By N. Cruz. McKendree College. 2018.

The rele- vance of medically supervised use of methamphetamines to abuse employing much higher doses is not possible to assess discount 1 mg finasteride visa. Frequencies of congenital anomalies (brain cheap finasteride 5 mg, anencephaly, eye, cleft palate) were increased among mice and rabbits whose mothers were given methamphet- amines during pregnancy at doses up to 20 times the therapeutic adult human dose (Kasirsky and Tansy, 1971; Martin et al. Summary of amphetamine/methamphetamine use Medically supervised use of amphetamines and methamphetamines during pregnancy does not seem to pose significant risks for increased frequencies of congenital anomalies or maternal–fetal complications. Risks for congenital anomalies and pregnancy compli- cations for those who abuse this class of drugs may exist and probably involve serious complications secondary to vascular disruption and other cardiovascular accidents. Estimated prevalence rates of cannabinoid use during pregnancy vary widely, ranging from 3 to more than 20 percent of gravidas. Prolonged labor and meconium-stained amniotic fluid apparently increased in frequency in one uncontrolled study of 35 women who smoked marijuana late in pregnancy (Greenland et al. Perinatal infant effects Significantly lowered birth weights have been reported among infants whose mothers used marijuana during pregnancy in three studies (Cornelius et al. Among more than 1200 infants whose mothers smoked marijuana during pregnancy, 137 during the first trimester, the frequency of major congenital anomalies was not increased (Linn et al. Although not generally accepted, a syndrome (fetal growth retardation, craniofacial and other minor dysmorphologic features) was proposed in a clinical case series that included five infants born to women who used two to 14 joints (cigarettes) of marijuana daily throughout pregnancy (Qazi et al. The infants probably had fetal alcohol syndrome and this finding has not been replicated. Most animal teratology studies of marijuana are negative, particularly if dosing (amount, route of intake) was comparable to the human situation. Withdrawal symptoms Among infants born to women who used marijuana near the time of delivery, certain neonatal neurobehavioral abnormalities (tremulousness, abnormal response stimuli) were found (Fried, 1980; Fried and Makin, 1987), but other studies found no differ- ences (Tennes et al. Summary of cannabinoid use Mild fetal growth retardation and maternal lung damage are the only untoward out- comes that can reasonably be attributed to marijuana use during pregnancy. Importantly, woman who use marijuana during pregnancy frequently use other sub- stances know to be harmful substances (i. It is an epidemic that began in the mid to late 1970s and has reached users of virtually every age, sex, ethnic, and socioeconomic subgroup. The use of cocaine is accepted to be dangerous to intrauterine development and can cause birth defects (not a syndrome), fetal growth retardation, and transient withdrawal symptoms. Postnatal intellectual development also seems to be adversely affected by the drug. Cocaine use among pregnant women We first estimated the prevalence of cocaine use during pregnancy at 9. Survey results in public hospitals range from 11 to 31 percent (Brody, 1989; Nair et al. Much of the professional community was unprepared to deal with the large number of cocaine-exposed fetuses over the last decade (Landry and Whitney, 1996; Kuczkowski, 2005). In one study, approximately 77 percent of pregnant cocaine abusers at a large public hospital used other drugs of abuse and/or alcohol (Little et al. We found that cocaine crosses the placenta and is metabolized in the placenta through plasma cholinesterase to ecgonine methyl ester, a major active metabolite (Roe et al. Coronary artery vasospasm and arrhythmias occur at even very low doses of cocaine (Lange et al. Chronic cocaine use can lead to myocardial infarction, congestive heart failure, dilated cardiomyopathy, or severe ischemic events in the heart or brain (Box 16. In more severe situations, cocaine can aggravate vascular weakness and cause serious vascular accidents (intracerebral infarctions and hemorrhages, acute ischemic brain events). Death from cocaine toxicity is usually preceded by hyperpyrexia, shock, unconsciousness, respiratory/cardiac depression. Chronic cocaine