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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 9 to 33 of 49. Go back in thread:
Posted by Denise528 on March 6, 2002, at 12:23:47
In reply to Re: Lithium » Denise528, posted by BarbaraCat on March 4, 2002, at 13:41:25
Hi,
Thanks to both of you for the advice, I might try upping the dose of Lithium to 300mg, the way I'm feeling right now I'll probably double it. It just doestn't make sense I can't understand why the ADs aren't working this time round, no matter how much I take. I'm also taking St Johns Wort, Sam E, Vitamin B supplments, Omega 3 fish oil, all to no avail. The only thing that is helping me this time round is the Zyprexa but not in the way that I want. Sorry for venting my frustration but I'm so disappointed and scared that nothing will ever work again and that I am stuck like this for ever and ever amen. I just don't understand why they can't do more diagnosis, why its all so hit an miss. Anyway I will get my thyroid checked and thanks again for the tips.
Denise
Posted by BarbaraCat on March 6, 2002, at 12:59:12
In reply to Re: Lithium, posted by noa on March 5, 2002, at 18:12:10
Good point, Noa. I am hypothyroid and have just increased my thyroid dosage as a precaution since I've started lithium. One thing I think is very important - take thyroid with both T4 and T3. The usually prescribed kind is synthroid or generic like levothyroxide which only has T4. This is not enough for folks with depression. We seem to need the T3 which is available in the natural dessicated brand, like Armour, or adding Cytomel, a synthetic form of T3. There's been voluminous data on this and I wonder sometimes how many of us on this board would be greatly helped by adding T3 to their mix. - Barbara
> For me, lithium did seem to add antidepressant effect but then my hypothyroidism acted up and my mood headed south again. I made the decision to discontinue the lithium but that apparently was not necessary--I could have continued the lithium and just increased my thyroid doses.
Posted by BarbaraCat on March 6, 2002, at 13:11:04
In reply to Re: Lithium, posted by Denise528 on March 6, 2002, at 12:23:47
Denise,
So sorry you've been feeling so awful. Could you explain what's going on? If it's any consolation, I'm just emerging from an absolute bummer of a bout with depression and crying jags, despair, fatigue - horrible stuff. I don't even know if it's due to the lithium increase, the thyroid increase, or klonopin increase, the fact that all the above finally kicked the remeron in - I don't know. Maybe the fear/depression finally ran it's course. But I too was at the point of defeat and discouragement to say the least and didn't think I'd ever be feeling better. But I am.It finally turned the corner and the difference now is that I have the inner knowing that I can cope with whatever comes up. I didn't have that before, I was too sick both in mind and body and spirit. Hang in there. It's a crap shoot, but just think of how much stronger we are because of this than the average bear. One other thing about the thyroid. I wrote a post to Noa, but I'll repeat it. Most doctors won't prescribe thyroid unless test numbers definitely show hypothyroidism. Most doctors will then only prescribe synthetic T4. There is much evidence that we mood affectives need the T3 form. If you want to read further, goto www.thyroid.about.com. A great site with wealth of information. Fight the good fight! - Barbara
Posted by noa on March 6, 2002, at 18:05:04
In reply to Re: Lithium » Denise528, posted by BarbaraCat on March 6, 2002, at 13:11:04
yes, the thyroid.about.com site helped me a lot, as did reading the moderator's book, "living well with hypothyroidism" and "the thyroid solution" by Arem.
Also, I found my endocrinologist through the doctor recommendation page at the thyroid site.
Posted by Ritch on March 6, 2002, at 23:48:34
In reply to Re: Lithium; thyroid site, posted by noa on March 6, 2002, at 18:05:04
> yes, the thyroid.about.com site helped me a lot, as did reading the moderator's book, "living well with hypothyroidism" and "the thyroid solution" by Arem.
>
> Also, I found my endocrinologist through the doctor recommendation page at the thyroid site.Hi Noa,
Is it the case now that "hypothyroidism" is considered a subclinical thing that requires treatment now (per the American. Endo. folks)?
I saw a number a while back and it was TSH >2.0 *now* is considered something that needed to be treated with thyroid hormones.Does that sound right?
