represent all Free T3 and bound T3 levels.  Testing for total T3 levels is not going to be accurate enough to find out if you have Low T3.

You may need to request blood testing for Low T3 from your doctor, or you may need to order it yourself if your doctor will not order it.  
Blood tests checking for Low T3 Level:

TSH
Free T4
Free T3

This is where it gets a bit confusing.  The reference range for Free T3 is broad.  

Free T3 Reference Range:

2.3 to 4.4 (depending on the lab).  
If your Free T3 is under 3.0, we would consider this to be a Low T3 level.

Testing results we commonly see in patients with Low T3:

TSH: normal range usually between 1.0-3.5 (reference range is .45-4.5)
Free T4: 1.1-1.4 (reference range is .8-1.8)

Here is a typical scenario:
I don't know what to do I have all the symptoms of low thyroid.  My hair is falling out.  I am exhausted, no energy whatsoever.  I have gained weight, even though I try to eat well and exercise.  But honestly, I am too tired to exercise.  Sorry for the TMI, but I am constipated, bloated and fiber makes it worse.  I am feeling pretty low mood wise and so tired.  My skin is really dry, and all I want to do is sleep.  
I went to my general practitioner, and she ran my blood work for thyroid.  My doctor says my thyroid is fine.  But I don't feel fine! Then she just told me to go on a diet and gave me a prescription for an antidepressant.

I cannot tell you how many times I have seen this scene.  That is because your general practitioner, endocrinologist, internist, PCP are looking for disease or if something is broken.  But what if there is not a disease (thank goodness)?  They really do not know what to do with you.  To check for thyroid disease, your doctor will run a TSH (thyroid stimulating hormone).  
The TSH is a signal from the brain monitoring the thyroid status.  If you have thyroid disease causing an underactive thyroid, the TSH will be elevated. And if you have an overactive thyroid, the TSH will be very low.  But the TSH is checking for thyroid disease.  We have a lot of patients that do not have thyroid disease but still have a subclinical, ‘hypofunctioning’ of the thyroid.  
Trying to keep this relatively simple, your thyroid gland makes T4 thyroxine, which is a very stable molecule and will travel in the system and mainly your liver will convert T4 to T3.  Triiodothyronine (T3) is a very unstable molecule but is the active thyroid hormone.  In Subclinical Hypothyroid, you will often see a normal TSH, normal T4 and a lower Free T3.
Subclinical Hypothyroid:

TSH reference range is .45-4.5 = see anywhere from .45 to 2.5
FreeT4 reference range is .8-1.8 = will see .8 to 1.1
FreeT3 reference range is 2.2-4.4 = will see 2.0 to 2.9

Again, your conventional primary care doctor, endocrinologist, GP, internist are looking to make sure you are not going to die of a disease.  They are not going to check your Free T3.  And rarely they may check your Free T4.  But if they do, they do not know what to do if the TSH is normal.  
We find by optimizing your T4 and especially your Free T3; the Subclinical Hypothyroid symptoms go away.  We still keep the TSH in the normal range but try to optimize the Free T3 to 3.5-4.4.  
This is done in many ways based on the patient's personal and family health history, their symptoms and goals.  We might implement a combination of vitamins, minerals, glandulars, medication and lifestyle factors to treat subclinical hypothyroid.   

Hopefully, this has been informative and helpful to you. If you have any questions or personal stories, please feel free to email us at [email protected].

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Our bodies make three different forms estrogens:

Estrone (E1)
Estradiol (E2)
Estriol (E3)

Estrone is usually considered an unhealthy estrogen.  It is still bioidentical, but you do not want loads of estrone around when you are balancing the hormones.  Estrone is common in young girls when they first get their periods and after menopause.  Estrone metabolites can raise the risk for cancer.  This is why you do not want a high level of estrone, which can also cause moodiness, feeling munchie, puffy and grumpy.  With bioidentical hormone replacement therapy (BHRT), we do not use estrone for the above reasons mentioned.

Estradiol is the strongest of the three bioidentical estrogens.  Estradiol is common in conventional hormone replacement in the form of oral, patches or transdermal.  Premarin and Prempro are not estradiol and are not bioidentical.  Because estradiol is the strongest of the estrogens, it has pros and cons to use.  

Pros of Estradiol:  

Great for keeping bones strong
Eliminating hot flashes and night sweats
Neuroprotective for the brain
Great for short-term memory and memory recall
Helpful for libido and sex drive

Cons of Estradiol: 

Estradiol likes to grow things.   (i.e. grow the lining of uterus, which can cause a risk of uterine cancer)
Can cause spotting, bleeding, periods
Grow breast tissue
Cause breast tenderness
Enlarge breasts which can be a risk factor
Moody (weepy, irritable, anxious) 
Can be similar to a 24/7 feeling of PMS
Weight gain

Many women report gaining on average 6 to 8 lbs when taking conventional estradiol hormone replacement.  It is primarily in the breasts and stomach.
   
So how do we get the positive benefits of estradiol without the negative side effects? The best way to properly balance estradiol is to take estriol with it.

Estriol (E3):
Estriol is the gentlest form of estrogen.  Some people refer to it as the weakest form, but I think that is a misnomer.  When you combine estriol with estradiol you can get the beneficial effects of estradiol and estriol, without the negative side effects of estradiol.