use is associ- ated with epileptogenic seizures and cerebral atrophy (Pascual-Leone et al. Maternal cocaine use during pregnancy was associated with significantly shortened mean gestational periods and increased frequencies of preterm labor (Chasnoff et al. This drug is significantly associated with an increased frequency of precipitous labor (Bateman et al. Gestation length and frequency of preterm delivery among women who used only cocaine during the first trimester were not found to be significantly different from women who did not use cocaine during pregnancy (Chasnoff et al. Others have found no association with preterm labor or low birth weight when other obstetric complications were con- trolled (Miller et al. However, other risks (birth defects, low birth weight, prematurity, decreased length, and lower head circumference) were said to be related to polydrug use, and could not be attributed to cocaine use (Addis et al. Cerebrovascular accidents and related cocaine toxicity Fatalities following adult cocaine use have frequently been reported. However, only four cases have been documented that involve pregnant women (Burkett et al. Of the published cases, two were due to subarachnoid hemorrhage resulting from ruptured aneurysms and a third case involved a pregnant woman admitted to the hospital in a comatose condition after about 1. She was maintained on life-support sys- tems and eventually died approximately 4 months later, never having regained conscious- ness. The fourth maternal death was attributed to cardiac ischemia and arrhythmia (Burkett et al.

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The recommendations in this book are based on this evidence-based integrative approach buy discount finasteride 5mg line. When women put an earnest effort into Step 1 of The Gottfried Protocol— and implement a customized food plan; specific supplements that include missing vitamins buy discount finasteride 1 mg on-line, minerals, and amino acids; and targeted exercise—they find most of their symptoms of hormone imbalance disappear. After completing Steps 1 and 2, few women need bioidentical hormones (Step 3), but for those who do, the doses and duration of treatment are often lower than if they’d skipped the lifestyle design and herbal therapies. Sometimes it just takes a small adjustment to induce big changes: I relish the moment a patient realizes that her presumed life sentence of low sex drive can be altered with a particular form of meditation and a maca smoothie. By nature I am a skeptical person, but I’ve seen the benefits of The Gottfried Protocol over and over in my own practice. We are conditioned as women to live in such a way that gets our hormones to work against us, and I want to help you adjust your hormones naturally so they are allies. As I’ve witnessed the healing that women experience when their hormones are reproportioned, as I’ve documented both the results and the transformation that occur in everyday lives, I’ve come to believe that The Gottfried Protocol is far more likely to succeed than a prescription medication— particularly a medication that is completely foreign to your body. Chapter 1 offers several questionnaires— checklists to help you identify your main hormonal imbalances. After responding to these questions, you will have a good idea if you are high or low in any of the targeted hormones, and then know which chapters you should read first. Chapter 2 offers an overview of what hormones are, what they do, and how they interact. Chapter 3 describes when it all starts to go awry: perimenopause, which typically begins between the ages of thirty-five and fifty (menopause, on average, occurs at age fifty-one in the United States). Based on exhaustive research and drawing on my years of clinical experience (plus forty-five years in a female body with seemingly every hormonal symptom possible), I describe the common causes of specific hormonal imbalances and what to do about them. I’ve included a summary of The Gottfried Protocol according to root cause, a glossary of terms, a table of hormones described in this book and their jobs, how to find and work collaboratively with clinicians, recommended laboratories for home testing, and the food plan that I recommend to my patients and follow myself. In reading each chapter, you’ll refer to the questionnaires at the beginning of this book to help you assess your symptoms