Mitch
Posted by BarbaraCat on March 7, 2002, at 0:40:59
In reply to Re: Lithium; thyroid site » noa, posted by Ritch on March 6, 2002, at 23:48:34
Mitch,
Jumping in here. Hypothyroidism is alarmingly prevalent, actually a TSH > 1.5 and some say even >1.0 is hypo. TSH levels can show normal, but symptoms of hypo are present, and many doctors are treating for symptoms. The Endo folks are not necessarily the most respected voices here, and were the last to recognize and acknowledge the validity of the T4/T3 debate in treating depressive conditions.Alot of hypotheses about why there are so many cases (especially among women), but pesticides, stress, flouride, etc., seem to be implicated. I'd suggest you take a look at the about.thyroid.com site if interested. Some pretty fascinating stuff there. - Barbara
> > yes, the thyroid.about.com site helped me a lot, as did reading the moderator's book, "living well with hypothyroidism" and "the thyroid solution" by Arem.
> >
> > Also, I found my endocrinologist through the doctor recommendation page at the thyroid site.
>
> Hi Noa,
>
> Is it the case now that "hypothyroidism" is considered a subclinical thing that requires treatment now (per the American. Endo. folks)?
> I saw a number a while back and it was TSH >2.0 *now* is considered something that needed to be treated with thyroid hormones.
>
> Does that sound right?
>
> Mitch
Posted by Psydoc on March 7, 2002, at 5:05:55
In reply to Re: Lithium; thyroid site » noa, posted by Ritch on March 6, 2002, at 23:48:34
It has long been my impression that most endocrinologists tend to undertreat hypothyroidism in people with mood disorders. The best indicators of the adequacy of the treatment are the feeling of well-being of the person beingh treated and the level of TSH. It usually requires that sufficient thyroid hormones (optimally T-4 + T-3) be administered to cause the TSH to fall to the lowest quarter of the normal range.
If your doctor is reluctant to use the combination of T-4 plus T-3, pringt out the paper from the New England Journal of Medicine at:
http://content.nejm.org/cgi/content/abstract/340/6/424 and bring it to your next visit.Best regards . . .
Ivan Goldberg
psydoc@psycom.net
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
Posted by Ritch on March 7, 2002, at 11:37:21
In reply to Re: Lithium; thyroid site » Ritch, posted by BarbaraCat on March 7, 2002, at 0:40:59
> Mitch,
> Jumping in here. Hypothyroidism is alarmingly prevalent, actually a TSH > 1.5 and some say even >1.0 is hypo. TSH levels can show normal, but symptoms of hypo are present, and many doctors are treating for symptoms. The Endo folks are not necessarily the most respected voices here, and were the last to recognize and acknowledge the validity of the T4/T3 debate in treating depressive conditions.
>
> Alot of hypotheses about why there are so many cases (especially among women), but pesticides, stress, flouride, etc., seem to be implicated. I'd suggest you take a look at the about.thyroid.com site if interested. Some pretty fascinating stuff there. - Barbara
Barb, Thanks for the link (I bookmarked it), I will check into it later. My TSH was 1.4 the last time, but my endo is *deadset* against adding T3 or T3+T4 for my cycling. My pdoc isn't going to rock the boat with my endo by writing for that either. Actually I don't see any harm in adding a *tiny* amount to bring TSH down to around 1.0 (who knows maybe it would help a lot-not just a little)?Mitch
Posted by BarbaraCat on March 7, 2002, at 12:33:11
In reply to Re: Lithium; thyroid site » BarbaraCat, posted by Ritch on March 7, 2002, at 11:37:21
Mitch,
Be wary of getting TSH too low. Hyper symptoms are no fun, and can set off hypomania, agitation, insomnia, headaches. Supplementing with thyroid hormone can also suppress your natural production. Your TSH of 1.4 seems to be in an ideal spot and I'd certainly hesitate to mess with that.If you have doubts about the accuracy of your TSH readings, you might try the basal thermometer test. It's efficacy is somewhat anecdotal, but remains a time honored method of testing. Shake down mercury thermometer before going to bed at night. On waking, before moving around or going to the bathroom, place thermometer in the armpit for 10 minutes. If readout is less than 97.4, chances are you're hypothyroid. - Barbara
Posted by Ritch on March 7, 2002, at 13:51:04
In reply to Thyroid » Ritch, posted by BarbaraCat on March 7, 2002, at 12:33:11
Posted by JackD on March 7, 2002, at 14:05:05
In reply to Re: Lithium » capricorn, posted by BarbaraCat on March 3, 2002, at 14:08:30
> Not on it's own, but it's the spark plug that makes my Remeron work. It's made all the difference, since any antidepressant pooped out on any dose. - Barbara
>Barbara, any helpful feedback you could give me regarding your experience with Remeron in addition to a mood stabilizer would be greatly appreciated. JohnX2 has suggested I may be Bipolar II, and from further research I've done I realize it is more than likely I am. Oh, and I LOVE Remeron... the trick now is for me to "lock onto", as John said, to Remeron's positive effects.
