Women's Hormones

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November 12, 2000 | 152,299 views

By I. Michael Borkin N.M.D.

Originally Published in AlternativeMedicine, Issue 37

Female hormonal health is not just relatedto menstruation and menopause - it is a matter of lifelong well-beingand longevity

While a great number of women in our culture develop some kindof sexual reproductive organ dysfunction, most are misled abouttrue sexual and reproductive health and what options exist to achieveit. People tend to think of women's "hormone problems"as starting in midlife with the onset of menopause. In fact, a dysfunctionalpattern can begin during adolescent years or even before birth.The severity of hormonal problems may increase with age, but itis not aging per se that is the root of declining health. It ismost often the cumulative physiological effects of stress that causedisruption of the natural rhythms and balancing mechanisms of women'shormones (see Quick Definition), thereby eventually compromisingoverall health as well as sexual and reproductive health.

Quick Definition - Sexand stress hormones are chemical messengers formed inendocrine organs and certain body tissues and then carried in theblood to other areas of the body. Depending on how specific theireffects, hormones can alter either the functional activity or thestructure of one or more organs. Synthetic hormones are differentfrom naturally occurring hormones; they are structurally altered(so as to be patentable).

Allopathic (conventional) medical thinking fails to look foror treat the root causes of women's hormonal imbalances. Forexample, more young women today are experiencing infertility becausethey are not ovulating, yet they are being given fertility drugslike Clomid without comprehensive hormonal evaluations. Though thesewomen often succeed in conceiving, they generally end up payinga price for short-sighted symptom management. The future healthconsequence is that other symptoms will appear and hormonal imbalancewill progress.

Similarly, women are led to believe that it is normal to experiencedistressing menopausal symptoms. They anticipate having to acceptthe conventional treatment choice of hormone replacement therapy(HRT) with synthetic hormones. Women are encouraged to do this inspite of the fact that estrogen supplementation places them atrisk for breast cancer and other serious health problems. HRTand fertility drugs -- as well as birth control pills and otherhormonal therapies -- were all designed to treat only specific symptomswith no regard for the effects they have on the entire body. Becauseof this non-holistic approach, we are seeing an increase in theincidence of not only breast cancer and sexual reproductive organdysfunctions but also uterine and ovarian cancer.

Another problem with conventional HRT is that it generally employsthe wrong forms of estrogen and progesterone. Synthetic estrogensor the estrogens that are excreted in pregnant mare urine are oftenused. And of the three estrogen hormones (estradiol, estriol andestrone) found in women's bodies, most conventional pharmaceuticalproducts use only estradiol. Many HRT formulas also contain syntheticprogestin (as opposed to natural progesterone), which is includedto help balance the effects of synthetic estrogen. Yet an artificialhormone cannot function in concert with another artificial hormoneto create balance in the body. Worse, these HRT formulas ignorethe increasingly common wisdom that it is progesterone deficiency-- not estrogen deficiency -- that leads to early or difficult menopauseand many other health problems affecting women.

A lot of women are discovering that conventional HRT does not givethem the overall health and well-being they had hoped for, and theyare seeking out healthier alternatives. What everyone will hopefullysoon realize is that menopausal and sexual reproductive problemsare actually symptoms of overall hormonal imbalances. Women needto get a complete picture of their hormonal status and find appropriatetherapeutic steps to maintaining balance.

Meanwhile, millions of women continue to experience dysfunctionssuch as PMS, depression, decreased libido, fibrocystic breasts,food and sugar cravings, uterine fibroids, irregular or excessiveuterine bleeding and endometriosis (see Quick Definition below).Those whose dysfunctions are extremely painful or debilitating aretold that their "health is more important than their reproductiveorgans" and that "a hysterectomy would be the best thing."Unbelievably, an estimated trillion-plus dollars was spent duringthe twentieth century to remove women's reproductive organs. Hysterectomynow out-numbers almost all types of surgery performed in the U.S.

Reproductive organs play an important role in more than reproduction.Many studies show that each aspect of the female sexual anatomyserves an integral part in the health and well-being of the entirebody. Each function is part of the whole, part of a system, or symphony,of interrelated parts and timing.

