A4M EXAM TEST PAPER ANSWERS AND QUESTIONS
SET A+
✔✔detoxification organs - ✔✔liver
GI tract
kidneys
skin
lungs
✔✔xenoestrogens - ✔✔environmental compounds that mimic the effects of natural
estrogen
✔✔Phase I Detoxification - ✔✔enzymes in the cytochrome P450 system use oxygen to
modify toxic compounds, medications and steroid hormones into intermediate
compounds
occurs in the liver
SNPs:
increased phase I clearance without increased phase II clearance? can lead to the
buildup of intermediates that may be more toxicant than the original substance
decreased phase I clearance? will cause toxic accumulation in the body. adverse
reactions to meds are often d/t a decreased capacity for clearing them from your system
✔✔Phase II Detoxification - ✔✔the intermediate compounds are neutralized through the
addition of a water soluble molecule which the transformed toxins are then able to be
eliminated through urine or feces
stage 1: glutathione conjugation- requires glutathione (strongest antioxidant made by
the body) and vitamin B6
stage II: amino acid conjugation- requires glycine, taurine, and glutamine
stage III: methylation. needed to detox estrogen and breakdown homocysteine. requires
folic acid, choline, methionine, trimethylglycine, and s-adenosylmethionine (SAMEe)
stage IV: sulfating. requires cysteine, methionine, and molybdenum
stage V: acetylation. requires acetyl CoA
stage VI: glucuronidation. requires glucuronic acid.
,✔✔increased risk of breast cancer? - ✔✔if estrogen metabolism favors the 16 OH
pathway
if you have a low P to E ratio
✔✔How Estrogen and Progesterone work together: - ✔✔E2 lowers body fat by
decreasing lipoprotein lipase in your fat cells. P increases body fat storage by
increasing the amount of lipoprotein lipase
E2 increases insulin sensitivity and improves glucose tolerance. P decreases insulin
sensitivity and can cause insulin resistance.
✔✔low P to E ratio - ✔✔can cause abnormal bleeding, increased risk of uterine cancer,
increased risk of breast cancer, and infertility
✔✔high P to E ratio too high in progesterone - ✔✔will break down protein and muscle
tissue, will make diseases like fibromyalgia worse
decreased sexual interest
fatigue
depression
insulin resistance/diabetes
✔✔where is testosterone made? - ✔✔an androgen made in the ovaries and adrenal
glands, only small amount is free (available to use) and the rest is bound to sex
hormone binding globulin
✔✔Causes of testosterone deficiency: - ✔✔adrenal stress, oral contraceptives
(increases SHBG), chemo, childbirth, statins, depression, endometriosis, aging,
psychological trauma, surgical menopause
✔✔testosterone dosing - ✔✔Dosage range: 0.25 mg cream to 4.0 mg cream q day
(most common dose: 0.25 mg-2 mg) transdermally
If menopausal, will need hormone holiday
✔✔How to increase T? - ✔✔Decrease caloric intace, exercise, sleep, increase protein,
weight loss, stress reduction, take arginine/leucine/glutamine, zinc supplementation
✔✔Synthetic testosterone (methyltestosterone) increases risk of? - ✔✔liver cancer
✔✔low in estrogen and cannot be replaced but needs testosterone replacement? -
✔✔do not replace testosterone alone- can increase plaque formation in coronary
vessels and increase risk of heart disease
✔✔Causes of elevated testosterone? - ✔✔PCOS, peri/meno, aggressive exercise, too
high T dose, given DHEA which may raise testosterone
,✔✔what type of DHEA replacement will not affect testosterone levels? - ✔✔keto-DHEA
should not raise testosterone levels
✔✔How to lower elevated testosterone levels? - ✔✔Saw palmetto: 240-260 mg BID
Metformin: 500 mg qd
Spironolactone 100 mg BID (least favorite)
Urtica dioica (nettle) 300 mg BID- the root binds to and increases SHBG which
decreases the amount of bioavailable testosterone