P.S. Sorry to pirate this thread.
Posted by Dave1 on March 7, 2002, at 17:31:32
In reply to Re: Lithium » Denise528, posted by BarbaraCat on March 6, 2002, at 13:11:04
Hi,
I'm taking anafranil - 250mg/day. And lithium - 1200mg/day. It started to help my depression about a week ago.
Bye,
Dave
Posted by BarbaraCat on March 7, 2002, at 18:53:14
In reply to Remeron and Lithium -Barbara, posted by JackD on March 7, 2002, at 14:05:05
Hi Jack,
Glad to offer any help I can. I've had depressions and panic like symptoms periodically since my teens. Was on most of the old antidepressants and finally the SSRI's when Prozac became available. Zoloft was the one I was on for the longest, about 6 years. After 3 years of successful treatment, the depression started breaking through, as well as the panic attacks, so my doc kept upping the dose. This actually made me feel worse and so I tried going off ADs. Four attempts at quitting, some as long as 1 year and I felt OK, but the cycling of depression/panic would start up again and I'd have to go back on. Tried everything, celexa, effexor, paxil, wellbutrin, serzone. They'd all work for a short time then poop out and any increase would leave me feeling agitated and depressed, not to mention sexually and emotionally numb.Remeron was a different feeling altogether from the start and for two months at 30mg I have never felt better. Motivated, happy, calm, wonderful. Then at month 3 it pooped totally and I went into a bleak, dark and scary depression, feeling the rug had been pulled out yet again. This was back in late November.
My pdoc had been suggesting lithium as an augmentor all along, but I resisted, mainly because of the health cautions. Lithium requires monthly blood and urine tests since it has to fall within a window of blood level or can be toxic and cause renal failure. I'm very health conscious and this scared me, but figured the emotional stress I was under was probably killing me so what the heck. I'm also *so far* only taking 300 mg a day instead of the usual much higher doses for bipolar disorders.
While in the midst of a crushing depression, I started feeling better within 3 days of the lithium and could feel the same earlier effects from Remeron kicking in. The two act synergistically. The extra mood elevation has allowed me to get back to exercising which for me is the most effective antidepressant, but totally impossible when my brain in miswired.
I suspect I'm bipolar II as well from my past history of occassional hypomania (never long enough, alas), followed by horrible depression, as well as my non-response to AD's. So to make a very long story come to the point, I once again LOVE Remeron, but without the Lithium (and klonopin and thyroid as well which are crucial for me), it would be worthless. Hopefully I can remain at the low end of 300 mg and avoid the health stuff. Feel free to converse anytime. BTW, what makes you suspect BP-II for yourself? - Barbara
Posted by JackD on March 7, 2002, at 20:50:53
In reply to Re: Remeron and Lithium -Barbara » JackD, posted by BarbaraCat on March 7, 2002, at 18:53:14
Ah, a medicine love story; lithium and remeron. I hope I have as much success... I suspect bipolar since I have had very strong and rapid responses to meds, especially the more activating ones. However, after short while the meds soon stop working and make me even worse off than I was to begin with. I also have ADD, which is often comorbid with Bipolar. From the literature I've read symptoms of Bipolar II seem much more fitting than Bipolar I. Also, in retrospect, I have always been SO inconsistent with almost every aspect of my life. Even as far back as elemtary school through now (college), my teachers have said I'm very unpredictable and inconsistent. I'm sure there are a few more reasons for my prognosis, but I can't think of any off hand. Well, anyway, thanks for your input.