The Endocrine Interplay

What needs to be understood is that, for example, if a woman'sthyroid or adrenal glands are depleted or functioning inadequately-- a fairly common occurrence in our stressful culture -- she willlikely experience problems with her sexual reproductive organs.The connection between these organs and the thyroid, the adrenalsand other endocrine glands is that they are all governed by endocrinehormones. This is an important interrelationship, which is why whatdisrupts one gland can disrupt another, causing a kind of dominoeffect or vicious cycle. The immune system and the thymus are involved,too, because immune response is inhibited by abnormal hormone levels.

The endocrine system (see below) is responsible for homeostasis,the body's ability to maintain stable internal conditions, includingbody temperature, regardless of changing external conditions.Balance is crucial to all life processes. Thebody functions within very specific margins, and being forced tofunction outside of those margins can cause a whole series of negativeevents, even death. The endocrine system also controls the processesof reproduction, metabolism, growth and development.

The Endocrine System and the Female Cycle

The endocrine system regulates the body's major continuous andprolonged processes, including reproduction; growth and development;cellular metabolism and energy; blood balance of nutrients, electrolytesand water; and the mobilization of body defenses against stressors(things that cause wear and tear on the body's physical and mentalresources). It is made up of eight different glands located strategicallythroughout the body:

Besides these major organs, the system includes pockets of hormone-producingcells in tissues in the small intestine, heart, kidneys and stomach.The endocrine system develops and begins producing hormones by theend of the second trimester of fetal development.

In the order of endocrine command, the hypothalamus is the body'sCEO, orchestrating the events of the rest of the endocrine system.The hypothalamus controls autonomic reflexes (such as the activityof the heart and smooth muscles), and it houses the body's "thermostat"and biological clock, which maintains the body's rhythm of 24-hoursleep-wake cycles. The somewhat mysterious pineal gland also hasa role in biological timekeeping, being an organ sensitive to retinalresponse to light. The pineal gland, believed to coordinate fertilityhormones, produces melatonin, the hormone known for its sleep-triggeringability.

The hypothalamus also initiates part of the adrenal stress response,causingthe pituitary to secrete the hormone that travels to the adrenalglands to stimulate secretion of cortisol, DHEA and aldosterone.The hypothalamus also initiates the female cycle by producing gonadotropin-releasinghormone (GnRH), which signals the pituitary to secrete follicle-stimulatinghormone (FSH). FSH stimulates the ovaries to secrete estrogen, thesex hormone thatstimulates development of breast, uterine and ovariantissue (and in synthetic HRT forms is associated with excessivecell growth that leads to cancer).

When estrogen reaches a certain level, it signals the hypothalamusto trigger the pituitary to secrete luteinizing hormone (LH). Estrogenlevels then fall, while the level of LH rises and peaks (aroundday 14 of a 28-day cycle), stimulating ovulation, the release ofan egg from its ovarian follicle. After ovulation, the follicle(now called the corpus luteum) is filled with cholesterol, whichis converted first to pregnenolone and then to progesterone. Thisnewly-made progesterone is used in part for the building up of theuterine lining. If after about 13 to 15 days the egg is not fertilized,the uterine lining is sloughed off (in menstruation) when both estrogenand progesterone levels drop.

Both estrogen and progesterone are necessary inthe female cycle, and their balance is key for full health. Manywomen in our culture have an imbalance of these hormones, especially,insufficient levels of progesterone to counter excessiveestrogen -- an imbalance further exacerbated by chronic stress.Progesterone is a hormone important to a number of body functions.During times of stress or conditions of chronic adrenal hyper-stimulation,progesterone is capable of being converted into the stresshormone cortisol.

When one goes through chronic or severe long-term stress, the hypothalamusat first triggers an overproduction of the adrenal hormones (especiallycortisol and DHEA). This eventually leads to adrenalinsufficiency, a state in which the exhausted adrenalscannot respond adequately.

The thyroid gland is also adversely affected by chronic stress.This gland's roles include regulating calcium metabolism andglycolysis, the breakdown of glucose for body energy fuel. Undernormal conditions, the fight-or-flight response causes the thyroidto increase glucose breakdown. In conditions of chronic stress,however, the thyroid is continually overstimulated and eventuallybecomes depleted. Thyroid function is also disrupted by excessiveestrogen, but this can be prevented by adequate progesterone levels.