Camellia sinensis (green tea) 270 mg- increases SHBG
Glycyrrhiza glabra (licorice root) 3.5 grams of licorice containing 7.6% glycyrrhizic acid-
decreases testosterone synthesis
Spearmint tea- lowers T levels and may raise FSH and LH, may improve hirsutism
White peony (paeonia laterflora)- increases prog, reduces elevated test, modulates
estrogen and prolactin
✔✔Therapeutic benefits of testosterone: - ✔✔osteopenia/porosis, weight loss,
depression, aging skin, anxiety disorder, memory maintenance
✔✔Where is testosterone produced? - ✔✔95% of t circulating in the blood is made in
the Leydig cells of the testes, which is 4-8 mg a day
The remaining 5% of the circulating t is made in the adrenal glands
✔✔labs for testosterone replacement evaluation - ✔✔BMP
Total t, free t vs. salivary testing
DHT
Estradiol
Estrone
DHEA
CBC
Cortisol
SHBG
Progesterone
PSA
Albumin
Traditional lab work: SMA
DRE every 6 months if patient is on testosterone replacement
✔✔PSA levels - ✔✔PSA <4.0 but rising by 1.5 ng/ml in one year or 0.75 ng/ml per year
over two years should have further evaluation
PSA >4.0 should have further evaluation
✔✔cause of t deficiency in males? - ✔✔Aging processes, stress, toxins that are
endocrine disruptors, nutritional deficiencies, low GnRH levels, high prolactin levels,
impaired development, DM, diet, infections, temperature, trauma, alcohol abuse, drugs
, ✔✔what causes low GnRH levels in males? - ✔✔one cause is opiates- heroin,
morphine, methadone
✔✔what causes high prolactin levels which can decrease testosterone in males? -
✔✔Increase with stress, prolactinomas, chronic renal failure, hypothyroid, drugs:
dopamine antagonist, phenothiazines and imipramine, drugs that interfere with
dopamine synthesis, alpha methyldopa, drugs that deplete dopamine stores, reserpine,
drugs that directly stimulate prolactin production, H2 blockers, estrogens
✔✔diets effect on testosterone - ✔✔low cholesterol diets may lower testosterone
Vegetarian diets, if low in protein, can increase SHBG which lowers free testosterone
High protein, low carb diets may increase testosterone
✔✔infections that lower testosterone - ✔✔mumps, EBV, herpes, coxsackie,
arbodengue, marburg virus, GC
✔✔temperature effects on testosterone production - ✔✔varicocele and hydrocele
impaire temperature regulation of the scrotum
Scrotal cooling may be improved by wearing boxer shorts, avoiding tight jeans and long
periods of driving
✔✔drugs that decrease testosterone production in males? - ✔✔psychotropic drugs,
antidepressants, aminoglutethamide, keoconzaaole, cimetidine, spironolactone,
cyproterone acetate, barbiturates, anticonvulsants, digoxin, HMG-CoA reductase
inhibitors, chemo, cannabinoids, heroin/methadone, amiodarone
✔✔testosterone dosing in males - ✔✔Compounded cream is preferred method
5-50 mg cream
May compound chrysin in the same syringe with testosterone. Chrysin is a natural
aromatase inhibitor to lower estrogen levels. Male skin has higher concentration of
aromatase enzyme on the surface. Chrysin has a natural yellow color, does not stain
skin. Dose of chrysin depends on the level of estrone or estradiol- usually 5-50 mg
cream. Cannot put chrysin in a gel base. May compound progesterone in the same
syringe as t and chrysin.
✔✔testosterone cream dosing for males - ✔✔Compounded cream is preferred method
5-50 mg cream
May compound chrysin in the same syringe with testosterone. Chrysin is a natural
aromatase inhibitor to lower estrogen levels. Male skin has higher concentration of
aromatase enzyme on the surface. Chrysin has a natural yellow color, does not stain
skin. Dose of chrysin depends on the level of estrone or estradiol- usually 5-50 mg
cream. Cannot put chrysin in a gel base. May compound progesterone in the same
syringe as t and chrysin.
