Dr. A. Eloise Cortal | Regenerative Injection Therapies | Prolotherapy & Platelet-Rich Plasma Injections
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Office Updates

10/30/2023

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As we're saying goodbye to October and hello to November, I would like to share a couple of current office updates and future plans.
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​an update on phone numbers

For some reason, about a month ago my schedule got very chaotic with patients being scheduled at the wrong clinic (ex: they wanted to see me in Salem, but ended up on my Portland schedule).

Now I've known this could happen, since I work at two separate locations under one practice name, but it's never been too much of an issue before.

I believe now staff are confirming location a little bit more during phone calls ("for the Salem office, you're wanting to see her at the Salem office, right?"), so it looks like everything has smoothed out.

But just in case you don't have both phone numbers, here they are:
Portland: 503-232-3215
Salem: 503-990-8395

We were considering "closing down" the schedules at the respective clinics (Portland staff would only be able to schedule me for my Portland schedule), but it seems like the chaos has calmed down. In any case, please at least save into your phone the number for the office you physically see me at, and call that one when you're scheduling follow-ups.

updates around the office

Some days I will have a colleague or medical intern shadowing me. For the most part they are all looking to further develop their injection therapy skills, or exposing themselves to this field in order to learn more about it (and decide whether to pursue it post-graduation).

I strive to respect everyone's needs and boundaries, so during the days I have someone in the office with me, I do a quick check with each patient as soon as they get here (for injection procedure and/or re-evaluation follow-ups post-injections). I check in to see whether they are comfortable having someone observe the entire visit, just the injection procedure component, or not at all.

That way there are no surprise visitors during visits, and my colleagues/ students get observation experience with those who feel comfortable with them being present.

​a few more office updates

Alpha Stim
I have been doing a lot of research into different in-office electrotherapy devices, such as cranial electrotherapy stimulation (CES), transcranial magnetic stimulation (TMS), and vagus nerve stimulation devices.

After a lot of careful consideration, I have decided to offer Alpha Stim at both of my clinics.This is a CES device that is FDA-cleared for anxiety, insomnia and pain.

I will start offering these 30-minute sessions during office visits (you can schedule a typical in-office follow up for this).

When treating anxiety, depression, or insomnia, those sessions can be billed to insurance (limit: 4 sessions). That way I can offer a more approachable trial run for this device to my patients, and those who benefit can decide whether to obtain one from my office or the Alpha Stim company for at-home use.

Ketamine
I have been following the research and medical use of ketamine for the last few years with a lot of interest.

As this field develops, we are seeing more evidence-based uses of ketamine for pain, insomnia, anxiety, and depression.

I am often brainstorming with patients more and different options after chronic pain management or conventional mental health treatment of therapy and pharmaceuticals have been exhausted.

There is of course no one magic bullet for any of these complex chronic concerns, but I am interested in learning more about it, as it could be one more additional treatment option I can offer my patients.

I will only be offering oral options, which should be used in conjunction with ongoing mental health counseling. I will not be offering it IV.

Here are a few articles on some of the medical uses of ketamine, if you are interested in learning more:
https://www.medrxiv.org/content/10.1101/2020.07.13.20153247v2.full
https://www.nature.com/articles/s41398-021-01230-z
https://www.psychiatrist.com/jcp/oral-ketamine-for-depression/

In order to prescribe ketamine I have to take additional continuing education and certification. So, I don't have that yet, but I expect towards the end of the year, or the beginning of 2024, this will be one more treatment I can offer patients.

​a note on billing codes, and when more than one code is used for one visit

​If your visits with me are not billed to your insurance plan, you can just go ahead and skip this fairly dry subject.

For the rest of you, I wanted to take a moment to describe how and when I use what codes. I hope that no one's eyes glaze over in boredom, but I feel that I'm the best to discuss this subject because when insurance billing questions come up, it is usually our office manager Iris who handles this. And Iris is great, we all love Iris, however she is not present during the visits, so she just has to guess why and how I'm using the various codes that I do.

A common category is called an extended time code.

The best way I can describe this, is think back to the last visit you had with a "standard" medical provider for your concern (pain, hormones, diabetes, thyroid, GI, you name it).

How long was that visit?
How many other conditions did you discuss and make a plan for that day?

If your provider was following typical norms, the average appointment time is 5-7 minutes, and is focused just on that one concern.

If you bring up another concern, the provider often will tell you that you have to book a separate visit to address that second concern.

Now compare that to a typical office visit with me, which lasts 30-60 minutes. I am often working up many concerns at once (your chronic joint pain, your allergies, your hormone deficiency, reviewing your blood sugar labs, and what is this weird new thing on my skin???).

With how codes are set up, I'm not going to bill four office visit codes just because I cover four of your concerns (and that's a very low estimate for what's typical in my visits).

Instead, I will bill an office visit code with an extended time code.

The first code tells your insurance company we had a medical visit. The second code tells them we went into a lot of depth above and beyond typical office visits.

Other types of codes I use, in addition to office visit codes, are:

  • Injection therapy codes (prolotherapy, trigger point injections, PRP). That's pretty self-explanatory.
 
  • Other in-office procedures, such as blood draws, hormone pellet insertion and biopsies.
 
  • Alpha Stim sessions, as mentioned above.
 
  • Physical rehab and treatment codes: these cover hands-on care (such as myofascial release, exercise rehabilitation, joint manipulation) and other services, such as fitting braces and orthotics. I don't bill them too often, as usually with these patients there is a massage therapist, chiropractor, physical therapist, etc., also helping them out, but occasionally it does come up.
​

​ok, that's enough updates for now

I hope you have a lovely fall, and can enjoy our entry to the cozy, warm, hibernation season. I've been enjoying breaking out my herbal tea blends again, and snuggling up under blankets with a good book.

I wish you the very best in feasting, friends, family, loved ones, or any other seasonal quality time you enjoy,
Dr. Angela Cortal

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Hormone Pellet Therapy

8/30/2023

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For today's topic, I'd like to touch a little more on hormones because I will be introducing a new hormone treatment option.
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hormone pellet therapy

I will tell you the honest back story. I had been resisting getting into the topic of hormone pellet therapy for the first decade-plus of my practice. This was entirely due to negative experiences I had in my earlier years in practice.

Multiple times I ran hormone labs on patients who had gotten hormone pellets (from a very well-known pellet company who shall remain nameless). Every time, the sky-high levels completely freaked me out.

So I just put the whole topic out of my mind, leery that it could in fact be done well. I focused on developing and refining all the rest of my knowledge, experience, and optimization of hormone care, and not touching the topic of hormone pellets with a 10-foot pole.

Then a few years back, a colleague changed my mind on all this. I wasn't specifically looking into learning or providing hormone pellets, but I ended up learning a lot from her.

She is one of the most experienced hormone experts in the Seattle area. She has a very full practice of happy patients and is frequently sought by professional and educational organizations, on the topic of training healthcare providers how to best address hormone imbalances.

And it sure didn't seem that she was overdosing all her patients on hormones. In fact, it seemed like they were all responding well, and many were happy to have the option. It seemed like she was doing them right. And because she teaches other providers (and has now become a good friend of mine), this last June I finally put aside my reservations and learned from the pro.

what are they?

Hormone pellets are about the size of a grain of rice, and contain hormones (estrogen and testosterone) that slowly release for about 3 to 6 months. The pharmacy that I will be using compounds the estrogen and testosterone pellets for my patients. That way I can offer just the dose that each patient needs and fine-tune doses for each patient.