Hyperthyroidism (overactive thyroid functioning) and especiallyhypothyroidism (low functioning) have become more common. The classicsymptoms of hypothyroidism include sluggishness, early morning fatigue,cold extremities, lowered basal temperature and menstrual problems,including scanty periods.

Adrenal and other hormonal gland dysfunctions can cause some ofthe above symptoms and more, including cravings for sweets, weightgain, allergies, heart palpitations, insomnia, depression, fatigue,poor memory, foggy thinking, headaches, nervousness, inability toconcentrate, recurrent infections and glucose intolerance.

One very damaging adrenal dysfunction is excessive cortisolproduction, which causes, among other serious problems, increasedcalcium mobilization from the bones, leading to osteoporosis, orloss of bone density. In a person with a healthy stress response,excessive levels of cortisol are automatically buffered. Constantstress destroys this feedback loop.

Hormonal imbalances compromise not only physical health butalso psychological health, manifesting as problems ranging fromdepression to panic disorder. One way the body tries to compensatefor imbalances created and exacerbated by the demands of stressis to overproduce key hormones. Another way it tries to compensateis by converting sex hormones to stress hormones, thus further diminishingreproductive functions and the enjoyment of sexual health.

It is helpful to learn about these hormonal interdependencies becausethey allow one to see the bigger picture, that the problems commonlyassociated with menses or menopause are actually indicators of greaterendocrine imbalance. For many women, the next step in understandingthe bigger picture might be to look at digestive health -- suchas the possibility of malabsorption syndrome or food allergies --and at nutritional supplementation strategies (see Supplementationbelow) that help restore or maintain hormonal balance.

One of the biggest reasons why hormonal imbalances are misunderstoodis because "modern" medicine disregards the way the humanbody deals with its environment. Consider that the body's responsesbasically have not changed for 50,000 years. We still respondto our environment with the most primal of mechanisms: the "fight-or-flight"mechanism, the release of adrenaline and other stress hormones.The stress response, initiated in the hypothalamus and pituitary,and regulated by the adrenal glands, is responsible for redirectingenergy and resources away from the reproductive organs when we areunder severe or chronic stress, directing it instead to the musclesand organs that are necessary for survival. This redirection isallowed to take place because, on the body's list of priorities,survival comes first and reproduction comes last.

The reproductive system is the only body system whose functionsare biologically expendable. With this in mind, we see how the abilityto reproduce becomes a privilege in the body, not a right. Fertility,or the ability to ovulate, is therefore a good indicator of theoverall health of a woman.

The fight-or-flight response can be a detriment as well as a lifesavingresponse. In a modern environment, many things -- ranging from allergicreactions to being cut off while driving -- can evoke this mechanism.Throughout daily life, there are many hidden as well as overt sourcesof stress. Most of the time, our response to stress ends withouta literal "fight" or some form of physical activity, asour ancestors would have engaged in. One of the problems with thisis that adrenaline, unlike most hormones, has no enzyme "switch"to turn it off. Once released it must be used or it remainsactive. As a result, we remain in a state of hyper-stimulation,with abnormal levels of adrenaline and cortisol, the primary fight-or-flighthormones. Other hormone levels, such as the pancreatic hormone glucagon,also become dysregulated. If hyper-stimulation persists, we havediffi- culty inducing a relaxation response, and we do not returnto a normal state.

Over a period of time, if chronic stress continues, the body adaptsto adrenal hyper-stimulation, continuing in a perpetual fight-or-flightmode. This is called maladaptation, a process in which endocrinesystem organs begin to break down. This process eventually reachesthe point where the adrenals become exhausted and cortisol levelsdrop. One example of what can result from adrenal exhaustionis fibromyalgia, a conditionthat can arise when the protective benefits of normal cortisol levelsare lost.

The adrenals are usually first in the order of endocrine functionbreakdown, followed by the insulin-producing portion of the pancreas,thyroid, ovaries, parathyroid, pineal, pituitary and finally, thelink to the autonomic nervous system, the hypothalamus. Thethymus gland, which produces immune defense cells, is also affectedin the endocrine breakdown process. Each of these glands controlsspecific functions, and as each breaks down new symptoms appear.Symptoms are subtle at first. Then over the years, as the body goesfurther into deficit, the symptoms will increase and worsen.