SET A+
✔✔detoxification organs - ✔✔liver
GI tract
kidneys
skin
lungs
✔✔xenoestrogens - ✔✔environmental compounds that mimic the effects of natural
estrogen
✔✔Phase I Detoxification - ✔✔enzymes in the cytochrome P450 system use oxygen to
modify toxic compounds, medications and steroid hormones into intermediate
compounds
occurs in the liver
SNPs:
increased phase I clearance without increased phase II clearance? can lead to the
buildup of intermediates that may be more toxicant than the original substance
decreased phase I clearance? will cause toxic accumulation in the body. adverse
reactions to meds are often d/t a decreased capacity for clearing them from your system
✔✔Phase II Detoxification - ✔✔the intermediate compounds are neutralized through the
addition of a water soluble molecule which the transformed toxins are then able to be
eliminated through urine or feces
stage 1: glutathione conjugation- requires glutathione (strongest antioxidant made by
the body) and vitamin B6
stage II: amino acid conjugation- requires glycine, taurine, and glutamine
stage III: methylation. needed to detox estrogen and breakdown homocysteine. requires
folic acid, choline, methionine, trimethylglycine, and s-adenosylmethionine (SAMEe)
stage IV: sulfating. requires cysteine, methionine, and molybdenum
stage V: acetylation. requires acetyl CoA
stage VI: glucuronidation. requires glucuronic acid.
,✔✔increased risk of breast cancer? - ✔✔if estrogen metabolism favors the 16 OH
pathway
if you have a low P to E ratio
✔✔How Estrogen and Progesterone work together: - ✔✔E2 lowers body fat by
decreasing lipoprotein lipase in your fat cells. P increases body fat storage by
increasing the amount of lipoprotein lipase
E2 increases insulin sensitivity and improves glucose tolerance. P decreases insulin
sensitivity and can cause insulin resistance.
✔✔low P to E ratio - ✔✔can cause abnormal bleeding, increased risk of uterine cancer,
increased risk of breast cancer, and infertility
✔✔high P to E ratio too high in progesterone - ✔✔will break down protein and muscle
tissue, will make diseases like fibromyalgia worse
decreased sexual interest
fatigue
depression
insulin resistance/diabetes
✔✔where is testosterone made? - ✔✔an androgen made in the ovaries and adrenal
glands, only small amount is free (available to use) and the rest is bound to sex
hormone binding globulin
✔✔Causes of testosterone deficiency: - ✔✔adrenal stress, oral contraceptives
(increases SHBG), chemo, childbirth, statins, depression, endometriosis, aging,
psychological trauma, surgical menopause
✔✔testosterone dosing - ✔✔Dosage range: 0.25 mg cream to 4.0 mg cream q day
(most common dose: 0.25 mg-2 mg) transdermally
If menopausal, will need hormone holiday
✔✔How to increase T? - ✔✔Decrease caloric intace, exercise, sleep, increase protein,
weight loss, stress reduction, take arginine/leucine/glutamine, zinc supplementation
✔✔Synthetic testosterone (methyltestosterone) increases risk of? - ✔✔liver cancer
✔✔low in estrogen and cannot be replaced but needs testosterone replacement? -
✔✔do not replace testosterone alone- can increase plaque formation in coronary
vessels and increase risk of heart disease
✔✔Causes of elevated testosterone? - ✔✔PCOS, peri/meno, aggressive exercise, too
high T dose, given DHEA which may raise testosterone
,✔✔what type of DHEA replacement will not affect testosterone levels? - ✔✔keto-DHEA
should not raise testosterone levels
✔✔How to lower elevated testosterone levels? - ✔✔Saw palmetto: 240-260 mg BID
Metformin: 500 mg qd
Spironolactone 100 mg BID (least favorite)
Urtica dioica (nettle) 300 mg BID- the root binds to and increases SHBG which
decreases the amount of bioavailable testosterone
Camellia sinensis (green tea) 270 mg- increases SHBG
