For those that are needing more information about Telemedicine, we have put together a Q&A to answer common questions. If there is a question you still have that is not listed here, please do not hesitate to give us a call!
What is Telemedicine? Telemedicine is like a Skype or Face Time call. It is a two-way, face-to-face video conference.
Why are you not just using Skype or Face Time then? Skype and Face Time are not HIPAA compliant/secure. Our program that we use is
Do I have to download something? Nope. The link that we send to you automatically connects you to the secure video conference.
Do I have to do it on my phone? Nope. You can do it on your computer but your computer MUST HAVE speakers and a video camera.
So how does this work then? Suzi will send you a text if you want to use your phone, or an email if you want to use your computer. You click on the link in the text or email and that connects you to the call. You will see Suzi on the screen.
Can I not just wait a few months to go over my results? We recommend that you continue your care just like normal with this face-to-face video visit. This allows us to make sure your medications are working correctly and give you plenty of refills just like normal.
We have all heard of it and many of us suffer from it…PMS or Pre-Menstrual Syndrome. Symptoms such as bloating, hunger, headaches, and moodiness can begin anywhere from 5 to 11 days before menstruation. Most women (about 90%) get some sort of PMS symptoms each month and this is especially true for women in their 30s.
What are the symptoms of PMS?
Physical symptoms of PMS can include:
Swollen or tender breasts
Bloating or a gassy feeling
Headache or backache
Constipation or diarrhea
Emotional symptoms of PMS can include:
Increased appetite or food cravings
Sleeping too much or too little
Trouble with concentration or memory
Tension or anxiety
Depression, feelings of sadness, or crying spells
Less interest in sex
How/why does PMS occur?
After ovulation, progesterone and estrogen increase to prepare the uterus for pregnancy. If pregnancy does not occur, these levels begin to decline quickly. It is the decrease in progesterone that triggers symptoms such as the increased craving for chocolate and the mood swings.
How do I test for PMS?
A qualified bio-identical hormone replacement center can do a simple blood draw to test your hormone levels (preferably on days 19-21 of your cycle). This test and your symptoms will let your doctor know how to treat you.
How can I treat PMS?
Once your labs results have come back, your doctor may want to prescribe you supplemental progesterone for all or part of your monthly cycle. This increase in progesterone can combat many of the physical and emotional symptoms of PMS.
What can I do at home to help control PMS?
Exercise—this helps your body deal with stress and releases endorphins that help create a positive mood.
Get enough sleep—sleep is critical to your body’s ability to deal with stress and succeed in repairing any cellular damage that occurs during the day.
Eat healthy—make good food choices (at least most of the time). Meat, veggies, and fruits should makeup the bulk of your diet.
Dr. Melissa Miskell is the Medical Director of Hormones by Design, a bio-identical hormone replacement center in Waco and Boerne, Texas. Her highly trained Nurse Practitioners have been treating hormone patients for more than 10 years and are accepting new patients. In San Antonio, call (210 305-5077. In Waco call (254) 230-4225 to schedule with Women’s Health Nurse Practitioner, Suzy Hancock. In Boerne call (830) 981-9540 to schedule with our Family Nurse Practitioner, Nancy Beebe.
It feels like one day we are chasing toddlers and the next we are nearing menopause. Two common symptoms that usher in this phase of life are hot flashes and night sweats. For most women, establishing care with a qualified bio-identical hormone center makes these symptoms more manageable.
However, there are patients that cannot take bio-identical hormones (or simply do not want to). What can those patients do? Here are some natural options for alleviating the frequency and severity of hot flashes and night sweats.
Exercise– Many scientific researchers have proven that exercise stimulates the release of feel-good hormones called endorphins. Brisk walking, jogging, and swimming are good aerobic activities that can help release tension in the body and mind.
Relax and Mediate– Practice deep abdominal breathing. Sit in a quiet spot to inhale and exhale slowly for just 15 minutes. Controlled breathing (characterized by slow and deep breaths) can calm and relax the body. Waking up in the middle of the night because of night sweats? Using this technique may help calm you.
Keep a Diary – Keep track of the time of episodes, the stress level or emotional state when it occurs, food and drinks consumed prior to occurrence, clothing worn, sleeping conditions (if it’s a night sweat), activities done and other elements that might have triggered the episode. This can help you avoid those triggers.
Supplements – There are pharmaceutical grade supplements available that will help you through these symptoms. For example, I recommend Xymogen’s Femquil. This supplement helps your body deal with xenoestrogens (hormone disrupting compounds found in the environment) and promotes healthy hormone balance. (More on Xymogen below).
