A promising new article proposing that the addition of T3 for thyroid treatment is the way to go!

A hopeful new article proposing that adding T3 to thyroid treatment is the way to go!

In a recent article by thyroid patient Mary Shomon, there was mention of an interesting article by Dr. Wilmar Wiersinga that came out this year in the journal Nature Reviews Endocrinology titled “Paradigm shifts in thyroid hormone replacement therapies for hypothyroidism.” And I find this article fascinating.

I’m going to break it down a bit and add more important observations that I’ve not seen expressed elsewhere and which are important, because the truth stands out about T4-only and decades of patient experiences.

In the abstract summary of his article, he states:

Evidence is mounting that levothyroxine monotherapy cannot assure a euthyroid state in all tissues simultaneously, and that normal serum TSH levels in patients receiving levothyroxine reflect pituitary euthyroidism alone.

Informed thyroid patients can only shout Hallelujah!!

But actually, the evidence has been there all along…and the medical profession has not been listening!

For over 50 years since T4-only was pushed upon thyroid patients in the early 1960’s (not the 1970’s mentioned in the actual article), we haven’t done well on levothyroxine. But when we came into our doctors offices and complained of those pesky symptoms of continued hypothyroidism while on levothyroxine, the replies from our doctors have ranged from “You need to exercise more and eat less”, to “it’s just your age”, to “It’s part of being a busy mother” to  “Here’s a prescription for an anti-depressant/statin/BP med”….on and on.

My own mother was the classic example. She as put on Synthroid in the early 1960s in her forties. And from that time on until she died in her early eighties still on Synthroid, she paid continual and growing problems: chronic depression, rising cholesterol, heart problems, weight gain, body stiffness, inability to stand for long periods, poor stamina, dry hair and skin, and problems with her cognitive abilities. And today, informed patients know that all those symptoms are classic symptoms of continued hypothyroidism—all common in far too many patients on T4-only in their own degree and kind…sooner or later.

Stop the Thyroid Madness is the direct result of thyroid patients gathering in groups on the internet by the turn of the 21st century and proclaiming T4-only has only served to make them sicker!

Dr. Wiersinga also states in his abstract:

Levothyroxine plus liothyronine combination therapy is gaining in popularity; although the evidence suggests it is generally not superior to levothyroxine monotherapy, in some of the 14 published trials this combination was definitely preferred by patients and associated with improved metabolic profiles. Disappointing results with combination therapy could be related to use of inappropriate levothyroxine and liothyronine doses, resulting in abnormal serum free T4:free T3 ratios. 

That is a bit confusing to say “evidence suggests it is generally not superior to levothyroxine monotherapy”. What about the clinical presentation of patients shown every day in the offices of doctors over the past 50+ years?  Why have so many thyroid patients on levothyroxine for example, been put on anti-depressants, statins, BP meds, pain meds and more?

The Medical Dictionary defines “clinical presentation” this way: The constellation of physical signs or symptoms associated with a particular morbid process, the interpretation of which leads to a specific diagnosis.

Why has there been such a gap between what a doctor learns in medical school /continuing education vs the clear clinical presentation by millions that underscored how poorly T4-only really has been?

As far as those “disappointing results” which Dr. Wiersinga mentions with combined T4/T3 therapy, informed thyroid patients have the answer: low iron and cortisol issues—both issues which all-too-many levothyroxine patients acquire due to being a poor treatment, and which either T3 or natural desiccated thyroid will reveal. Or, the patient is held hostage to the TSH lab test, leaving them underdosed, and again, many acquire either low iron and/or a cortisol problem.

Dr. Wiersinga concludes in his abstract:

However, in selected patients, new guidelines suggest that experimental combination therapy might be considered.

We agree and bravo!!

But Informed thyroid patients have a strong reply: why limit a better treatment to only “selected patients”?? Why continue to put each and every thyroid patient on one of five thyroid hormones, which more than 50 years have revealed has been an abject failure in too many, sooner or later?

Why not put the majority of your thyroid patients, not a selected few, on a medication which gives back the exact same hormones that one’s thyroid would be making in the first place, aka Natural Desiccated Thyroid Hormones? “Selected patients” should only refer to those who may need T3-only since they could have a conversion problem. 

The full article also describes three paradigm shifts, plus a proposed fourth one:

1)    1891, when the real gland (sheep at the time) was first used to treat hypothyroidism. 