The pellet is inserted just below the skin, usually above the buttock area (think right above your back pocket) during an office visit. It does involve anesthesia (numbing up the area) and a small incision, though the incision is so small that it doesn't even require a stitch. Just some bandages and the patient is on their way.

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"Hormones text with male and female sign" by wuestenigel is licensed under CC BY 2.0.

how do they fit into the hormone treatment option realm?

I view them as just another option. I have had quite a number of patients ask about them over the years. It is the preferred route for many people. In times past, I had to refer out, and hope that the provider my patient found could responsibly match them to the right hormone dosage.

Now I can offer this to any patient where it is a good fit, and monitor them myself.

​who should consider this option?

You may be a good candidate if you:

  • Are currently taking estrogen and/or testosterone and want to skip having to take your dose every day (or week)
  • Want your hormones dosed in a more even-keeled way (because pellets provide a sustained release so there is no up-and-down swing, the main example being testosterone injections)
  • Often forget to take your dose (and then deficiency symptoms pop up)
  • Find it a pain to deal with the pharmacy every month
  • Travel and find it difficult to take your prescription with you (or have it mailed to different addresses)
  • Or just generally are tired of your current format and want to try something different

It is important to first be dialed in on your current hormone prescription in some other route (such as creams, pills, or injections) so that I can calculate a pellet dosage from your current prescription.

If you have never taken these hormones (estrogen/ testosterone), have a bleeding disorder, or are taking a blood thinner, then you may not be a good candidate.

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"Female and male hormonal balance concept image" by wuestenigel is licensed under CC BY 2.0.

how long do pellets last?

Generally women see maximal benefit for the first 3-4 months, then the pellet declines in potency. For men, the time frame is more around 4-6 months.

These are general expectations. Everyone is on a spectrum, so some may feel that the dose decline on the earlier end, and some will feel that it lasts much longer than what I wrote above.

the cost and other details

The exact cost of the hormone pellets (and their insertion) depends on the ingredients and dosage.

Initially, the costs of pellet procedures will range from $250-400 (with women being on the lower end and men on the upper end, as men tend to require larger doses thus more pellet supply costs).

This pricing may change after I have treated a handful of patients, if there are more unanticipated costs to providing pellets, but this is our starting plan.

Insurances do not cover this cost.

Your insurance should cover your office visit (and labs) like usual (if yours does), but insurances do not consider hormone pellets Standard of Care, and thus they are not Medically Necessary.

Lab monitoring is also an essential piece. Not only do we need (somewhat) current labs while you have been taking your current hormone prescription, but we will plan labs to occur at a specific time post-insertion to check your response.

This, and all other pertinent information, will be discussed during the initial visit.

​so what's the first step?

If you are interested in discussing and potentially pursuing this option, please take the first step and schedule a follow up visit (Portland: 503-232-3215; Salem: 503-990-8395).

Just a regular 30-minute visit is fine. It can be virtual or in-person.

There is a lot for us to talk about so that together we can make an exact game plan and then schedule the actual pellet insertion visit (I will be doing them at both offices).

I hope you have been able to get out there and enjoy our summer a little bit before we return to fall time.

Let me know when you need more support keeping it all moving and going, I am here for you!

Dr. Angela Cortal

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Back to my occasional series of writing about self-care, and today's topic is pain.

6/5/2023

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That's a big topic, I know. Huge. I have way more to say than I can possibly fit in this post (I did in fact write a book on this topic 3 years ago), so here I'm just going to be focusing on the highlights. This includes things I think that most people can safely try at home, things for those with chronic pain to be aware of, and other ideas that I'm commonly discussing with patients that I don't really put into the, "needs to be monitored by a healthcare professional" category.
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First up, what are we dealing with here?

Many of my patients seek me out because they want to further investigate and figure out their pain. Often my "job" at the first visit is to assess what has been imaged, tested, and treated, and understand what that past workup can tell us in terms of someone's potential diagnosis and the cause of their pain, so we both can figure out how to move forward.

Just a few common sources of pain in my practice include:

  • Osteoarthritis (commonly just called arthritis), or Degenerative Joint Disease
  • Hypermobility (injury, localized hypermobility, generalized hypermobility that includes Ehlers-Danlos Syndrome)
  • Tendonitis
  • Muscle spasms
  • Trigger points (in muscles) - I differentiate them from muscle spasms as our treatment approach differs
  • Ligament and joint injury, weakness, laxity (loss of elasticity in the tissue), instability
  • Spinal injuries and degeneration, leading to disc disease, nerve impingements, and spinal joint arthritis
  • Other types of autoimmune or inflammatory conditions that also can affect joint and musculoskeletal pain
  • And of course there are so many other areas of chronic pain in the body, such as nerves, digestive tract, bladder, reproductive organs, and more.

Many, many more. So I'm mostly focusing on the musculoskeletal system here. As each condition has its own triggers, risk factors, and how it affects us, our pain, ability to function, investigation and treatment course options are individualized for each person.

But with that being said, I would like to share a few self-care ideas that can help a variety of common underlying sources of pain…

Moving your body

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"Water Aerobic Tools" by leyla.a is licensed under CC BY-SA 2.0.
Sorry, but you knew that exercise was going to be on this list, didn't you?

Instead of me giving each patient a standard recommendation for the type of exercise, number of days per week and minutes that everyone should be doing, I want this to be individualized, too.

First up, are you moving your body regularly?
If not, start with moving it in a way that feels good, and that you enjoy.

Forcing yourself to do exercise that you hate because a healthcare professional told you you "should" do it is a recipe for reinforcing negative thought patterns when it comes to natural body movement.

Instead, move in a way you enjoy.
Let's all start there.

If you are not moving, then choose a way to gently reintroduce movement (I say reintroduce as nearly all of us were more active in our younger years).

For some, that is water aerobics.
Or chair yoga.
Or tai chi or other meditative practices may be a good fit, particularly if gentle movement and improved balance are goals.

Some enjoy jogging. I do not. But some think that Zumba sounds like the worst punishment possible, and I find it really fun.

Good thing there are endless ways we can express physical movement in our lives.

And here's just a few more specific ideas on this topic:

Controlled Articular Rotation (CARs) is a great introduction to improving mobilization all over, especially in those joints that are painful, stiff and limited in their range of motion, without introducing too much resistance and strain.
Here's one explanation and guide on this topic.
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Stretching can be a great self-care tool at home, just be aware of how your body responds. Some tight muscles feel great after a stretch.
But in areas of joint pain, hypermobility, muscle spasms, and trigger points, sometimes stretching can put undue stress on joints and muscles that are already struggling to heal and recover. Run your exercise program by the expert you trust the most in this field.

And sometimes, less movement is the key.

Health conditions that include high cortisol, stress, anxiety, fatigue, and insomnia are sometimes worsened by too much high-intensity or aerobic exercise. Stressed-out bodies often don't respond well to exercise that can stress them out more.

In these cases, yin yoga or other slower-paced exercise is a great addition.

For tight, spasmodic muscles, sometimes intentional relaxation of those muscles is more beneficial than stretching - especially as stretching can sometimes be too aggressive.

Finding a position of maximal release involves identifying the points in the body where the muscle attaches, and bringing those sites closer together. By relaxing and breathing slowly over 1-2 minutes, the muscle is given the opportunity to find a lower "set point" of tension.

Here is just one style in this video, to release the piriformis muscle in the pelvis region (this video was recently passed to me by a patient).