The more stress endured, the worse the hormonal problems become.When the endocrine system is severely dysregulated, the hypothalamusis affected. If the production of corticotrophin-releasing hormone(CRH) becomes severely affected, the psychological symptoms canbecome debilitating. Because CRH controls fear through stimulatingadrenal secretion, an abnormal level of CRH can make it difficultto perform routine chores or leave the house. The fear responsein turn worsens hormonal problems by further stressing the adrenals,which respond by converting more sex hormones to stress hormonesand becoming more maladapted -- a vicious cycle.

The Creation of Maladaptation

A woman's hormonal problems can begin even before birth,during her fetal development. If her mother is under chronic stressand adrenally hyper-stimulated, the mother's body will draw on thedeveloping fetus's "survival chemistry" to supplementher own body's hormonal needs. During the second trimester, theplacenta produces on average about 450 milligrams of progesteronea day, and some of this progesterone will be routed to the stressedmother and converted for stress purposes. In the third trimester,the developing baby's adrenal glands begin to produce stress hormones,and these can also be taken and used by the mother.

Quick Definition - Endometriosisis the buildup of endometrial (uterine lining) tissue outside theuterus, most often in or on the fallopian tubes, ovaries and pelvicarea. It is thought to be caused by or exacerbated by estrogen dominance(too much estrogen in relation to progesterone), and it can in turncause organ dysfunction or intestinal blockage. Symptoms includepainful menstruation and frequent and severe bleeding.

Women are rarely cautioned about this kind of fetal stress beforeor during their pregnancies. Nor are they told how the developingbaby's adrenal glands will enlarge to meet the mother's demand foradditional stress hormones. A baby born in this state of secondaryhyper-stimulation produces too much stress hormone. While the baby'sadrenal glands can eventually decrease their output, the glandswill tend to reinflate more easily -- like a balloon -- every timeextreme demands are made upon them.If severe or chronic stress persists,however, hyper-stimulation continues. As the baby grows and maturesinto an adult, this maladaptive cycle will be perpetuated, causingher sex hormones to be routed from her reproductive system and usedfor her own stress purposes.

Breaking the Stress Cycle

Once a maladaptive stress cycle has been established, it will continueuntil appropriate intervention takes place to restore hormonal balance.This can be done at any age, and functional hormonal testing isthe first step. The best type of stress and sex hormone testingis known as a circadian test, which is performed over a 24-hourperiod.

Sampling is easily accomplished at home, and the test results willdetermine the exact levels of accumulated stress and sex hormones.Using a collection kit, a woman can obtain a saliva sample everyfour hours for 24 hours by chewing on a salivette (a small dacronroll). The results will show specific hormonal changes that occurevery four hours, demonstrating a 24-hour graphic representationof the body's stress reactions.

Salivary testing is the best test method because salivacontains free fractions of stress and sex hormones. Free fractionsare the utilizable hormones, those that the body actually has accessto. Many studies have been conducted showing the validity of assayingthese steroid hormones in saliva. The usual hormone tests, conductedwith blood samples, measure total hormone production, a value thatincludes bound (not free) hormones that are unavailable for thebody's use. It is important to measure free fractions to getan accurate picture of how sex and stress hormone levels are varyingby body function and activity.

Also, conventional hormone panels usually test only the blood plasmalevels of the sex hormones and only at the moment of sampling (whenthe blood was drawn). The Female Circadian Panel from Sabre Sciencesevaluates fluctuations of the salivary hormone levels of estrogen(estradiol), progesterone, testosterone, cortisol, DHEA and melatoninover a 24-hour period. Important clues about endocrine health arerevealed by circadian fluctuations. For example, we know that becausehuman skin regenerates mostly at night, high nighttime cortisolvalues mean that less skin regeneration is taking place.

Steps to Restore Hormonal Health

Establishing a Baseline

Comprehensive hormonal testing should be performed to establisha baseline before a woman chooses any kind of hormonal treatment,and then should be repeated periodically thereafter. Baselinetest results are also needed to order custom-made transdermal hormonalcreams from Sabre Sciences and various compounding pharmacies aroundthe country. Women should also consider additional testing, suchas a comprehensive, 5-hour glucose tolerance test and a lipid panel(cholesterol, triglycerides and HDL). An abnormal (especially high)level of cholesterol, the basic building block of sex and stresshormones, indicates that the body is attempting to provide morestress hormones. In some cases, testing for gastrointestinal problems,allergies or even parasites is advised.