2)    1960 – 1988, when desiccated thyroid use declined and levothyroxine use increased

3)    the 1990s, when it was reported that T3 was needed after thyroid removal (but wasn’t pursued)

And the 4th paradigm shift might occur, he explains, when those of us with poorly functioning thyroids could see regeneration from embryonic stem cells, as outlined in a 2012 study. Pretty exciting!

But I think a 4th paradigm shift has already occurred! A growing body of doctors have changed the way they treat hypothyroidism, and it’s by prescribing natural desiccated thyroid. As a southerner would say “Bless their little souls!!”

Until the possibility of stem cell treatment of our hypothyroidism becomes a reality, which may not be soon enough, we all hope to see better understanding by our physicians about what treatment really hasn’t worked well, and what treatment really does.

i.e. observation of clinical presentation needs to return to the way doctors practice medicine!!

Adding T3 to our treatment, and especially with natural desiccated thyroid, has changed lives. And we can at least shout “Bravo” to  Dr. Wiersinga for positively proposing that Endocrinologists consider the fact that perhaps, T4-only is NOT the way to go and adding T3 just might be for very good reasons. And by the way, thyroid patients also know that the TSH lab test is as much a failure as T4-only.  

Seize the Wisdom!

Yours truly,

Janie A. Bowthorpe

View the original article here

An Open Letter to All Physicians from a Nurse about thyroid treatment

An Open Letter to All Physicians from a Nurse about thyroid treatment

Note: if you are signed up to receive these blog posts via email, don’t reply to the email. Instead, click on the title of the blog post, which will take you directly to the blog, and scroll down to where you can comment.

Thyroid patient Dawn, who is also an RN, was shocked to see the contents of a letter that a patient’s doctor had sent out to this patient. It was filled with terrible inaccuracies about thyroid treatment, exclaimed Dawn, and she was horrified. No wonder so many thyroid patients are exasperated with their doctors!

So Dawn compiled this excellent letter, refuting several comments made by this doctor, but directing it to ANY doctor who holds these false views.

Take the time to share this on your Facebook pages, your blogs, to your doctor, you name it. Spread the word as we work to Stop the Thyroid Treatment Madness!!

*******

An Open letter to physicians regarding the use of “Pig Thyroid Hormones”

I am writing this letter in response to any physician’s stance against the use of any forms of Natural Desiccated Thyroid (NDT) hormones as replacement for inadequate thyroid hormone levels. I will attempt to include links to medical-journal/peer-reviewed/scientific-based information to help you catch up on the latest in thyroid treatment and information.

I know that you, as a physician, have very limited time when it comes to researching various information on treatment protocols. I acknowledge that you were given limited training on thyroid diagnosis and treatments during your medical school programs, as well as in internship and residency programs, and have likely had to rely on the information provided by Pharmaceutical sales reps.

As such, I believe that your views are unfairly skewed and not fully fleshed out towards the use of T4-only medications such as Synthroid, Levoxyl, and others.

1) Regarding your assertion that Synthroid/T4 only medications are “bio-identical” in structure and thus, are an “adequate replacement” for a thyroid that makes 5 hormones (T4, T3, T2, T1 and calcitonin)

Please review the following photos, showing the chemical structure of human thyroxine (T4) and the chemical structures of T4-only medications such as Tirosint and Synthroid: (source: Synthroid Manufacturer’s Full prescribing information). As you can see below, there is a great difference between the molecular structure of Synthroid and human thyroxine.

As you can see, the molecules are identically formed, and therefore are the ones which are truly “bio-identical in structure”.

2) Regarding your assertion that the TSH is a stable and reliable test which should be looked at first, while T4 and T3 levels fluctuate frequently and are not stable enough to be considered. 

Here are several medical journal articles which should make anyone rethink the use of the TSH lab test:

http://www.sciencedaily.com/releases/2010/03/100315230910.htm

http://jcem.endojournals.org/cgi/content/abstract/90/9/5483

http://www.thyroid-info.com/articles/david-derry.htm

http://thyroid.about.com/od/thyroiddrugstreatments/l/blderryb.htm

And not only the above, but there are a large body of thyroid patients who, for decades, have reported having a very “normal” TSH lab test while having very obvious symptoms of hypothyroidism, including a low temperature, fatigue, exercise intolerance, feeling cold, dry skin, depression, hair loss and more.