There are many styles of muscle release techniques, please ask your chiropractor, physical therapist, or myself for ideas specific to the muscles you are seeking to release.

Myofascial care at home

Myofascial treatment is a very broad term that encompasses hands-on care that you can receive from an acupuncturist (gua sha, cupping), chiropractor (Graston or IASTM), physical therapist and others.

A common aspect of all these types of treatments is breaking up any fascial adhesions that can build up in the superficial and deep connective tissue layers of the body, which can cause pain and limited range of motion.

An additional benefit is these therapies (either performed by someone else, or as self-care) also tend to improve circulation, movement of nutrition and oxygen to the areas of chronic pain.

A few common at-home tools to aid in this include foam rollers, dense rubber balls (Lacrosse balls or Melt balls), and other roller massage home tools.

Working out fascial adhesions can be sore, even a bit painful or tender. When doing this at home, it is good to know precisely which muscles you are intending to treat, so that you don't inadvertently painfully compress a nerve instead of the fascial layers you are trying to release. Sometimes pain is no gain, so be aware of your anatomy.

Here's a few home exercises on self myofascial release you can try.
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Supplementation: what I commonly use, and what I commonly recommend to avoid
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"Turmeric Supplement Capsules and Bottle" by formulatehealth is licensed under CC BY 2.0.
Supplements are just that, a supplementation to an otherwise comprehensive approach. I don't use them in a vacuum as all the other more foundational aspects are really key.

My book has all the research and backstory on supplements, so here we'll just hit the highlights, plus what new I have learned over the last three years since its publication.

Glucosamine is still one of my go-to supplements, because it supports connective tissue regeneration processes - which is often supportive in cases of arthritis, tendonitis, sprains, injuries and more.

It's generally a good approach to try one new thing at a time. That way you can assess how you believe it works for you. The same is often helpful with supplements. For that reason, plain glucosamine (sulfate or HCl) is preferable over the "joint support" blends that might have 5-10 ingredients. If that combo supplement doesn't seem to do much, you won't really know if just one or two of the ingredients may have been the better fit for you.

A few brands hit the 500-750 mg per capsule dosage (Thorne and Vital Nutrients are the ones I most commonly use), which is then easy to aim for the 1500 mg daily dose that has most commonly been researched.

Turmeric/curcumin is another supplement where I focus on the minor details. Taking a bioavailable form (may say Meriva or phospholipid bound on the label) means that a lot more of that supplement is being absorbed through your digestive tract and making it to your joints (or wherever else you're using this common antiinflammatory supplement).

A couple of good quality brands (Thorne and Pure Encapsulations) make capsules in the 500-750 mg range to hit the daily 1500 mg that is most commonly shown in research to be as effective as over the counter antiinflammatories, and in some studies even as effective as prescription antiinflammatories and low-dose opioid painkillers.

You can find these and similar brands in many locations: in health food stores, my Salem office has an inventory managed by an office-mate there, and many places online. If you are supplement shopping on sites available to the public, just be sure to buy directly from that manufacturer (such as directly from the Thorne "store" on Amazon). There is a scary and unfortunate amount of fraud that happens in the supplement sales world out there.

The prescription platform I use in the office, FullScript, gets their supplements directly from the manufacturer, so I feel safe and secure when I'm ordering my own personal supplements there.

Ursolic acid is a new one for me. Let me introduce you to this compound.

I just found out about this really interesting botanical extract from a colleague Dr. Jeff Clark last year. After trying to find additional treatment options for neurologic inflammatory conditions, he read up on the research on this compound. Ultimately he started making a concentrated ursolic acid product from rosemary extract, in topical and oral forms, which he calls Bear cream and Bear capsules.

After speaking with him and reviewing the information he's collected on ursolic acid, I did my own multi-hour deep-dive into the research. And I found a whole lot more interesting applications than just nerve anti inflammatory support (though that is interesting in and of itself). I found many studies on maintaining muscle mass, preserving nerve function, improving osteoarthritis and rheumatoid arthritis joint pain, and even reducing uric acid levels.

Then I decided I wanted to try it out on as many patients as were interested, so I've been stocking the topical application Bear cream in my office for the last few months, and trying it out on patients when it seems it might help.

Because the Bear cream contains DMSO, it absorbs within a few minutes, so during an office visit I can try it out with a patient and they can report back what they think in real time.

My very non-scientific guesstimate is that about half of patients with joint pain notice a difference, and at least 75% with tendonitis and ligament pain notice a difference.

Though no treatment will be the 100% effective magic bullet for everyone, I have found it to be another useful tool in my Chronic Pain Toolbox, as one more additional non-pharmaceutical option to be tried for arthritic, tendon, and ligament pain.

For some it provides palliative pain relief so that they can sleep, exercise, work, or otherwise function a little more comfortably while we're doing all we can to help figure out and/or treat the more underlying causes of the pain.

And after trying it on myself, friends, family and a few dozen patients over these last few months, I am just now starting to carry it in the office (in addition to it being available directly from Dr. Clark via the above link). It's on the shelves at my Salem office, and will soon be at my Portland office as well.

If you are interested in trying a sample, please ask during your next office visit with me! I'd love to collect even more information on how I can use and recommend this in my work with patients.

And of course, I want to think about all those other background factors and triggers of chronic pain

Most of you know that I like to dive deep into investigating all the metabolic, hormonal, inflammatory, and immune influences in chronic pain. So don't be surprised when I seem to be getting off topic talking about insulin, testosterone or uric acid, when all you wanted was to know what I think about cortisone injections :)

It's all connected. I just can't help but dive down all the rabbit holes.

(Oh and if you did want to know, I'm not nearly as opposed to cortisone as many patients presume. I just think they are overused with little to no thought being given as to why the arthritic pain is there in the first place. And too many of my patients have been "fired" when the cortisone injection didn't work and they weren't a surgical candidate or did not want to pursue surgery. Or worse, were a "failed surgery" patient - has a worse medical phrase ever existed?!)

So stay cool, stay hydrated, go have a little fun while you're moving your body, and let me know when you need more support keeping it all moving and going,
Dr. Angela Cortal

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Visit codes and other billing details

5/15/2023

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Ok, my subject line was just a tad sarcastic. But in all seriousness, myself and my staff get questions all the time about office codes, procedure codes, billing insurance, and more, so I thought I'd break down a couple of the most common myths, misconceptions, and tricks I've learned over my 10+ years of billing insurance in a medical practice.
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​first up, know your deductibles

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"Compare Health Insurance" by sinclair.sharon28 is licensed under CC BY 2.0.
We're nearly midway through the year (I still can't believe it) so most folks who have standard deductibles, and get regular medical care have already met them, so now that emotions are not at the fever pitch they always are come January, let's talk about them a little bit.

My office, like most out there, tries to get the most accurate basic insurance coverage information that we can for all new patients. For many reasons, sometimes that doesn't quite work out.
Here are a few top reasons why we might not have accurate information:

  • The insurance rep on the phone just gave us straight up incorrect information (happens more commonly than you might think)
  • Your HR department decided to switch plans on you
  • The appointment was booked with so little advance notice that my staff was not able to call to verify coverage at all
  • There is a small error on our end (even one digit of a member ID number for example), and staff couldn't reach you in time so was unable to determine your insurance coverage

These are not excuses, just explanations. As patients (I get regular medical care too, of course), it is our responsibility to be familiar with our insurance coverage details. If you don't think you have any deductible, and my office or another tells you your insurance company says you have a $2,000 deductible.... well... there's a pretty big disconnect somewhere along the line.

