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This protocol was developed for practitioners using Fullscript in the United States and the templates cannot be applied to accounts operating outside of the United States

Protocol development in integrative medicine is not typically a simple process. Individuals require individualized care, and what works for one patient may not work for another.

To establish these protocols, we first developed a Rating Scale that could be used to discern the rigor of evidence supporting a specific nutrient’s therapeutic effect.

The following protocols were developed using only A through F-quality evidence.

Class
Qualifying studies
Minimum requirements
A
Systematic review or meta-analysis of human trials
 
B
RDBPC human trials
2+ studies and/or 1 study with 50 + subjects
C
RDBPC human trials
1 study
D
Non-RDBPC human or In-vivo animal trials
 
F
Theoretical based on biochemistry/physiology/pharmacokinetics
 

Xenoestrogens are synthetic or natural foreign substances that mimic endogenous estrogens by imperfectly binding to the body’s estrogen receptors. (33) They are able to alter gene expression and cellular function through the initiation of various signaling cascades. (45) Chronic exposure to xenoestrogens obtained through the environment, the diet, and other sources such as product packaging, can impact human health. (33)

Xenoestrogens are widely referred to as endocrine-disrupting chemicals (EDCs). EDCs can interrupt natural production, action, and elimination of natural hormones. (33)  Xenoestrogens are associated with a wide variety of health concerns, including obesity, diabetes, asthma, cancer, altered hormonal and immune functions, and disrupted neurodevelopment. Exposure to xenoestrogens can have important implications during pregnancy and lactation, as EDCs may transfer from mother to fetus or to breastfeeding children. (33)(45)

The following list provides some of the contributing sources of xenoestrogens: 

  • Δ9-Tetrahydrocannabinol (THC)
  • By-products from food preservatives (e.g., butylated hydroxyanisole) and industrial surfactants (e.g., alkylphenols)
  • By-products from plastics (e.g., bisphenol A (BPA) in water and food packaging, thermal coating on paper receipts, inner linings in food cans, dental repair materials, etc.)
  • Consumption of fish, animals, and/or their by-products exposed to water contaminated by urban sewage or wastewater treatment plants
  • Dietary phytoestrogens (e.g., genistein, daidzein, resveratrol, S-equol) 
  • Mycoestrogens (e.g., mycotoxins produced from some fungal strains found in the food chain)
  • Pesticides (e.g., dieldrin, endosulfan), herbicides (e.g., chlordecone, methoxychlor), dioxins (e.g., 2,3,7,8-tetrachloro-p-dioxin – TCDD)
  • Pharmaceuticals (e.g., ethinyl estradiol, equine, mestranol, tamoxifen, trenbolone)
  • Personal care products (e.g., containing butylparaben, ethylparaben, methylparaben)
  • UV filters in sunscreens and cosmetic products (e.g., benzophenone-2, 4-methylbenzylidene camphor) (22)(24)(33)(45)

It is important to note that compared to other xenoestrogens, phytoestrogens do not bioaccumulate as they are reliably metabolized and excreted from the body. They may provide various health benefits including the promotion of antioxidant activity, cardiovascular health, and pro-apoptotic effects. However, they can also alter estrogen synthesis and metabolism through tissue-specific agonistic or antagonistic action. (22)

Please note that the following ingredients may either support estrogen production or increase its metabolism to counteract the disruptive effects of xenoestrogens caused by EDC’s interference with estrogen receptors. Practitioners may need to pre-emptively determine the direction of estrogenic imbalance prior to initiating a specific ingredient protocol.

DHEA

50 mg to adults and older adults, once per day, for 1-12 months (1)(4)(7)(10)(18)(23)(26)(42)(46)(48)

DHEA acts as a precursor for the production of androgens and estrogens with sex-dependent outcomes:

  • Reduced fat mass but no effect on bone markers in men (8)(17)(20)(46)(48)
  • Increased bone mineral density and IGF-1 and reduced C-terminal telopeptide of type-1 collagen levels in women (20)(46)(48) 
  • Improved strength and physical function in frail older women (18)
  • Improved sexual function in menopausal or postmenopausal women similarly to hormone replacement therapy (13)(40) 

Healthy perimenopausal and postmenopausal women:

  • Increased estradiol and estrone (7)(18)(26)(42)(46)(48)
  • Increased serum DHEA, DHEAS, testosterone, and androstenedione, regardless of use of concomitant conjugated equine estrogens (4)(7)(10)(18)(26)(42)(46)(48)
  • Reduced serum cortisol and sex hormone-binding globulin (4)(18)

Healthy middle-aged and older adult men:

  • Increased estradiol (17)(48)
  • Increased DHEA, DHEAS, testosterone, and 3β-androstanediol (1)(17)(48)

200-400 mg, once per day, for 1-3 months (5)(6)(35)(49)

  • Increased 2OHE1/16α-OHE1 or 2OHE1/E3 ratios (indicator of estradiol metabolism) in pre- and postmenopausal healthy non-obese and healthy obese women, women at higher risk for estrogen-dependent breast cancer, cervical intraepithelial neoplasia (CIN), vulvar intraepithelial neoplasia (VIN), or systemic lupus erythematosus, and patients with recurrent respiratory papillomatosis (5)(6)(25)(27)(29)(35)(37)(43)(49)
  • Conjunctionally induced CYP1A2 and glutathione S-transferase activities, which may contribute to estradiol metabolism (35)
  • Increased 2OHE1/16α-OHE1 ratio in patients with wild-type CYP1A1 but not CYP1A1 Msp1 polymorphism, which may increase susceptibility to estrogen-related breast cancer (43)
  • Increased 2OHE1/16α-OHE1 ratios positively correlate with clinical responses in remission of papillomatous growth and reduced requirements for future surgeries (36)(37)
  • Increased regression of CIN and reduced itch, pain, lesion size, and severity of VIN (5)(29)
Indole-3-carbinol in the Fullscript catalog

Diindolylmethane (DIM)

100-200 mg, once or twice per day, for 3-6 weeks and up to one year (9)(12)(19)(44)

  • Increased the 2OHE1/16α-OHE1 ratio, indicating increased estrogen metabolism in pre- and postmenopausal women with early-stage breast cancer, in patients with prostate cancer, or in patients with thyroid proliferative disease  (9)(12)(34)(44)
  • Increased sex hormone-binding globulin and cortisol in women (9)(44)
  • Reduced the active metabolites of the xenoestrogen pharmaceutical tamoxifen during adjunct use, possibly reducing effectiveness (44)
  • DIM detected in prostate tissue with reduced nucleic androgen receptor expression and prostate-specific antigen (PSA) (15)
  • Increased BRCA1 to normalize protein expression in women with an increased breast cancer risk (19)
  • Reduced pelvic pain and improved bleeding pattern in women with endometriosis when used as an adjunct to the progestin medication dienogest, and reduced estradiol in endometriotic tissues (28)
  • Increased estrogen hydroxylation and DIM detection in thyroid tissue may have implications in modulation of thyroid proliferative disease and its risk of development (34)
Diindolylmethane in the Fullscript catalog

Black Cohosh (Cimicifuga/Actaea racemosa)

20 mg, twice per day, as Remifemin ®, or 40 mg, once per day, as CR BNO 1055 extract, for 3-6 months in postmenopausal women (2)(3)(14)(16)(21)(30)(31)(32)(38)(39)(47)(50)(51)

  • Safely and effectively treated menopausal vasomotor symptoms (e.g., hot flushes) by 26% for up to six months by the first month of treatment (2)(3)(11)(14)(16)(21)(30)(31)(32)(38)(39)(41)(47)(51)
  • Increased sleep efficiency and physical domains in QoL scores, and decreased wake after sleep onset duration (16)
  • Improved anxiety and depression scores (30)
  • CR BNO 1055 possessed weak estrogen-like activity, reduced bone degradation, and increased bone formation (50)(51) 
  • Reduced the number and severity of hot flashes caused by tamoxifen (xenoestrogen pharmaceutical) and Kupperman Menopausal Index (KMI) scores in menopausal syndrome induced by LHRH-a treatment (14)(47)
  • Provided similar efficacy to 0.6 mg conjugated estrogens, low dose transdermal estradiol, and 2.5 mg tibolone, with a greater safety profile than tibolone (2)(3)(30)(51)
  • Provided greater efficacy than 20 mg fluoxetine  (31)
Black Cohosh in the Fullscript catalog

Disclaimer

The Fullscript Integrative Medical Advisory team has developed or collected these protocols from practitioners and supplier partners to help health care practitioners make decisions when building treatment plans. By adding this protocol to your Fullscript template library, you understand and accept that the recommendations in the protocol are for initial guidance and may not be appropriate for every patient.

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References
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  51. Wuttke, W., Seidlová-Wuttke, D., & Gorkow, C. (2003). The Cimicifuga preparation BNO 1055 vs. conjugated estrogens in a double-blind placebo-controlled study: Effects on menopause symptoms and bone markers. Maturitas, 44 Suppl 1, S67–S77. https://www.ncbi.nlm.nih.gov/pubmed/12609561 (B)

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