and perhaps even identify issues that you didn’t know could be related to hormones. Along the way, you’ll also meet other hormonal characters, including insulin, pregnenolone, vitamin D, leptin, and growth hormone. You’ll learn what each hormone is, what its job is, what you feel like when it’s functioning properly—and when it is not—and what might have caused the imbalance in the first place. After introducing you to the hormone in question, I dive deeper into the science behind what’s happening in your body to cause that hormone to become imbalanced. Understanding the science is important to some of my patients, while others feel they don’t care about it and just want to know how to feel better now. That’s where The Gottfried Protocol comes in; we make a plan instead of taking a shot in the dark. Her hormones perfectly balanced, she has high energy throughout the day, stable moods, and no food cravings. Colleagues never worry that she’ll weep in the middle of a big meeting or start sweating profusely. Well-intentioned friends don’t gently suggest “seeing someone, a therapist, maybe? I believe the majority of women want to look better, feel better, and age more gracefully. A common myth about hormones is that you don’t need to worry about them until menopause. The truth is, many hormone levels, such as estrogen and testosterone, start to drift downward when you’re in your twenties. Some hormones, such as cortisol, may spike too high and pull other hormones offline. Women younger than thirty may not yet feel affected by the aging process, but perhaps they want to get pregnant or avoid the diagnosis of breast cancer their mom just received. Those in their thirties may feel increasingly tense and overwhelmed, in need of better strategies on how to relax. They may want to prevent the high blood pressure, prediabetes, and accelerated aging that come with chronically high stress levels. Women in their forties and fifties may want to regain some of the buoyancy of their youth. Perhaps they want to wake up feeling restored again, without the brain fog from disrupted sleep. Women in their sixties, seventies, and eighties may want to optimize their cognitive and executive functioning—to improve their thinking, memory, and competitive edge. I don’t want women to suffer; I don’t want them to be underserved by their doctors, miseducated by the media, tired, frazzled, and ashamed. I’m not a magician who can turn back the hands of time and make you twenty- five again, nor do I believe that’s best for you. What I can do is return something you’ve lost: the properly proportioned hormonal organization that provides clarity, confidence, and longevity.

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I try to choose how I respond to stressors rather than going into amygdala hijack order 5 mg finasteride overnight delivery. I’ve learned that contemplative practice is a nonnegotiable aspect to my day: it has improved my attention order finasteride 1 mg free shipping, made me more mindful of what I eat— which helped lead to a 25- pound weight loss—and given me a deeper sense of real choice during my day. I am more patient with my kids, better organized, happy in my work, and more joyful overall. Yes, I still lose my cool, but I’ve become far more skillful at what was clearly my Achilles’ heel: high cortisol and the roller- coaster ride it can take you on. I understood what William James meant by “The greatest discovery of any generation is that a human can alter his life by altering his attitude. I taught myself how to uplevel and downlevel my nervous system more consciously and expertly. Part B: The Gottfried Protocol for Low Cortisol As mentioned in The Gottfried Protocol for High Cortisol, the following solutions are for informational and educational purposes only. Start first with the lifestyle resets, and consult a physician about the advisability of applying further approaches to your symptoms or medical condition, particularly herbal therapies such as licorice, which may cause blood pressure to rise excessively. Step 1: Targeted Lifestyle Changes and Nutraceuticals Get some exercise, perhaps African dance. A fascinating study of college students compared mood and cortisol levels before and after they attended one of three ninety- minute classes: yoga, African dance, or a biology lecture. African dance raised cortisol and mood, yoga lowered cortisol and