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choosing when to use insurance based on deductibles

I'll use myself as an example. I'm looking to get a new insurance plan in a few months. If I get one with a $1,000 deductible, I'll just start using my insurance right away. I know I'll get bills for my care coming my way, saying that the cost of those visits was applied to the deductible. I'll be responsible for paying them in their entirety until that deductible is met.

If I choose a plan with a $5,000 deductible however, that's pretty high. I might not actually meet that deductible before its annual renewal, and I'd be paying those higher "total billed amounts" the whole time. So what I will be doing, if I choose a plan with a higher deductible, is paying for my visits directly to the providers I see. That way I can get the "Time of Service" self-pay discount (usually around 25% off). I can then send those itemized invoice receipts (also called superbills) to my insurance company so they can count towards my deductible in case I do end up meeting the full $5,000 (which would easily happen if I need surgery or other emergency care for example).

I am also deciding what type of Health Savings Account to open up, which either way will pay for such costs as co-pays, medication, and whole office visits that are not billed to insurance.

Sound complicated? It is.
Medical care in this country is stupendously complicated.

If this is all making your head spin, talk to your HR person and discuss what is the right fit for you, based on your insurance plan specifics and your healthcare requirements.

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"Medical bills WITH health insurance." by attercop311 is licensed under CC BY 2.0.

I don't recommend the "let's just bill it and see" approach

How many of you have heard me say, "when it comes to insurance, surprises are generally not a good thing." I say that often for a reason.

The most common reason I see in office for wanting to know your coverage details, is that if a patient has no coverage for visits or a type of injection service, then it is more affordable for them to pay up-front.

Like what I mentioned above, self-pay rates are often about 25% less. The reason for this is as providers contracted with insurance companies, we have to play by many, many rules. However, they let us provide discounts to those who do not bill any insurance for that service because they know how much back end expense there is to billing insurance (reception staff to verify coverage, medical assistants to coordinate pre-authorizations, office billing staff to submit codes, address their incorrect claims, etc, etc, etc).

That being said, the choice to self-pay needs to be made at that office visit. Not months later when someone has found out that what they thought was covered (or never checked to see whether it was covered) is in fact not covered. I'm sure everyone can see how the work was already put in on our end, so the appropriately-named Time of Service discount can't apply later on.

Here's just one sad tale to illustrate the importance of knowing your insurance coverage details. About five years ago a patient asked me to run more extensive labs than would have been my initial workup, requesting a lot of extra allergy and food panel testing.

As many of you know, I take into consideration patient requests. I truly try my best to listen to every patient.

Unfortunately for him, he was not aware that he had a $2,000 deductible for lab coverage, so he was hit with a very large bill.

I do my best to use my past knowledge of running hundreds and hundreds of labs to know what insurance companies often cover (vs. what they often don't), but at the end of the day I hope everyone can see that it's not my job to know my patients' insurance coverage details inside and out.

It's just not possible for me to know everything about everyone's plans.

So, please, please, please familiarize yourself with your insurance plan benefits. And if you are not finding the details you are looking for in your insurance coverage booklet and talking to your HR person, and end up calling your insurance company, please write down the rep's name and call # when you take down those details.

Patients have told me that they were able to get some past services covered, when their insurance was initially denying coverage, because they were able to provide the call # and rep name who assured them it was in fact covered.

Yes, this is ridiculous.
No, we shouldn't have to fight so hard to get the medical care we pay for.
But this is the system that we have at the moment.

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"health insurance claim paperwork" by franchiseopportunitiesphotos is licensed under CC BY-SA 2.0.​

I'm going to get even more into visit code weeds for a minute

One recent change, along with all of the above, is updating some of our billing rates on both office visit and procedure codes. For patients who self-pay, some of those have increased, and others have stayed the same.

The reason for this is multifold. For the office visit rates themselves, I will let you in on a little history. My office visit self-pay rates had not increased since I started practice in 2012. But the prices of.. well... everything else all around us has. We had planned on finally increasing our rates in 2020, but you know the end of that story. So we kept our rates stable on every single code until now, and have finally increased some. So for example, a visit that may have had a self-pay rate of around $120 is now around $160.

If you have any questions or concerns, please talk with me. I am open and do my best to address all my patients' needs. And that sometimes means addressing the financial reality as well. If you want to schedule a shorter follow-up visit (less complex, lower visit codes therefore lower rate), please just let me know. We have our standard new patient and follow up times, but in addition I do my best to accommodate every need I can.

For procedure codes (which includes all types of injection visits), again some of those codes have stayed the same, and some have increased slightly.

Most patients will not notice or be affected by these changes, since the changes mostly affect codes that we bill out to insurance anyway (such as trigger point and scar adhesion release injections). Prolotherapy rates are unchanged.

The reason for the injection code rate increase is actually that some of our codes were being billed out all backwards. More complex trigger point injection codes were being billed out to the insurance company at rates lower than the more simple injections. I won't bore you with more details, but that's the reason for that.

If you would like an updated procedure (injection) code rate document, I can share it at any time (email directly or during a visit) as can my staff.

​

thank you all who have hung in there through this whole post

I know this wasn't the most exciting email you've ever read, but because insurance is such a huge and tricky topic, I think it's worth diving in every once in a while. I like to think I've learned most of the rules of their game, and try to share that knowledge and experience with my patients.

Next message will be much lighter- I'll be highlighting some of the home care, tools, and resources I share with patients that address joint and muscle pain.

I hope you are staying cool and well hydrated (I am a Naturopathic Doctor after all),
Dr. Angela Cortal

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Semaglutide Injections (Ozempic and Wegovy)

4/21/2023

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Back at the beginning of the month I told everyone that I'd soon be writing all about Ozempic. And after taking a few weeks to collect all my thoughts, research, and clinical knowledge, I'm ready to share with you all what I know and what I've learned up to this point.

​*** warning for those who do not want to read about BMI, weight loss treatments, and medical descriptions such as overweight and obesity. A talk about these medications necessitates that I talk about all of this in-depth, so if this does not feel like a good topic for you, please skip this, delete this message now, and I'll catch you next time***
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First up, what exactly am I talking about?

Due to pharmaceutical commercial success in this country, many of my patients have seen the, "Oh, Oh, Oh, Ozempic" commercial advertising this category of weekly injectable medication.

Ozempic is the brand name for the generic medication Semaglutide. The other brand name is Wegovy. The medication category is Glucagon-Like Peptide-1 (GLP-1) Receptor Agonist. There is one oral option approved for use in Type 2 diabetics, but most in this medication class are injectable medications.
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A brief history and why all the buzz nowadays?

Semaglutide and other GLP-1 Receptor Agonist class medications have been used for decades for Type 2 Diabetes, so they are not anything new.

The FDA's recent change in approving them for use as a weight loss medication (in those who do not have elevated blood sugar) has been the big change over the last two years.

Whereas previously these medications were only approved as second-line medications for blood sugar management (so only a portion of those with Type 2 diabetes), starting in 2021 the FDA approved their use in those with a BMI of 27 or greater.

We're talking a change of before perhaps tens of thousands of people in the US being approved to use them to now over half of the adults in the US. This massive change now means that hundreds of millions in the US are now approved to use this medication for weight loss.
​

A real quick aside on BMI, overweight and obesity classifications and the "epidemic of obesity"

So, this whole topic is fraught. Very, very fraught. It is impossible to disentangle our society's historic and current discrimination towards those with larger bodies, the decades and centuries of biased "research," and our entire culture's general aversion to larger bodies when we discuss this topic.