You can try one or all these options. They are all safe and do not involve the use of hormones. Need more information on what you can do to help with your hormonal symptoms? You can still see a qualified bio-identical hormone center. On occasion, problems with your thyroid can cause symptoms like hot flashes or night sweats. A simple blood test can help your doctor determine what you need (whether vitamin or prescription) and how much.
Interested in ordering the Femquil mentioned here? Xymogen provides our pharmaceutical grade supplements we use in the office. Simply go to Xymogen.com, Patients, Xymogen Xpress, and register. Call or email our offices to get your Referral Code. Physician Code is always: Miskell.
Dr. Melissa Miskell is the Medical Director of Hormones by Design, a bio-identical hormone replacement center in Waco and Boerne, Texas. Her highly trained Nurse Practitioners have been treating hormone patients for more than 10 years and are accepting new patients. In Waco call (254) 230-4225 to schedule with Women’s Health Nurse Practitioner, Suzy Hancock. In Boerne call (830) 981-9540 to schedule with Family Nurse Practitioner, Nancy Beebe.
Yep, you know you are having a hot flash when you feel like you are going to spontaneously combust. Nothing sounds better than standing in front of the open freezer door (and even then, that is not cool enough). Well, there are some things in life that promote hot flashes. If at all possible, you should try to minimize doing these things…
Drinking alcohol—I know, that glass of wine at the end of the day is one of the ways you relax. I understand! However, alcohol can trigger a histamine response in many women (you can see this when your cheeks start to get flushed after drinking). This histamine response can also trigger a hot flash. Try to limit your alcohol consumption and take a supplement like Xymogen’s Hist DAO before drinking. (More on Xymogen below)
Eating spicy foods—Mexican, Thai, or Chinese…all these foods tend to be spicy. Consumption of spicy foods tends to make you flush and sweat, leading to increased hot flashes. Limit your consumption of spicy foods when possible.
Smoking—If you needed one more reason to quit, here it is. Smoking increases hot flashes. However, if you have a genetic predisposition to poor estrogen metabolism and increased sensitivity to environmental toxins smoking can make menopause in general more severe. Consider kicking the habit.
Getting overheated—By this I mean getting overheated with no real way to cool down effectively. Painting in a hot room with no air conditioning, or just being outside during a summer day in Texas. Once you start the sweating and flushing, a full-blown hot flash can follow. Try to plan these activities when the temperatures are not soaring.
One thing to always consider when dealing with hot flashes is when to see a hormone specialist. Remember you don’t have to suffer. Bio-Identical hormones can help replenish your levels to where you feel good again! A simple blood test can tell your hormone doctor what you need to be taking and how much.Dr. Melissa Miskell is the Medical Director of Hormones by Design, a bio-identical hormone replacement center in Waco and Boerne, Texas. Her highly trained Nurse Practitioners have been treating hormone patients for more than 10 years and are accepting new patients. In Waco call (254) 230-4225 to schedule with Women’s Health Nurse Practitioner, Suzy Hancock. In Boerne call (830) 981-9540 to schedule with Family Nurse Practitioner, Nancy Beebe.
Want to order some of the Hist DAO mentioned above? You can order pharmaceutical grade supplements through Xymogen Xpress. Simply go to Xymogen.com, Patients, Xymogen Xpress, and register. Call or email our offices to get your Referral Code. Physician Code is always: Miskell.
By now most people have at least heard about hormone replacement. But how do you know if you need it? Well, here are five distinct signs that hormone replacement could benefit you.
Hot Flashes – If you have ever had one, you KNOW what I am talking about. When it feels like your entire body is going to ignite and you need to stand in front of the open freezer, you are experiencing a hot flash. This is a sure sign that your hormones are changing, and you need to investigate hormone replacement. You don’t have to put up with this…it can be fixed.
Night Sweats – Can sometimes go hand-in-hand with hot flashes but waking up with your nightgown soaking wet doesn’t have to be tolerated. Not only is this a huge nuisance, it will inevitably interfere with your sleep, causing all the health issues that correspond with sleep deprivation as well.
Weight gain – Yes, getting “thicker around the middle” can be related to hormone imbalance. Particularly for women, weight gain is usually in the abdominal area. Thyroid can also play a role in weight gain and should be checked along with hormone labs.
Fatigue – Remember how much more energy you had when you were in your 20s? Well, part of that energy was due to your increased hormone levels during that time. Hormone replacement (in particular Bio-Identical Hormone Replacement) can help to replenish these hormone levels and get back the “pep in your step!”