Posted by jane d on March 7, 2002, at 23:29:40
In reply to Hypopthyroidism in people wioth mood disorders., posted by Psydoc on March 7, 2002, at 5:05:55
I hadn't realized until now that the NEJM was allowing free access to some (most?) articles over 6 months old including the one recommended by Ivan Goldberg (many thanks!) below. You do need to register for it but that's easy enough. Just wanted to spread the word in case anyone else out there didn't know this.
Jane
> It has long been my impression that most endocrinologists tend to undertreat hypothyroidism in people with mood disorders. The best indicators of the adequacy of the treatment are the feeling of well-being of the person beingh treated and the level of TSH. It usually requires that sufficient thyroid hormones (optimally T-4 + T-3) be administered to cause the TSH to fall to the lowest quarter of the normal range.
>
> If your doctor is reluctant to use the combination of T-4 plus T-3, pringt out the paper from the New England Journal of Medicine at:
> http://content.nejm.org/cgi/content/abstract/340/6/424 and bring it to your next visit.
>
> Best regards . . .
>
> Ivan Goldberg
> psydoc@psycom.net
> %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
Posted by Thrud on March 7, 2002, at 23:52:35
In reply to Hypopthyroidism in people wioth mood disorders., posted by Psydoc on March 7, 2002, at 5:05:55
Hi Psydoc,
Maybe you can help me with a little puzzle that has vexed me for a couple of years.
A couple of years ago I tried l-tyrosine as a monotherapy for depression/panic/crushing fatigue because I was so sick of SSRIs. After about 2 weeks it really kicked in and I excitedly told my family that I felt well for the first time in 10 years. There was one major problem though...it made me completely impotent, more than any SSRI. In the end it pooped out after a couple of months and I had to move on to other meds.
I did a lot of research on l-tyrosine to see where it is used in the body and see if I could pinpoint some biological basis for my problems: I simply shouldn't have felt that good (or that impotent) on a simple amino acid. I was using the standard dose of 1500mg per day.
It seems to be involved in the endocrine system a lot, including the thyroid. I also believe that the thyroid is connected to sexual function (through some hormone I guess) but I could find nothing linking higher levels of l-tyrosine to impotence. In fact the opposite always seems to be reported: the increase in brain dopamine is supposed to increase sex drive. My TSH levels are tested periodically and have always been normal.
I have celiac disease and know that there is some comorbitity with thyroid autoimmune problems. Could there be a thyroid problem which is not reflected in TSH levels? If it helps, I have just been found to be low in testosterone and LH.
I have discussed this all this with my pdoc and he is referring me to an endocrinologist. In the meantime, if you have any insights to offer I would be very, very appreciative.
Thrud
Posted by BarbaraCat on March 8, 2002, at 0:09:45
In reply to Re: Remeron and Lithium -Barbara, posted by JackD on March 7, 2002, at 20:50:53
Yep, your story sounds very similar to mine. I think we may be one of the few folks on this board who are on the lithium/remeron combo so I'll be interested to hear how your faring. Keep in touch. - Barbara
> Ah, a medicine love story; lithium and remeron. I hope I have as much success... I suspect bipolar since I have had very strong and rapid responses to meds, especially the more activating ones. However, after short while the meds soon stop working and make me even worse off than I was to begin with. I also have ADD, which is often comorbid with Bipolar. From the literature I've read symptoms of Bipolar II seem much more fitting than Bipolar I. Also, in retrospect, I have always been SO inconsistent with almost every aspect of my life. Even as far back as elemtary school through now (college), my teachers have said I'm very unpredictable and inconsistent. I'm sure there are a few more reasons for my prognosis, but I can't think of any off hand. Well, anyway, thanks for your input.
Posted by JohnX2 on March 9, 2002, at 1:14:44
In reply to Re: Hypopthyroidism in people wioth mood disorders. » Psydoc, posted by Thrud on March 7, 2002, at 23:52:35
Thrud,I've looked into and also tried l-tyrosine and
also l-phenylalanine suplemenatation with short lived poop out
results. My understanding of the biological pathway is that the
amino acid in the vast majority of neurons already saturates
the bottlneck enzyme called "tyrosine hydroxylase".
phenylalanine (via phenylalanine hydroxylase)-> tyrosine (via tyrosine hyrdroxylase)-> l-dopa -> dopamine -> norepineprine
The phenylalanine is converted to tyrosine through
a phenylalnine hydroxylase enzyme. Subsequently tyrosine
gets converted to l-dopa via a "tyrosine hydroxylase" enzyme.