To say someone with a larger body can be healthy is still considered a radical statement in many social and medical circles.

But it shouldn't be. And science backs it up.

If you would like to learn more about the racist origins of the BMI, how the BMI is not a measure of health, and how our medical system perpetuates anti-fat discrimination to the detriment of us all, I will stop here before I really get rolling and just include a few resources at the bottom of this message for those who would like to learn more.
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"Pharmacist Holding a Box of Ozempic" by chemist4u is licensed under CC BY 2.0.

Alright, so back to the weight loss shots

I have been sticking my ostrich head in the sand these last two years since Ozempic and Wegovy have been approved. I admit that. I rebel against the weight-loss paradigm and dogma (I enthusiastically support a Health at Every Size medical model - ask me more about this the next time you see me).

I also saw how the earlier generation of weight loss drugs (such as phentermine or Phen-fen) were basically speed and pulled from the market due to heart-harming effects.

I was figuring like everything else, that this is a trend that would soon burn itself out.

But I was wrong. This category of medication has continued to gain momentum and use over the last few years. I have had more patients discuss it with me in the last few months than all the previous years put together.

So let's get into the science behind them.

The GLP-1 Receptor Agonist class medications (let's just bundle them all under the generic name Semaglutide from here on out) work on the pancreas. The pancreas is one of your digestive organs that regulates a lot of functions. Our focus here is on insulin production and release. Insulin is a hormone that works all over your body, directing the glucose (sugar in your bloodstream) where to go - basically where to be used as energy.

Semaglutide stimulates cells in the pancreas called islet cells, which release the insulin.

The effects of this medication are many and wide-spread, including:
  • Slows gastric (stomach) emptying, thus slows absorption of dietary carbohydrates (sugars)
  • Increases satiety (feeling full) via appetite suppression, which also leads to decreased carbohydrate intake overall
  • Decreasing blood glucose levels (which also decreases Hemoglobin A1C numbers on labs)
  • Decreases oxidative inflammation (which can have cardiovascular benefits)

Over time all of these effects lead to a sustained weight loss as seen in research. One- and two-year trials show that weekly injections of these medications lead to an average 15.2% loss of body weight (again, slowly and over time). The average starting weight of research participants in some of the longer-term trials was 233 lbs, and on average they lost 35 lbs (so ending weight of 197.5 lbs on average).

A weight loss medication that has been studied for decades and shows a pretty decent and sustained weight loss. Must be magic, right?!

Well, contrary to Ozempic's use of the 70s song Magic in their commercials, no it's not magic. It's tinkering with the pancreas in order to trigger biochemical and hormonal changes that lead those taking it to feel full, longer, eat less, and lose weight. Yes, that much is certain.

But they are not without a cost.

Two-year trials show that over 82% of those on Semaglutide report digestive side effects. Gastrointestinal symptoms of upset stomach, nausea, diarrhea, vomiting, and constipation are common. Very, very common.

And there is some concern about thyroid cancer (this comes from early animal trials) and a potential for pancreatitis, but in looking at the larger picture, those are not the dangerous side effects I'm most concerned about.

I am most concerned about the drugs working, but at an unhealthy cost. Most of medicine seems overly fixated on weight loss, no matter the potential negative mental health ramifications (or metabolic, or hormonal...).

Research shows that dieting increases anxiety, depression, and disordered eating patterns. Whether that is dieting that someone is doing on their own (often due to societal pressures) or from a disparaging medical provider, the potentially-catastrophic effects are the same.

The last thing I want to do is harass my patients about weight loss and scale readings, all the while wreaking harm in the process.

And yet, I'm not against this medication on principle. In fact, I have started managing the medication for a very small number of my patients.
​

So where does that leave us?

If you can't tell by now, I feel very conflicted on this whole topic.

I want to support all my patients the best I possibly can. I want to address and remove any harmful stigmas that are rooted in bias rather than actual medical knowledge.

And at the same time, I have the (perhaps naive) view that if any provider can use Semaglutide in the most harm-reducing way, maybe it's me.

And lastly, since I believe that I can skillfully help patients (who are candidates) through the process of using this medication, it's really not up to me and my beliefs to put up barriers to their access.
​

So, here's what I want you to know if you want to chat with me about this

No medication is magic, every intervention has potential side effects.

The current FDA indications are as follows:
  • BMI of 27-30 if someone has additional risk factors for cardiovascular disease (such as hypertension or high cholesterol)
  • BMI of 30 or greater
  • These medications have not been studied for safety (nor efficacy) in anyone with a BMI less than 27

I am formulating a handout for each patient to use as a guide through this process. I will be working closely with each of my patients, so that they can receive the outcomes they are looking for in the safest way possible.

I am not a proponent of any diet. Those who have known me for a while may know my background and knowledge in some of the low-carb and ketogenic diets, and while I still can use that information in those for whom it's the right fit, I have left the "one diet fits all" dogma in my past.

I personally follow and support an Intuitive Eating approach. This approach may naturally trend towards certain types of food intake for certain people (such as vegetarian, or low-carb), but only because it is the right fit for that person.
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Next step? reach out

If you would like to discuss this further with me, please make an appointment (in-person or virtual). There is a lot of information I need to obtain, and a lot of information I want to share with each patient before we get started.

This is a type of treatment that must be monitored closely, to minimize negative side effects and maximize safety.

This is definitely not the right route for everyone, even those who technically meet the criteria above. But for some it may be the right treatment plan that they would like to choose to explore, so I will be here with you every step of the way.

Adding to my upcoming rotation of topics will be more discussion on diets and Intuitive Eating, as I see this as a crucial subject and more timely than ever before.

In health,
Dr. Angela Cortal
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Male hormones

3/31/2023

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My thoughts on testosterone

I spent many paragraphs in my last post talking all about estrogen and progesterone. So now it's time I spend a little time highlighting testosterone.

Before I dive in, my warning for this message is that by virtue of talking all about testosterone, I will again be talking about reproductive organs and sexual function. Specifically. In depth.
So now you've been warned.
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First up, let me dispel the common myths.

#1 Testosterone is not addictive.

The FDA does classify it as a controlled substance (which involves extra rules around prescribing, refills, and monitoring), but it is not addictive.  Other prescriptions that are controlled substances do have the potential for creating addictions (such as opioids), but testosterone is not one of them. They just all got thrown in the same "control level" bucket.

#2 Erectile dysfunction (ED) does not always mean low testosterone.

One potential sign of low testosterone can be low libido (sexual interest, arousal) and/or ability to get or maintain erections for penis-owners, but it's no guarantee.

I do run hormone panels on all patients with symptoms that are potentially influenced by hormone levels, but not every case of ED is due to low testosterone. And even for those who do experience ED, have low testosterone levels, and are on testosterone-replacement therapy, not all cases of ED respond to higher testosterone levels.
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Well, then, what gives?

Bodies are complex. Hormones are complex too, and while many of my patients may be forgiven for thinking that I believe that every possible condition is always due to hormonal dysfunction, that's just not the case.

Hormones are important, hormone deficiencies can wreck someone's quality of life, but not everything is due to low hormones. ED included.