Lack of Sex Drive – Don’t be afraid to admit it…you may be apathetic about sex. Not really wanting or caring if you have sex is a sign that your hormones levels are declining. Women need testosterone too (in much smaller doses than men) in order to help keep their sex drive active. If you find yourself just not in the mood, you need to see a qualified hormone replacement doctor. Believe me, your significant other will thank you.
There are multiple other signs and symptoms that hormone replacement can help alleviate. However, if you currently have any one of these five, you should see a doctor. A simple blood test can show the levels of all your hormones and thyroid.
Dr. Melissa Miskell is a bio-identical hormone replacement expert who has been practicing for 18 years, and is the Medical Director of Hormones by Design in Waco, Texas. Suzi Hancock is a Women’s Health Nurse Practitioner that will love to see you in our Waco office! Hormones by Design is currently accepting new patients at (254) 230-4225.
We now accept insurance for lab testing in our Hormones by Design offices!
In an effort to make top-notch care more affordable or our patients in Waco and Boerne, we will now take insurance for labs, as well as, still offering cash labs. So come in and we can test everything from your cholesterol, to your liver function, to your level of inflammation…all through your insurance. We want to make sure that all your blood markers are at the best possible levels because we want you as healthy and vibrant as possible! Interested in being tested? Call our office today or drop by for your blood draw on or after September 4th, 2018.
Office visits will still be the one simple price of $100. Labs will now be sent to you insurance.
If you do not currently have insurance, it’s no problem! We have made the hormone labs necessary for injections even more affordable. As an example, Estradiol, Progesterone, Testosterone, and SHBG will now be only $40, or $10 per lab test for injection patients.
The health of your gastrointestinal tract (GI tract) affects your entire body. One of the main supplements that I recommend to my patients is a good quality high-dose probiotic. Why you ask? Let me tell you…
Your gastrointestinal tract is a complex ecosystem containing thousands of species of bacteria. These bacteria can be found in your stomach and small intestines, but the majority are found in your colon. Collectively these areas make up your “microbiome.” These intestinal flora aid in digestion, synthesize vitamins and nutrients, metabolize some medications, support the development and functioning of the gut, and enhance the immune system.
There are times when this balance of beneficial bacteria gets out of balance such as with the extended or recurrent use of antibiotics, poor dietary habits, or recent infection. This is where the use of a probiotic becomes advantageous. A good multi-strain probiotic can help to recolonize the GI tract to the proper balance of beneficial bacteria. But how do you recognize a high-quality probiotic?
It is multi-strain. This means that it has more than one type of bacteria in each capsule. The one I recommend the most contains Lactobacillus acidophilus, Lactobacillus plantarum, Bifidobacterium longum, & Bifidobacterium lactis.
It is packaged so that oxygen cannot reach the capsules or is consistently refrigerated (even during transport) so that the organisms cannot get overheated and die.
It is high dose. For maximum results the GI tract needs maximum exposure. For those patients that have GI issues or tend to have weakened immune systems, I recommend 100 Billion CFU (the measurement for bacteria is Colony Forming Units) daily. Other patients that simply need to maintain GI health can take the 100 Billion CFU capsule every other day or just several times per week.
Some foods also promote healthy and abundant GI flora. For example, sauerkraut and kimchi are fermented foods that contain probiotics. Other foods provide the precursors to probiotics called “prebiotics”. Those are foods like: asparagus, onions, garlic, cabbage, and artichokes. These foods are mainly carbohydrates that cannot be digested by the body, but are food for the probiotic (or good) bacteria. Following these guidelines will get you to a better place with your bowel movements (diarrhea or constipation), vaginal health, skin health, and even a healthier immune system.
I have quite a few patients that are concerned about their bone health, and the first question they normally ask is “how much calcium should I be taking?” The answer is that amounts vary according to the patient, and you should not be taking calcium alone.
The first question you should ask is what is bone made of? Bone is composed of several calcium-based minerals and collagen. This means that if you are going to take a supplement to support your bones, you need to take multiple supplements.
Here’s the basics of bone health:
1. Calcium is still a necessity. However, not all calcium supplements are created equal. My preference is for what is called MCHC (Microcrystalline Hydroxyapatite Concentrate). This is a standardized, and safe-source bone extract from New Zealand bovine, that contains a crystalline calcium and phosphorus matrix. It is also what your bones are made of.
2. Vitamin D3. Yes, you need Vitamin D3 (cholecalciferol) to support bone health as well. Vitamin D’s best-known role is to keep bones healthy by increasing the intestinal absorption of calcium.
3. Collagen. This is supported through a silicon based supplement (specifically orthosilicic acid). Collagen helps bone withstand sudden impact, and determines how “tough” your bones are.