raised mood, and the lecture changed neither mood nor cortisol. Before I began medical school, I was a bioengineer, and my best friend, who happened to be a rocket scientist, was a remarkably calm woman who never seemed to get stressed out like me. She had a great way of approaching problems, which I call the modular approach: she would take a problem and, rather than trying to solve the whole gigantic hairy thing at once, break it down into component parts, or modules. The interesting backstory to adrenal healing is that much of the research on antistress effects of nutrients and herbs was conducted by Soviet researchers in the 1970s (and are published in Russian). One study showed that a combination of vitamin C (200mg three times per day) plus an intravenous combination of vitamins B1 and B6 restored cortisol production and diurnal rhythm. Step 2: Herbal Therapy Botanical therapies that are proven to raise cortisol include the following: Licorice (Glycyrrhiza). One study of children of women who consumed varying amounts of licorice found that the more licorice the moms consumed, the higher the children’s cortisol levels. Consider deglycyrrhizinated licorice, a capsule or chewable tablet with the chemical bits removed that raise blood pressure. I generally recommend that people with low cortisol try a small dose of root extract: 600 mg, standardized to 25 percent (150 mg) glycyrrhizic acid—and check their blood pressure with a home device and at their local doctor’s office. In patients with Addison’s disease, licorice and grapefruit juice have been shown to raise cortisol levels. In one study, licorice raised median cortisol serum levels and urinary cortisol, whereas grapefruit juice significantly raised serum cortisol. This makes me nervous because any adrenal support should be given extremely cautiously and with an entire whole-foods and lifestyle adjustment for sustained results. In other words, you need the foundation of nutrient-dense whole foods (not processed foods, and especially not refined carbohydrates, which worsen adrenal problems), restorative sleep, and supplements to fill nutritional gaps before resorting to a quick-fix prescription pill. Furthermore, if you take external cortisol for more than a few months, you could develop secondary adrenal insufficiency. If you still suffer with the symptoms listed in the questionnaire despite trying Step 1 and Step 2 of The Gottfried Protocol (pages 116–118), I strongly encourage you to ask your doctor to test your cortisol. If your serum, salivary, or urinary cortisol is low, then consider the bioidentical cortisol in Isocort, an adrenal- support pill from Bezwecken in which the cortisol is derived from fermented plants. The recommended dose is one or two pills up to three times a day—not to exceed six pills a day—taken with a meal. As with high cortisol, I do not recommend supplements derived from animal glands for similar reasons. Signs of Cortisol Balance When your level of cortisol is appropriate and not turning your brain into Swiss cheese, you feel calm, cool, and collected most of the time. Because you slept well, there are no bags under your eyes, you eat normally with no blood sugar swings, you feel like your body has a good rhythm, and your total load—the amount of physical and psychological stress you’ve got on your plate—is manageable and engaging. You are skillful at coping with stress through breath, exercise, time with girlfriends, massage, and mindfulness. You awaken eight hours later (or after however many hours is the perfect number for you and to urinate twice or less), feeling fully restored and ready to embrace what the day will bring. From puberty and throughout your fertile years (fertility ends at menopause, which occurs, on average in the United States, at age fifty- one), your ovaries produce estrogen, progesterone, and testosterone. Estrogen is the diva—it’s responsible for your breasts, hips, smooth skin, and a brain with a particular female orientation (plus tending to about three hundred other jobs and nine thousand genetic tweaks). Don’t Underestimate Progesterone When I went to med school, I was taught that declining estrogen was responsible for the hormonal havoc of women in perimenopause, which starts sometime around age thirty-five to fifty, occasionally earlier or later. But it turns out that progesterone is far more crucial than scientists once believed.