There are many other systemic health factors that influence the hormonal and vascular health of penises. Cardiovascular disease, diabetes, and peripheral vascular diseases are just a few other potential causes of ED. If you are concerned about ED your doctor should not just be checking your testosterone level. There is a lot more to investigate.
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"Human health - hormone balance" by wuestenigel is licensed under CC BY 2.0.
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Testosterone: not just for men

Testosterone is an absolutely critical hormone for everyone. I work with many patients to restore their testosterone to levels that work better for them and their quality of life. That list includes cis-gender men, cis-gender women, trans-gender men and gender-diverse folks. Low testosterone levels can impact pretty much anyone's quality of life.

Testosterone gets caricatured as just important for body-builders, libido and erections, but its effects are so much further reaching than just that.

Testosterone is important for mood health, a sense of vitality, well-being, energy, and motivation. I have lost track of the number of patients who report that, "I just feel better. I feel like myself again" once low testosterone levels are addressed.

Often, low testosterone levels feel blah. Blah mood. Lowish energy. Exercising regularly but feeling like no matter what you do, you never progress, never get stronger. Feeling totally apathetic. No interest in things that someone previously derived joy from, whether that is hobbies, physical activity, or sex. It's a very important hormone in helping us feel good.

Testosterone is also a vital anabolic hormone for our musculoskeletal system. That means it's a signal that tells our bodies to build more cartilage, ligament, tendon, and muscle tissue. Those messages are essential when healing from an accident, injury, or surgery. But they're also critical in maintaining adequate muscle and cartilage levels as we age.

Low testosterone levels are associated with muscle wasting (sarcopenia) and degenerative joint disease.

Degenerative joint disease is also known as osteoarthritis, the most common type of arthritis. Often just attributed to "wear and tear," osteoarthritis is actually a very dynamic process that responds to our bodies' levels of nutrients, inflammatory levels, and hormones (among many other factors. Pick my brain at your next visit to chat more about this).

Studies have shown that (cis)men in the lower percentages of testosterone develop more cases of osteoarthritis, they are more severe, and they eventually need total joint replacement surgeries earlier than their counterparts (same age) who have higher testosterone levels. Not abnormally high, just in the top-half of the normal range, rather than low-normal or pathologically low.
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What can I do on my own to support testosterone?

Similar to the hormone support plan I mentioned last time, testosterone also benefits from paying attention to nutrition, hydration, physical activity, sleep, and stress levels.

I won't rehash the entire message from last time. With testosterone, a focus on adequate protein levels is of particular importance.

That, and providing your body with resistance activity so that it can use the testosterone (whether that's just what your body makes, or with the help of hormone supplementation) to build muscle fibers, vascular health, and support brain neurochemistry. The list goes on.

But it all starts with resistance activity. Many, many types have been studied, and shown to have an immediate boost on research participants' innate testosterone levels. It seems that nearly any type of physical activity that pushes your body and makes your muscles work will do.

That includes weight lifting, CrossFit and other high-intensity interval training options. Heck, even cutting wood boosts testosterone. I tell patients to move their bodies in ways that they enjoy. Some enjoy the camaraderie of a group fitness class. Others love getting out and rock-climbing in the great outdoors. Do what you enjoy, and add a little challenge if you feel you need it.
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I have low testosterone. Do I have to do shots?

There is no type of testosterone treatment that is mandatory. Even if you have low testosterone, you do not have to do anything about it.

That being said, you may want to. As mentioned previously, testosterone levels affect quality of life: mood, energy, libido, physical performance, sexual interest and function.

So, for those reasons, a testosterone replacement trial is often begun. And that is just what it is. A trial. Not required. We're just seeing if increasing low testosterone levels improves the reasons that brought someone in to see me in the first place (or maybe these were concerns brought up later on).

Vagina-owners who are seeking improvement in their quality of life, but not the masculinizing effects of testosterone do not get shots. Often a cream containing the testosterone prescription is used.

Any testosterone prescriptions for this category of patients are compounded. That means we must use a compounding pharmacy. Your typical commercial pharmacy (Rite-Aid, Walgreens, etc.) does not have any type of testosterone appropriate for these patients. I could go into a whole tirade about how that's due to the fact that our medical establishment doesn't recognize testosterone as being important for my female patients, but I'll leave it at that.

For penis-owners and/or those looking for masculinizing effects of testosterone, 99% of the time we do just injections (which are available from commercial pharmacies). There are other options out there (primarily creams and gels), but they come with quite a few down-sides, so often shots are the way we go.

Injecting yourself can be scary for anyone who's never done it, but with a few tips, and a bit of practice, it is a breeze for most everyone. I have given thousands of injections to patients, I have injected myself many, many times, and I am happy to show anyone the self-injecting ropes when need be.
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Then what happens?

Well, the effects of the testosterone kick in. Some people notice an effect very quickly, within the first few days. By and large all these hormones we've been talking about (estrogen, progesterone, and testosterone), when replaced, tend to build up in someone's system over the first few weeks.

I often check in with patients about a month out, to make sure positive effects are being seen, make any dosage changes necessary, and address any unwanted effects that may arise.

Monitoring involves rechecking labs usually a few times in the first year of replacement, and annually in the future if no changes are being made. These are necessary to verify accurate testosterone dosage, long-term safety, and check for aberrant hormone metabolism (some will break down too much of their testosterone into estrogen, which can create secondary issues).

Additional requirements of testosterone replacement therapy are continuing annual exams, and following any further recommendations given such as PSA monitoring and urologist visits. These are no longer recommended annually as a general rule for all (cis) men who are on testosterone; I leave that up to the discretion of the primary care provider.

Again, no aspect of this is mandatory. For those who have low testosterone, and choose replacement, the timeline on replacement is up to them.

We are talking about addressing impacts to one's quality of life, not any medically unsafe situation that absolutely requires medicating.  Testosterone replacement, like any hormone prescription, works for the duration that someone uses it. 

Our bodies change over time. Obviously. And along with that comes changes in what hormone levels are "expected" (as in, hormone deficiency symptoms arise when levels are below that).

So any hormone plan I craft with a patient is always tailored to fit them, their initial concerns, their response, and their continued need for the hormone.
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"Doctor holding a stethoscope" by wuestenigel is licensed under CC BY 2.0.​

​When should you reach out?

Whenever you need more support, of course.
Whenever your current plan is not working for you. Whenever you need new ideas, new investigation, new treatment suggestions.

I am pretty good at brainstorming. Through my decade of practice, and doing so much hormone testing, prescribing, and problem-solving through that time, I nearly always have a Plan B. And Plan C. And Plan D, E, F, etc. Don't settle for a plan that isn't working for you.
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That's all I have for today

I hope that this has been helpful for those who have gone the route of testing and prescribing, for those who are curious, for those who have been told maybe they should pursue that route, and also I hope this was helpful even for those who are very hormone-wary. I welcome all questions and concerns as I am working through hormone investigation with my patients.

Next time I'm going to cover the weight loss injection medications. Ozempic. Wegovy. Semaglutide. I was naive enough to think that I could just ignore this huge trend in medicine, but I can no longer. So I will dive into my thoughts on the whole debacle around these medications, use, side effects, long term safety, and more. I won't be able to hold back from bringing out my soapbox on the larger topics of anti-fat bias - in medicine, in society, in our own mindsets.

I'm sure it will end up being quite the novella. So stay tuned for that. If you wish.

Yours in health,
Dr. Angela Cortal
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Female hormones and self care

3/7/2023

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(If you don't want to read anything about estrogen, progesterone, ovaries, vaginas, and uteruses - stop reading now and join me next time)

I would like to share a series of messages geared towards education on health topics. This blog is open to everyone, so of course I am not diagnosing or treating any medical condition (ok, I think my malpractice lawyers are happy now).