And then l-dopa can get converted to dopamine and then
potentially norepinephrine.In the vast majority of cells the diet swamps the enzyme
tyrosine hydroxylyse. So for most people taking tyrosine
precursor provides no benefit. However, you can bypass by
taking l-dopa as in parkinson's.Now for impotence, its interesting that we usually see this
a lot in medicines that are norepinephrine reuptake inhibitors.
A lot of people complained of this in Reboxetine. People found
relief for this with medicines that blocked the noradrenaline
"alpha-1" receptor like "Flomax". Also medicines with side effects
like priapism (permanent erection) such as Trazodone, block the
noradrenaline "alpha-1" receptor. So I wonder if your effect had
more to do with norepinephrine than dopamine.-John
> Hi Psydoc,
>
> Maybe you can help me with a little puzzle that has vexed me for a couple of years.
>
> A couple of years ago I tried l-tyrosine as a monotherapy for depression/panic/crushing fatigue because I was so sick of SSRIs. After about 2 weeks it really kicked in and I excitedly told my family that I felt well for the first time in 10 years. There was one major problem though...it made me completely impotent, more than any SSRI. In the end it pooped out after a couple of months and I had to move on to other meds.
>
> I did a lot of research on l-tyrosine to see where it is used in the body and see if I could pinpoint some biological basis for my problems: I simply shouldn't have felt that good (or that impotent) on a simple amino acid. I was using the standard dose of 1500mg per day.
>
> It seems to be involved in the endocrine system a lot, including the thyroid. I also believe that the thyroid is connected to sexual function (through some hormone I guess) but I could find nothing linking higher levels of l-tyrosine to impotence. In fact the opposite always seems to be reported: the increase in brain dopamine is supposed to increase sex drive. My TSH levels are tested periodically and have always been normal.
>
> I have celiac disease and know that there is some comorbitity with thyroid autoimmune problems. Could there be a thyroid problem which is not reflected in TSH levels? If it helps, I have just been found to be low in testosterone and LH.
>
> I have discussed this all this with my pdoc and he is referring me to an endocrinologist. In the meantime, if you have any insights to offer I would be very, very appreciative.
>
> Thrud
Posted by Psydoc on March 9, 2002, at 6:10:39
In reply to Re: Hypopthyroidism in people wioth mood disorders. » Psydoc, posted by Thrud on March 7, 2002, at 23:52:35
Hi . . .
In the 8/16/80 issue of The Lancet I puiblished some brief case reports regarding people who had a good response to l-tyrosine. Symptoms of AD(H)D and depression were controlled. The only problem was that in soime people the results were not long-lasting and in other people l-tyrosine seemed to have no effect on thinking, mood or behavior.
Unfortunately I am unable explain the effectiveness or loss of effectiveness of l-tyrosine.
Best regards . . .
Ivan Goldberg
psydoc@psycom.net
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
Posted by Zo on March 12, 2002, at 2:25:51
In reply to Hypopthyroidism in people wioth mood disorders., posted by Psydoc on March 7, 2002, at 5:05:55
Posted by Thrud on March 12, 2002, at 4:47:45
In reply to Re: Hypopthyroidism in people wioth mood disorders. » Thrud, posted by JohnX2 on March 9, 2002, at 1:14:44
Hi John,
> I've looked into and also tried l-tyrosine and
> also l-phenylalanine suplemenatation with short lived poop out
> results.I get the feeling that the body has "thermostat" levels set for just about every chemical in the body, and if it is a natural substance like tyrosine, it quickly figures out how to counter-act elevated levels (extra liver metabolism etc?).
It seems to take a fair time longer to figure out how to counteract (unnatural-to-the-body) psychmeds but does seem to eventually succeed in most people.>My understanding of the biological pathway is that the
> amino acid in the vast majority of neurons already saturates
> the bottlneck enzyme called "tyrosine hydroxylase".
>
> phenylalanine (via phenylalanine hydroxylase)-> tyrosine (via tyrosine hyrdroxylase)-> l-dopa -> dopamine -> norepineprine
>Yeah, I had a look at the metabolic pathways one day as well and noticed a possible bottleneck in tyrosine hydroxylase. I then bought some NADH which supposedly helps depression by increasing the production of tyrosine hydroxylase. It didn't really do much for the depression and also made me somewhat impotent. I don't really recommend it to anybody.