Note, however, that "normal" (negative) results fromconventional laboratory diagnostic tests do not always mean normalfunction. Some tests do not reveal serious existing conditions,others are not able to detect borderline conditions. One exampleis thyroid testing, which cannot indicate how well thyroid hormone(T3) is able to bind to target cells, a thyroid condition that canbe caused by high levels of estrogen. Woman suspecting hormonalimbalances or experiencing distressing symptoms should discuss testingwith a healthcare practitioner.

Effective Treatment

By evaluating hormonal changes over a 24-hour period, a patterncan be determined and a treatment protocol designed. An effectiveplan involving natural hormones, nutritional support and variousstress-relief therapies can be successfully implemented to reestablishthe proper menstrual dynamics, hormonal balance and well-being.

It should be mentioned that in many scientific circles, the 28-daymenstrual cycle is believed to be a result of the impact of themodern world. Up until the last hundred years, the menstrual cycleis said to have reacted to seasonal changes. Fertility was at itspeak during the fall months, thus helping guarantee the survivalof the newborn during the much more hospitable spring and summerenvironment. The menstrual/fertility cycle could last as long as90 days, and was absent during times of serious stress.

When evaluating the "modern" 28-day cycle and hormonalbalance it is important to understand that approximately the first14 days of the cycle are estrogen dominant and the second 14 daysare progesterone dominant. This is an over-simplification but ithelps to establish an understanding of the healthy dynamics of themenstrual cycle.

The first treatment consideration is that the maladaptive stressresponse must be interrupted so that sex hormones will no longerbe converted for stress purposes. Women must know that, until theseconversion pathways are closed, supplementation with the sex hormonesestrogen and progesterone is of little value because they will easilybe converted. First, therefore, proper levels of the adrenal hormonescortisol and dehydroepiandrosterone (DHEA) need to be reestablished.DHEA is a much talked about hormone these days because of its importancein maintaining youthfulness; a healthy DHEA level is consideredan indicator of longevity.

Hormonal restoral with transdermal creams is accomplished usinga dual-phase approach, which uses estrogen-dominant supplementationduring the first 14 days and progesterone supplementation duringthe second 14 days.

Transdermal Delivery System

In addition to individual needs, an important factor regardingthe correct levels of any kind of supplement is how quickly it ismetabolized and eliminated from the body. This is called metabolicclearance. A supplement, especially a hormone, should not accumulateor remain in the body too long, or it will interfere with the changesthat must occur -- in this case, the necessary shift from estrogento progesterone -- for supplementation to be effective.

A transdermal hormonal cream supplement works best. It is easilyapplied and delivered, bypassing the obstacle of breakdown in thedigestive system or liver. Most of the available hormonal creamsclaim to be transdermal, but are actually topical. A big problemwith topical creams is that most of them use an inexpensive oilcosmetic base. They are absorbed into fat cells, and months afterdiscontinuance they can still be found in body tissues. Also, atopical relies on the small size of the hormone molecule (progesteronebeing very small, estrogen very large) to transverse the layersof the skin and make its way into the bloodstream. A true transdermaldoes not rely on the size of the molecule; instead it has a vehicleto carry it to the target. This is called a liposomal delivery system,which employs a molecular coating to control absorption.

A "stealth" liposome has 100 bilayer lipid shells, identicalto cell membrane lipids, allowing it to pass through the skintissue. The shells slowly dissolve, releasing hormones and cofactorsgradually into the bloodstream.

The Sabre Sciences transdermal cream delivery system is also pulsatile,meaning that only a small, measurable quantity of hormone is releasedat one time. This not only allows for easy calculation of the amountthat will be in the blood but also comes closest to matching thebody's own cyclic hormone rhythm.

Recreating Healthy Dynamics

The key factor in positively influencing estrogen and progesteronelevels is to recreate or enhance the healthy dynamics of the menstrualcycle by maintaining estrogen dominance during the first 14 daysof the cycle and allowing a shift at mid-cycle to progesterone dominance.A one-phase treatment involves supplementation throughout the entirecycle using only estrogen or progesterone factors. If you use thisapproach, not only will you not restore hormonal balance but alsoyou will cause further imbalance, negatively affecting sexual andreproductive health as well as the health of the whole body.