With that being said, I feel that there is a lot of information all people can and should have easy access to. Education, awareness, and some tools that anyone can learn about on their own.
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Female hormones... What exactly are we talking about here?

First, a note on terminology. I used the phrase "female hormones" above so that anyone interested in this topic would know generally what I will be talking about.

But with that being said, I prefer to use more accurate terminology such as "testes owners”, "ovary owners”, "vagina owners”, "uterus owners”,  all just depending on the subject.

The reason for this is that I want to give the right information to the right person (or those who know and love them).

Many of my female patients have had a hysterectomy, so "uterus owner" information would not be relevant to them. The more specific the terminology, the more useful.

Same thing with menstruating versus not menstruating. There are different priorities, hormone imbalances, and self-care ideas that will be relevant depending on one's menstruating status.

That's why I use very specific phrasing, which may be new to you, but I don't think will be confusing to anyone. You only have to know what reproductive organs you have to follow along.
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"Hormonal pills on doctors workspace" by wuestenigel is licensed under CC BY 2.0.
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Hormones at play

So for today, I am going to focus on estrogen and progesterone. Everyone has all three sex hormones (estrogen, progesterone, and testosterone), but it's the estrogen and progesterone that are of particular importance for menstrual, peri- and postmenopausal concerns.

Through the menstruating years, every menstrual cycle is a roller coaster of estrogen and progesterone. The estrogen typically peaks the week of and week after the menstrual period itself, then the progesterone peaks the two weeks following that (presuming a 28-day cycle where ovulation is happening).

Menstrual concerns are varied. A top-of-my-head list includes long cycles, short cycles, no menstrual cycle appearing, spotting mid-cycle, bleeding mid-cycle, heavy cycles, clotting, cramps, breast tenderness, mood swings, insomnia, fatigue, anxiety, depression, constipation, and low back pain just to name a few.

Menstrual cycles, and some appearance of physical and sensation changes, are completely normal. But when those hormone shifts are impacting one's quality of life... then that's time to get some professional support.

Same with menopause. It is a natural stopping of the menstrual cycles (along with stopping ovulation) when those fluctuating hormone levels have come to rest at a level too low to trigger menstrual cycles and changes.

For some, it's an easy, breezy transition.

But for many, it can be a time that hormone shifts can again significantly impact quality of life. That can include hot flashes, night sweats, insomnia, fatigue, difficulty concentrating, memory issues or foggy headedness, anxiety, depression, joint pains, libido changes, vaginal dryness and/or discomfort.

Long-term post-menopausal hormone deficiencies can also be a risk factor in the development of osteoarthritis, cardiovascular disease, dementia, and osteoporosis.

There are a lot of factors that go into my initial investigation with new patients. But if some (or many!) of these concerns are present, we are often ordering lab testing. If insurance covers other testing ordered by me, such as blood sugar and thyroid tests, they cover hormone testing as well. The only insurances that don't cover lab testing by me are Medicaid plans, Medicare plans, and Kaiser.

Regardless of hormone testing and test results, there are some common tips and tools that anyone can use at home to care for their hormones.
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Self-care for top concerns

A hormone support plan often includes attention to nutrition, hydration, physical activity, sleep, and stress levels. I will dive into each of these topics.

Nutrition building blocks for hormones include protein, fats, and fiber. Getting in enough protein daily ensures that your body can create and circulate proper hormone levels. Healthy fats (such as pastured meats, eggs, also coconut, avocado, and olive oil) are also important.

Did you know that the backbone of every single hormone is a complex fat molecule?

People who have low cholesterol are actually at a potential disadvantage as they may be at greater risk for hormone deficiencies.

Fiber and hydration come up in particular for menstruating concerns. As the estrogen and progesterone alternately spikes then drops through the cycle, our bodies have to respond by increasing production (when one is supposed to be spiking) then increasing the breakdown (when it is supposed to be declining).

Many hormonal imbalances have an estrogen dominant aspect to them. That is a big subject, but one important aspect is to help facilitate the breakdown of estrogen. That is where the fiber and hydration come into play. Both soluble and insoluble forms of fiber help in the body and specifically in the digestive system to help get out the hormone metabolites (waste products) when it is time for them to go.

Dietary sources of fiber include nuts, seeds, vegetables - especially broccoli, cauliflower, kale, chard and salad greens. If you need a little fiber boost, adding one or two tablespoons of flaxseed meal into food is an easy way to do it.

Everyone has different hydration needs, but generally an intake less than 48 oz of water daily will lead to constipation and more sluggish bowels (thus slower elimination of those hormone metabolites which can lead to them getting reabsorbed from the bowels).

Sleep and stress reduction come into play as our restorative times are the times that encourage more production of progesterone, a naturally calming hormone. High stress levels provoke more production of cortisol. Cortisol, in appropriate levels, is the hormone that helps us wake up naturally. But in high levels it is often called "the stress hormone," and can be involved in long-term high-stress symptoms of insomnia, anxiety, heart palpitations, and more.
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"Female and male hormonal balance concept image" by wuestenigel is licensed under CC BY 2.0.

Now I'm going to talk about vaginas. A lot.

Everyone has had ample time to leave if this is not a topic for them.

But for my vagina owners out there, this message is for you.

A few vagina self-care tips:

--- Don't stick anything in your vagina to clean it or get rid of an infection. Seriously. If you think you have an infection, seek care from the provider who does your pap exams so you can be tested for an infection. Don't treat it yourself (don't google herbs and start sticking them up there!).

I have seen what effectively was a vaginal chemical burn, caused by insertion of food/herb items that could be picked up at a grocery store. Don't do it.

Vaginas are the original self-cleaning oven. Yes, I'm joking. But in all seriousness, they don't need cleaning inside.

--- If you are prone to recurrent UTIs or vaginal infections (or dysbiosis such as BV), then you probably know that you have to take extra vaginal/ vulvar care precautions. Wearing cotton underwear, showering immediately after exercise, cleaning/ showering after sexual intercourse (with partners and/or toys), being very careful with soaps and lotions, wiping front to back with toilet paper and maybe even buying bleach-free toilet paper.

If you still find yourself very sensitive to recurrent infections or dysbiosis, talk with your provider(s) about what test treatment steps may be available for you.

--- Use lubricant. If you have a vagina, and you engage in any type of sexual activity that involves said vagina, just do it. Use lube.

Yes, all vagina owners. Yes, even if you don't experience any type of vaginal dryness or discomfort ever.
Yes, still use it.

Using silicone lubricant helps keep vaginal tissue healthy.

It lowers the risk and rate of vaginal infections (and dysbiosis). It protects vaginal tissue during sexual activity and keeps it plump and intact. It provides a barrier that helps those who do experience vaginal dryness, discomfort, and pain.

It is good for all vaginas.

If you prefer using a water-based or oil-based lubricant, go right ahead. Any lubricant is better than none.

--- More on vaginal dryness:
It is very common around menopause. It can start before, during, or after the transition of periods stopping. If it is minor, and occasional, and silicone lubricant just isn't doing enough, you may want to look into hydration pearls (Bezwecken is one such manufacturer).

When we do need to step up the plan into hormone replacement territory, vaginal cream is a very common format I am using. It is terrific (and fast acting) to reverse vaginal dryness, but it actually works great for all manner of peri- and postmenopausal-related hormone deficiencies. This is because applying hormones to vaginal tissue is the #1 way to get a slow and steady daily dose from a hormone prescription.
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When should you reach out?