>So I wonder if your effect had
> more to do with norepinephrine than dopamine.
>
> -JohnI can't say. L-tyrosine is also used in the thyroid, thalamus, hypothalamus and adrenal glands. Any one of these could be screwy too. My low testosterone and LH levels has now given me an excuse to see an endocrinologist, so I will ask for a full work up.
I can't stand enforced celibacy for much longer................
Thrud
Posted by Thrud on March 12, 2002, at 4:52:49
In reply to Re: Hypopthyroidism in people wioth mood disorders. » Thrud, posted by Psydoc on March 9, 2002, at 6:10:39
Hi Psydoc,
Are there thyroid problems that might not be reflected in abnormal TSH levels, yet still affect mood and/or sexual function?
I've read that low thyroid hormone levels can cause impotency (although I don't know the mechanism) but then TSH levels should not be normal (mine always have been).
Thanks,
Thrud
Posted by BarbaraCat on March 12, 2002, at 11:42:05
In reply to Hypopthyroidism in people wioth mood disorders., posted by Psydoc on March 7, 2002, at 5:05:55
Dr. G.
Have a question for you. What is your opinion of taking T3 in the form of Armour or another dessicated thyroid hormone vs. synthetic T4 + Cytomel (synthetic T3) for hypothyroid with depression? Have you heard any positives about time release T3? (I haven't - felt like it dumped it's load all at once causing jitters). Thanks for feedback.
Posted by BarbaraCat on March 12, 2002, at 11:45:59
In reply to Love that Cytomel ! (nm) » Psydoc, posted by Zo on March 12, 2002, at 2:25:51
So speak to us, Zo. Why are you taking Cytomel? Hypothyroid? Depressed? Both? How much are you taking and how many times a day? Do you take it with levothyroxine or alone? Why do you love it?
I'm on 2 grains Armour thyroid. My TSH level is good, but I'm still dragging. Thinking of making the switch to synthetic T4 + Cytomel, but have not heard any 'real' stories praising Cytomel. - Barbara
Posted by noa on March 12, 2002, at 17:07:08
In reply to Re: Lithium; thyroid site » noa, posted by Ritch on March 6, 2002, at 23:48:34
I think one problem is that with the ease of TSH tests, testing is done more widely but the guidelines of "normal" being in the range of about 1 to 5 have been relied on too rigidly at the expense of listening to how the patient feels. Also, many doctors rely too heavily on just the one test--TSH--when other data may be needed. TSH is a good *screening* tool in my opinion, but not the be-all and end-all of diagnosing thyroid problems. But I think that manged care being what it is, unfortunately, SOP for many doctors is to rely on such screening tools as well as quick and easy numbers guidelines which were really intended to be statistical norms and not the definition of what is normal functioning for any one individual.
The 2.0 that you are referring to, I believe comes from an article in a British medical journal (please see the thyroid and depression folder --it is linked there) which suggests that anything 2.0 or above has a high correlation with subsequently emerging signs and symptoms of hypothyroidism, and therefore TSH results in the lower 1/4 of the so-called "normal" range should be considered not normal and treatment should be considered.
For me, I had a TSH at around 4.5-5. My pdoc prescribed cytomel and later, synthroid. My TSH then hovered around 2.5 for a while and I felt better than before, but not great. On lithium, the TSH went up to 3.8. I saw an endo who raised my doses gradually based on how it affected how I felt. He anticipated that my TSH target would be below 1, and subsequently wrote a letter to my Primary Care doctor saying that in his experience, patients with hypothyroidism and depression do best when thyroid is treated to the point of getting TSH below 1. My improvement leveled off at around .3, although even after that, I continued to feel increasingly better at that level of treatment.
I think the endocrinology *establishment* (ie organizations) should be distinguished from endocrinologists. You should go to an endo that you have recs about from other people--one who is up on the latest research about hypothyroid undertreatment, etc. and who does not rely solely on blood tests, but combines this data with listening to the patient about how they feel--but don't write off the whole profession, either. My endo has been fantastic--and my life drastically improved because I went to see him.
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