To support the adrenal system, dual-phase transdermal creams fromSabre Sciences contain DHEA and pregnenolone, important precursorsof sex and stress hormones. The creams also contain cofactors andnutrients (such as Alpha Lipoic Acid) as well as botanicals andhomeopathics, all of which help estrogen and progesterone work properly.Custom transdermal creams are formulated using an individual's hormonaltest results. Off-the-shelf dual-phase creams called BioEst™Phyto-Estrogen Formula and Bio-Femme™ Progesterone Formulaare also available. These creams are designed to enhance the healthydynamics of estrogen and progesterone activity in both pre- andpost-menopausal women. For example, women suffering from hot flashesor postmenopausal vaginal dryness are aided by the phyto-estrogencream.

Supplementation

The following list includes general recommendations for womenwho are "stressed out" or hormonally imbalanced and wouldlike to restore overall hormonal health. For best results, consulta qualified healthcare practitioner for guidance in establishnga supplement plan before assuming the important responsibility ofself-care.

While the use of these creams or any other hormonal therapy shouldbe initiated under the guidance of a healthcare practitioner, thecreams provide an individual the ability to adjust the dosage tothe exact amount needed during each phase. Supplementing with bothphyto-estrogen (from natural plant sources) and progesterone willre-balance the natural monthly cycle. Pre-menopausal women shoulduse the phyto-estrogen cream from day one through 15 of their monthlycycle (day one is first day of menses); the progesterone cream shouldbe used from day 16 through 28. Postmenopausal women can createa cycle by choosing a day to begin using the creams. After fourcycles, women should get fully retested to see whether the dosagesof the creams and other supplements need further adjustment.

Women have seen amazing results after employing these creams, especiallyin combination with other treatments, including nutritional supplements(see above) and therapies for normalizing adrenal stress. Some womenwithout a period for years, clinically diagnosed as being post-menopausal,have begun to menstruate again after using this system of hormonalsupplementation. Most women find that the healthy, youthful aspectsof their skin, hair and nails are reestablished, and they reportgreatly enhanced moods and feelings of well-being.

Again, it is important to look at all aspects of the reproductivesystem and its interplay with the endocrine system, especially adrenalhealth. It is equally important that women become observantand vigilant about what is happening in their own bodies. This iswhat it takes to maintain optimum sexual and overall health andmaximize longevity.

Contact: I. Michael Borkin, N.M.D., in professional practicefor 17 years, is dedicated full-time to endocrine research and isCEO/Director of The Foundation for The Advancement of EndocrineResearch. He is also Director of Research and Development for SabreSciences. A pioneer in transdermal delivery systems, his ideas havegiven birth to naturopathic therapies, including Neuro EmotionalSensory Training (NEST) and Quantum Magnetic Manipulation (Q2m).He is past president of the California State Naturopathic MedicalAssociation, and is an independent medical/nutritional consultant.Tel: 323-450-7101.

Sources

SabreSciences, Inc., EndoScreen Labs: hormonal test kitsfor women and men. (Doctors can order test panels; patients canorder user-friendly testing systems.) 910 Hampshire Road, SuiteP, Westlake Village, CA 91361. Tel: 888-490-7300. Web address: www.sabresciences.com.

Sabre Sciences, Inc., Transdermal Division:transdermal creams. 910 Hampshire Road, Suite P, Westlake Village,CA 91361. Tel: 888-490-7300.

The Foundation for The Advancement ofEndocrine Research: 1218 S. Eastern Ave. Las Vegas, Nevada89104. Tel: 323-450-7101. Hormonal research information (physiciansonly please).

Reprinted with permission from AlternativeMedicine magazine, September 2000/#37. For subscription informationcall 800-333-HEAL (4325). Website: www.alternativemedicine.com.

 

I had the opportunity to have Dr. Borkin come to my office andshow me his work. He has developed quite an interesting and comprehensivemethod of diagnosing hormone imbalances.

He uses a technique called Q2M (quantum magnetic manipulation)in conjunction with his version of a transdermal hormone cream whichappears to have resolved many of the concerns of the oldercreams.

Overall though, this is an excellent summary of a natural perspectiveon how the hormone axis becomes imbalanced.

Related Articles:

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Understanding Adrenal Function

AdrenalsAffect Survival of Breast Cancer Patients

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Parents, Peers, andAdrenal Stress

PolycysticOvary Syndrome (PCOS)

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