Whenever you need more support, of course.

I am here to investigate and offer treatment solutions when what you have been doing previously isn't working, or isn't sufficient.

Or when the plan had been working great, but now is not working out so well.

Or when you have been told that it's pointless to check your hormones or nothing can be done because, "it's normal for women, normal for your age," or some such aggravating and useless sentiment.

When you need things checked into, I am here.

When you need to talk hormone prescriptions, I am here.

I prescribe several forms of hormonal birth control (pretty much every type of prescription contraceptives except IUDs) and the options for prescription hormone supplementation are extensive.

I always want to do my best to match each person up to the hormone type, format, and dosage that is right for them.  Sometimes that takes a few tweaks early on, but I don't rest until the hormone replacement plan is working, and working wonderfully.

I also want to do my best in terms of monitoring and providing the most effective treatment at the lowest potential for side effects, which includes hormone lab testing.

If you would like to learn more about the history of hormone replacement therapy research, and why it seems there is so much disagreement out there in the medical community about hormones and hormone replacement, I suggest you read Estrogen Matters by Dr. Avrum Bluming. He is a breast cancer oncologist who really clearly communicates the research findings, and what actual health risks there are to hormone replacement (versus potential hormone deficiencies).
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OK, that's all I have for today

I hope that this has been helpful for those experiencing menstrual, menopausal, and vaginal concerns. Or those who know someone who could use this info, in which case please pass it on!

And next time, we will be talking all about testes and penises and testosterone, so now you've been forewarned.

I hope we all get to see a little sun this weekend,
Dr. Angela Cortal
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Winter Warming Ideas

1/3/2023

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I hope 2023 is off to a good start for you!
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I wanted to share a few tried and true warming ideas that are regulars in my household.
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Fire Cider

Fire cider is a very old home herbal recipe. The basis is to infuse warming herbs and spices, usually in apple cider vinegar, then strain after a few weeks and use liberally throughout the wintertime. It can be used in cooking (where you would use vinegar), as a shrub (vinegar drink usually with seltzer water) or just as a small daily tonic.

If you prefer, you can buy fire cider from local herbal companies such as Wise Woman Herbals, or at your local health food store.

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photo credit to moutainroseblog

Other warming practices:

You can also try topical application of capsaicin products (the hot sensation in Icy Hot) or black cumin seed oil or black pepper oil to areas of poor circulation such as hands and feet.

Be careful with the oils as you will want to test your skin after you have diluted the oil (diluted with a neutral oil such as almond or jojoba) as the oils are very concentrated and can cause a burning sensation if too strong or left on too long.

One drop of concentrated essential oil to ten drops of carrier oil should be adequate, but test your own sensitivity level.

The last idea I wanted to share will sound very odd, but I've noticed it really helps me keep up good circulation through this winter so far… and that is cold plunging. Yes, it's a bit of a fad with the biohackers, but I really think there is something there!

After taking a long, hot sauna, I plunge for anywhere from a brief dip to three minutes.

(If you try this you need to test out your own response, as you want to avoid feeling too chilled afterward.)

I noticed improved resilience to our cold weather even after the first day, and have continued to feel more comfortable this winter doing a sauna-plus-plunge once or twice a week.
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A word of caution

These are just ideas I think are safe and appropriate for most anyone to try in their life. This is generalized information and not medical advice.

Be especially cautious if you have any peripheral vascular condition, such as Raynaud's disease (see below), as some folks are especially sensitive to temperature changes in their extremities and need more customized support.
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I wish you a wonderful entry into 2023, and all the best for you coming year!

I also wish that all who are starting new resolutions, behavioral changes, intentions, and new practices act from a place of self-compassion, self-love, and listening to what our bodies need.

There are more than enough negative messages about what we "should" do or be (or buy) out there. In case you haven't heard this recently, you are enough. Your body is a good body.

We, and our bodies, are always doing the best we can, with the resources we have available. We all deserve rest, replenishment, and the ability to take good care of ourselves.

Please let me know how I can be of assistance to you while you take care of yourself in 2023,
Dr. Angela Cortal
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Recipe for Golden Milk plus info on annual screenings

12/9/2022

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Although I function more as a specialist than a primary care physician, I thought I would put the word out there to be aware of what types of screening exams and tests may be due as we close this year out and begin another.

Though the below-mentioned screenings and tests generally are not subject to deductibles and are usually zero co-pay/co-insurance, you still may want to plan accordingly (i.e. if you have a large deductible that will start back up January 1) as any follow-up exams, tests, and visits that may be necessary based on results do not fall under those guidelines.

Here's a non-exhaustive list:

  • Annual physical exam which will commonly include blood work checking blood sugar, thyroid, iron, and cholesterol levels.
  • Cervical cancer screening (pap): every 3 years* after age 21.
        *may be run sooner if there is any change in exposure history and/or partner                        change
  • Breast cancer screening (mammogram): every 1-2 years starting at age 40.
  • Prostate cancer screening (PSA test): every 1-2 years starting at age 55-69 depending on symptoms, personal, and family history.
  • Colorectal cancer screening (colonoscopy/FIT test): every 5-10 years starting at age 45.​
  • Osteoporosis screening (DEXA scan): starting at age 65 (may be as early at 50 depending on personal and family history). Rechecks every 2-15 years depending on results, personal history, and family history.

As you can see, a lot of the recommendations are personalized based on your past medical history and any pertinent familial risk factors. If you haven't checked in with your primary care provider in a while, ask them what they think you are due for, and go from there.

Let’s end on a warm note:

The antidote in my household to all this cold, wet weather has centered around vitamin D supplementation, warming soups and stews, and a kettle of hot water always ready to brew some tea on the stove.

Here's a little Golden Milk recipe that is widely known and used for warming when the winter weather sets in.

Because I, like most people, can't stand the book-length intro that seems customary on most recipe sites, I thought I'd share a thumbnail recipe here, with a link to the full details here if you'd like to read more.
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photo credit sprig&vine
Over the course of this winter season I will share a few more of my favorite home recipes for warming your body from the inside out.

I wish you a warm and toasty winter season,
Dr. Angela Cortal

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Injection course update

8/11/2022

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Here's the update for fall of 2022...

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I am currently up to my eyeballs in planning our prolotherapy medical brigade which will be happening this October in the Cancun area of Mexico.

It's an intense training program. We have online training, a full day of in-person training before the patients show up, then three very full days of constant patient care.

It is the very most condensed way to learn full upper and lower extremity prolotherapy, and is an amazing opportunity both for those wanting to learn prolotherapy for the first time, and also for those that are newer in the field and want to get a ton of hands-on practical experience, guided by experts in the field.

In addition, I will be teaching the introductory On Point course in September.

I am also in talks to plan a new course, which will be geared towards those who already have a basic understanding and clinical experience in prolotherapy. More details to come as I confirm those details.

If you are a healthcare provider who is looking to get into this field, I hope you have already found my training page and gotten onto my email list. That is the way I keep everyone up to date as to the upcoming injection therapy opportunities.

Lastly, I have a limited ability to offer private training, in any of the injection therapies that I cover in the other courses (scar adhesion, trigger point, prolotherapy). These are arranged directly and can be held at my clinic or yours. Please email hello {at} drcortal.com and we can start chatting about what you are looking for.

Have a very lovely day,
Dr. Angela
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