4. Vitamin K2. Vitamin K2 (as menaquinone-7) supports calcium utilization and absorption. Some younger patients do not require added Vitamin K2 supplements.
How do you know the right combination of supplements for your bone health? Ask your doctor. The good news is that there are supplements available that contain all these ingredients in one packet, or you can purchase them separately. If you are a post-menopausal woman with osteopenia or osteoporosis, you are going to need considerably more of each of these supplements to ensure that you arrest your bone loss.
When most practitioners talk about “anti-inflammatory” they are generally referring to prescriptions that mask swelling such as NSAIDs like ibuprofen or naproxen. When functional medicine practitioners talk about anti-inflammatory we are referring to the foods and supplements that prevent the cause of inflammation in the body.
Inflammation is the beginning of all disease states whether acute or chronic. Obviously acute inflammation is necessary for the body to start repairing damage from some harm inflicted recently such as a sprained ankle or a cut finger. Chronic inflammation is what you never want your body to experience.
First, how do I know if I have chronic inflammation?
Chronic inflammation manifests itself in many different ways. The most common are:
Joint swelling & tenderness
Muscle aches (not muscle soreness from exercise)
Abdominal pain & bloating
Any autoimmune disorder
If you have one or more of these symptoms, you are experiencing chronic inflammation.
So I have chronic inflammation, what do I do now?
Step number one when working to combat chronic inflammation is to look at your diet. I firmly believe that “you are what you eat.” However, making healthy choices can be confusing. The media and the internet are filled with conflicting information on “eat this food…but don’t eat this food…no, it’s ok to eat this food in moderation.” So what’s a person to do? I’m going to make this relatively simple.
A simple summary of what to eat:
Eat organic, grass-fed/free-range meats or wild-caught seafood/fish
Eat organic produce (this includes all fruits and veggies)
What not to eat:
Avoid as much of these as possible:
Grains of any type (yes, that means no bread)
Sugar in any form (use Stevia instead)
Artificial sweeteners (yes, pink ones, yellow ones & blue ones)
Caffeinated beverages (substitute herbal teas or better yet, just drink water)
Alcohol in excess
All dairy (yes, cheese too)
Eggs (food allergy testing can confirm if you must avoid these long-term)
If you have already progressed to an autoimmune disorder, then you need to be especially diligent in your eating habits and avoid everything on this list.
If you would like to get a firm answer on what exactly your food allergies & sensitivities are that are causing your chronic inflammation, see a practitioner that does testing. In my office, we use Alletess Food Allergy/Sensitivity testing. We welcome current patients to come in and request the test.
Focus on Curcumin
Once patients have begun to work on their diet to eliminate the foods that are perpetuating chronic inflammation, I look to one of my favorite supplements that can help reduce any remaining swelling & discomfort…Curcumin.
Curcumin is the active compound in Turmeric. It is yellowish in color and has been a part of Indian and Asian diets for centuries. Interestingly enough researchers began to notice that those countries had a much lower incidence of arthritis and other inflammatory diseases. Additional research has found that Curcumin plays a role in decreasing inflammation and protecting the body from inflammation.
I never recommend starting any supplement without speaking with your physician first. As with all medications your healthcare provider will make sure it will not interfere with any of your other medications. I also recommend that you consult a physician on what dosage of curcumin would be best for you.
As patients, we all strive to do what is best for our bodies. We eat well, exercise, and take any necessary medications when needed. However, what is not well known is that sometimes the medications we take can cause a depletion of important nutrients.
Don’t get me wrong, prescription medications are a necessity for many people and I am not in any way advising you to NOT take your prescribed medications. I simply would like to educate you on the nutrients you will need additional intake of, when taking certain medications.
Since there are a lot of medications that can cause nutrient depletion, I am going to break them up into a two-part series and only tell you about a couple of drugs at a time. This month I would like to address Antacids and Non-Steroidal Anti-Inflammatories (NSAIDs).
This category includes medications such as Pepcid, Tagamet, Prevacid, Prilosec, and magnesium & aluminum containing antacids (such as Gaviscon, Maalox, Mylanta).
Antacids work by neutralizing stomach acid or by inhibiting the release of a digestive enzyme (like pepcin). Unfortunately stomach acid is necessary to release vitamins from food, and when you decrease or stop the production of it, you absorb fewer vitamins.
These medications can cause deficiencies in the following nutrients:
Most common of these is deficiencies is B12. Vitamin B12 deficiency can cause anemia, depression, tiredness, and weakness. The good news is that Vitamin B12 is easy to supplement. When choosing a B12 supplement, you want to look exclusively for the methylated form…Methylcobalamin. Dosages range from 1 to 5mgs and it can be taken twice daily if needed. I recommend taking it in the morning and around noon. Vitamin B12 provides energy, so never take it too close to bedtime. Vitamin B12 is also “water soluble” meaning that you cannot overdose on it since the body automatically eliminates any excess through urine.