Glycyrrhiza glabra (licorice root) 3.5 grams of licorice containing 7.6% glycyrrhizic acid-
decreases testosterone synthesis
Spearmint tea- lowers T levels and may raise FSH and LH, may improve hirsutism
White peony (paeonia laterflora)- increases prog, reduces elevated test, modulates
estrogen and prolactin
✔✔Therapeutic benefits of testosterone: - ✔✔osteopenia/porosis, weight loss,
depression, aging skin, anxiety disorder, memory maintenance
✔✔Where is testosterone produced? - ✔✔95% of t circulating in the blood is made in
the Leydig cells of the testes, which is 4-8 mg a day
The remaining 5% of the circulating t is made in the adrenal glands
✔✔labs for testosterone replacement evaluation - ✔✔BMP
Total t, free t vs. salivary testing
DHT
Estradiol
Estrone
DHEA
CBC
Cortisol
SHBG
Progesterone
PSA
Albumin
Traditional lab work: SMA
DRE every 6 months if patient is on testosterone replacement
✔✔PSA levels - ✔✔PSA <4.0 but rising by 1.5 ng/ml in one year or 0.75 ng/ml per year
over two years should have further evaluation
PSA >4.0 should have further evaluation
✔✔cause of t deficiency in males? - ✔✔Aging processes, stress, toxins that are
endocrine disruptors, nutritional deficiencies, low GnRH levels, high prolactin levels,
impaired development, DM, diet, infections, temperature, trauma, alcohol abuse, drugs
, ✔✔what causes low GnRH levels in males? - ✔✔one cause is opiates- heroin,
morphine, methadone
✔✔what causes high prolactin levels which can decrease testosterone in males? -
✔✔Increase with stress, prolactinomas, chronic renal failure, hypothyroid, drugs:
dopamine antagonist, phenothiazines and imipramine, drugs that interfere with
dopamine synthesis, alpha methyldopa, drugs that deplete dopamine stores, reserpine,
drugs that directly stimulate prolactin production, H2 blockers, estrogens
✔✔diets effect on testosterone - ✔✔low cholesterol diets may lower testosterone
Vegetarian diets, if low in protein, can increase SHBG which lowers free testosterone
High protein, low carb diets may increase testosterone
✔✔infections that lower testosterone - ✔✔mumps, EBV, herpes, coxsackie,
arbodengue, marburg virus, GC
✔✔temperature effects on testosterone production - ✔✔varicocele and hydrocele
impaire temperature regulation of the scrotum
Scrotal cooling may be improved by wearing boxer shorts, avoiding tight jeans and long
periods of driving
✔✔drugs that decrease testosterone production in males? - ✔✔psychotropic drugs,
antidepressants, aminoglutethamide, keoconzaaole, cimetidine, spironolactone,
cyproterone acetate, barbiturates, anticonvulsants, digoxin, HMG-CoA reductase
inhibitors, chemo, cannabinoids, heroin/methadone, amiodarone
✔✔testosterone dosing in males - ✔✔Compounded cream is preferred method
5-50 mg cream
May compound chrysin in the same syringe with testosterone. Chrysin is a natural
aromatase inhibitor to lower estrogen levels. Male skin has higher concentration of
aromatase enzyme on the surface. Chrysin has a natural yellow color, does not stain
skin. Dose of chrysin depends on the level of estrone or estradiol- usually 5-50 mg
cream. Cannot put chrysin in a gel base. May compound progesterone in the same
syringe as t and chrysin.
✔✔testosterone cream dosing for males - ✔✔Compounded cream is preferred method
5-50 mg cream
May compound chrysin in the same syringe with testosterone. Chrysin is a natural
aromatase inhibitor to lower estrogen levels. Male skin has higher concentration of
aromatase enzyme on the surface. Chrysin has a natural yellow color, does not stain
skin. Dose of chrysin depends on the level of estrone or estradiol- usually 5-50 mg
cream. Cannot put chrysin in a gel base. May compound progesterone in the same
syringe as t and chrysin.