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In the latter condi- tion purchase finasteride 5 mg online, the stroke volume of the dilated ventricle is not preload-dependent order 5mg finasteride fast delivery, and therefore relatively normal left ventricular filling pressures can be targeted. In acute heart failure, particularly when myocardial ischemia is present, attention to Starling mechanisms with respect to preload and augmentation of stroke volume remains important. While titrat- ing nitroprusside to achieve hemodynamic goals, doses are rarely greater than 4 µg/ kg/min to maintain adequate vasodilation in the acute heart failure setting, and dosing this high should generally be avoided for prolonged periods (more than 72 h) due to the risk of thiocyanate and cyanide toxicity. The most common serious adverse effect of nitroprusside administration in acute heart failure is systemic hypotension. One should be particularly cautious when initiating nitroprusside in a patient with ischemia or infarction and a systolic arterial pressure of less than 100 mmHg. An increase in heart rate during the infusion is an ominous finding and usually presages hypotension. This 240 Auer typically occurs when stroke volume has not increased appropriately, often because of ongoing or worsening ischemia, valvular regurgitation, and inadequate cardiac reserve. Alterna- tively, the addition of a positive inotropic agent such as dobutamine is often advantage- ous and may allow for the continuation of nitroprusside. Such a combination is commonly used while stabilizing particularly severe, low-output heart failure until more definitive therapy can be instituted. When systemic hypotension and poor peripheral perfusion is present at the outset, nitroprusside should generally be avoided as initial treatment. As noted above, thiocyanate toxicity is a potentially serious side effect of pro- longed nitroprusside infusion and is manifest clinically by nausea, disorientation, psy- chosis, muscle spasm, and hyperreflexia when plasma thiocyanate concentrations exceed 6 mg/dL. This is uncommon in the management of acute heart failure where nitroprus- side therapy is usually a temporary means of support while awaiting definitive therapy. Cyanide toxicity is extremely rare in heart failure management and only occurs during prolonged, high-dose infusions, usually in the setting of significant hepatic dysfunction. The concept of intravenous vasodilator therapy in acute heart failure is based on correc- tion of hemodynamic derangement and stabilization of the patient while a therapeutic plan is devised. The necessity for prolonged treatment (>72 h) often portends a poor prognosis, particularly in the absence of a reversible underlying disorder. Hydralazine Hydralazine, like diazoxide, is a direct arteriolar vasodilator with little or no effect on the venous circulation. Thus, the same precautions apply in patients with underlying coronary disease or a dissecting aortic aneurysm, and a beta-blocker should be given concurrently to minimize reflex sympathetic stimulation. The hypotensive response to hydralazine is less predictable than that seen with other parenteral agents and its current use is primarily limited to pregnant women. Minoxidil In the case of refractory hypertension, powerful additional hypertension agents such as minoxidil may be necessary. The glucuronide metabolite appears to have some activity either alone or possibly as a reser- voir for endogenous cleavage back to the parent compound. Cardiovascular Drugs 241 of glucuronide and parent drug occurs, and pharmacologic effect may be enhanced in patients with decreased renal function. In general, lowering the blood pressure with antihypertensive agents, weight loss, or dietary sodium restriction decreases cardiac mass in patients with left ventricular hypertrophy. Regression is largely absent with direct vasodilators (such as hydralazine or minoxidil) despite adequate blood pressure control. Diazoxide Diazoxide, in comparison to nitroprusside and nitroglycerin, is an arteriolar vaso- dilator that has little effect on the venous circulation. Diazoxide is also longer acting and, in the currently recommended doses, requires less monitoring than nitroprusside, since the peak effect is seen within 15 min and lasts for 4–24 h. A beta-blocker such as propranolol or labetalol is usually given concurrently to block reflex activation of the sympathetic nervous system. This protection, however, is not complete, and it is recommended that diazoxide not be used in patients with angina pectoris, myocardial infarction, pulmo- nary edema, or a dissecting aortic aneurysm. Diazoxide can also cause marked fluid retention and a diuretic may need to be added if edema or otherwise unexplained weight gain is noted. Decreased binding in uremia or the nephrotic syndrome results in increased free drug in the circu- lation and increased response. Dose adjustment according to creatinine clearance: (a) >50 mL/min: normal dose; (b) 20–50 mL/min: two-thirds of normal dose; (c) <20 mL/ min: one-half to two-thirds normal dose. Adverse effects include marked edema (which may require high doses of loop diuretics) and hirsutism. Medical therapy for insulinoma should be considered in the patient whose insulin- oma was missed during pancreatic exploration, who is not a candidate for or refuses surgery, or who has metastatic insulinoma. The therapeutic choices to prevent sympto- matic hypoglycemia include diazoxide, verapamil, phenytoin, and the somatostatin ana- log octreotide. Diazoxide (which must be given in divided doses of up to 1200 mg/d) is the most effective drug for controlling hypoglycemia. However, its use is often limited by marked edema (which may require high doses of loop diuretics) and hirsutism.

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