Talk to your doctor about the proper dosing for you when supplementing for Folic Acid, Vitamin D, Calcium, Iron, and Zinc. Vitamin D is a fat-soluble vitamin. You can take too much of it, so be sure to have your blood tested to keep your levels in check.
This group includes medications such as Motrin, Aleve, Advil, Anaprox, Dolobid, Feldene, and Naprosyn.
These are all known to cause folic acid deficiency due to a decrease in the body’s ability to absorb folate from the intestine.
Folic acid deficiency can cause birth defects, anemia, and a higher risk of cardiovascular disease.
Also in this group is aspirin and other salicylates.
Long term use of aspirin is linked to deficiency in the following nutrients:
Vitamin B5 (Pantothenic Acid)
Aspirin can cause the body to expel more Vitamin C in urine than normal and Vitamin C is essential for a healthy immune response. Calcium is necessary for bone, heart & dental health. Iron prevents anemia, weakness, fatigue, hair loss, and brittle nails. Vitamin B5 helps with fatigue and listlessness.
Most of these nutrients are available in a high-quality multivitamin, however if you are on an aspirin therapy regimen, I recommend talking to your doctor about dosage to replenish these nutrients.
Now let’s address anti-depressants, antibiotics, cholesterol lowering drugs, and diabetic drugs. I would like to stress that I am NOT advocating that you stop taking any medication that your doctor has prescribed, only letting you know that you may require additional amounts of these nutrients to stay healthy while on that medication.
Anti-depressants include Prozac, Effexor, Lexapro, Wellbutrin, and many more. With long-term use of anti-depressants, you are going to deplete two things: Coenzyme Q10 (CoQ10) and Vitamin B2 (Riboflavin). You can get some CoQ10 from your diet, but most patients require a supplement. Natural sources are: red meat, oily fish, and some nuts. When choosing a CoQ10 supplement, make sure the manufacturer is reputable (preferably pharmaceutical grade). Your doctor can help you understand what dose of CoQ10 is right for you.
Vitamin B2 (Riboflavin) is found in foods such as beef liver, lamb, mushrooms, spinach and almonds. You can also find B2 as a supplement alone or in a B-Complex.
Antibiotics include medications such as Gentamycin, Neomycin, Streptomycin, Cephalosporins, Penicillins, and Tetracyclines. Most antibiotics are used only for a short amount of time. However, some patients are put on long-term antibiotic therapies. This long-term use can lead to depletion of:
You can increase intake of these vitamins and minerals through a healthy diet, but some patients will need to incorporate a high-quality multivitamin daily. No matter what choice you make for vitamin repletion, every patient will require a high-dose probiotic to recolonize the bacteria in the gastrointestinal tract. Talk to your doctor about what probiotic is right for you.
Drugs in this category are collectively called “statins” and include names like: Lipitor, Crestor, Zocor, and others. They too deplete Coenzyme Q10. Low energy is a common complaint from patients on statins and this can be partially due to depleted CoQ10. Seek a high-quality CoQ10 supplement to fight this fatigue.
Metformin and Sulfonylurea drugs are used to manage Type 2 Diabetes. Metformin being the oldest and most common drug in this category, depletes: Coenzyme Q10, Vitamin B12, and Folic Acid. All three of these directly affect energy levels, cardiovascular health, and the immune system. Since most patients continue with long-term Metformin therapy, I recommend repletion with high-quality supplements for these nutrients. When purchasing your supplements, be sure that your Vitamin B12 and Folic Acid are in the active/bioavailable form. Look for “methylcobalamin” for B12 and “5-methyltetrahydrofolic acid” for Folic Acid.
Want to know if you are nutrient depleted? We offer Spectracell Micronutrient Testing. This test looks at your nutritional status from a cellular level checking vitamins and minerals such as: B Vitamins, Vitamin K, Vitamin D, Selenium, Coenzyme Q10, Copper, and many more. Test results come with repletion suggestions for foods or supplements and the appropriate dosing.
If you currently take any of these medications and want to know if you are nutrient deficient, we offer testing in our office through a company called Spectracell. You can call any of our offices to request Spectracell testing.
There are hundreds of clinics attempting to treat hormone imbalance. What makes us different? We listen, then we take action. Our business model makes it possible for us to start your treatment on day one. Faster treatment = feel better faster.
Hormone Replacement Therapy in San Antonio, Waco, and Boerne