3) Regarding your idea as to what amount of T4 or T3 a human thyroid produces in a day (such as 100 mcg T4 and about 6 mcg T3 daily).

That information will vary. For example, another source states that a human thyroid makes on average between 3-5 grains of thyroid hormone per day:  “Estimates of average normal secretion for euthyroid humans are 94-110 µg T4 and 10-22 µg T3 daily (300).  If  you need more, it can be due to exogenous desiccated thyroid (giving it to yourself) vs. the superior absorption of natural release of thyroid hormones.” 

Source: http://www.thyroidmanager.org/chapter/thyroid-hormone-synthesis-and-secretion/

Either way, it varies according to each individual as to what amount of NDT will remove all symptoms.

4) Regarding your assertion that very few thyroid patients have issues with conversion of T4 to T3: 

As you may or may not know, many situations can cause problems with the conversion of T4 to T3 within the body, including a) mineral deficiencies (particularly low iron - a common issue in hypothyroid patients), b) gastrointestinal problems, c) liver problems, d) adrenal cortisol deficiencies (VERY common in T4 only-treated patients due to the inadequacy of being on nothing more than a storage hormone 5) the use of many commonly-prescribed medications including beta blockers or pharmacological doses of corticosteroids.

Source: http://www.naturalendocrinesolutions.com/articles/do-you-have-a-t4-to-t3-conversion-problem/

See Also:

http://press.endocrine.org/doi/abs/10.1210/jc.2008-1301

http://press.endocrine.org/doi/full/10.1210/jcem.84.2.5534

In addition to all the above, there are many thyroid patients who report that their FT3 “looked right” on T4-only, yet they continued to have symptoms of hypothyroidism while on thyroxine.

5) Regarding your assertion that there is no good way to dose Armour and other Natural Desiccated Thyroid Products

The growing body of thyroid patients around the world have frankly not had any issues with dosing NDT. Most dose it twice a day, such as first thing in the morning, and then the early afternoon. And it’s worked well.

Additionally, there are a variety of different strengths to choose from by the manufacturers of Natural Desiccated Thyroid meds such as Armour, NatureThroid, WP Thyroid, NP Thyroid, Erfa etc. For example….http://www.nature-throid.com/available_strengths.php

http://www.nature-throid.com/images/Nature-Throid-PI-Rev041121-03.pdf

6) Regarding the idea that a supposed “high dose of T3? has a stimulant effect…or is like a large dose of caffeine…or makes you feel good…or is addictive…or doesn’t make much sense physiologically…or may actually be dangerous, especially for the heart. 

I would hope that any doctor who proclaims to be a hormone-balancing “expert” would have a basic working knowledge of the need for T3 hormone in adequate levels for optimal cardiac functioning. Here are some helpful links which demonstrate the need for adequate T3 in order for cardiac functioning to be considered “optimal.”

The Journal of Clinical Endocrinology & Metabolism has reported that long-term levothyroxine replacement therapy in young adults is associated with cardiovascular abnormalities. http://jcem.endojournals.org/cgi/content/abstract/93/7/2486

And from this article: http://www.ncbi.nlm.nih.gov/pubmed/18221125 ”Clinical studies have shown that mild forms of thyroid dysfunction, both primary (subclinical hypothyroidism and subclinical hyperthyroidism) and secondary (low T(3) syndrome) have negative prognostic impact in patients with heart failure. In these patients, the administration of synthetic triiodothyronine (T(3)) was well tolerated and induced significant improvement in cardiac function without increased heart rate and metabolic demand “

From this article: http://jcem.endojournals.org/content/93/4/1351.full.pdf  “Altogether, our data indicate that short-term administration of substitutive doses of synthetic L-T3 state reduces activation of the neuroendocrine system and improves LV SV in patients with ventricular dysfunction and low-T3 syndrome”

And this study: http://www.hindawi.com/journals/jtr/2011/958626/abs/ “The potential of TH (thyroid hormones) to regenerate a diseased heart has now been tested in patients with acute myocardial infarction in a phase II, randomized, double blind, placebo-controlled study (the THiRST study)”

And this statement, from this American Heart Association-sponsored study states: http://circ.ahajournals.org/content/107/5/708.long “…low T3 concentrations are a strong independent predictive marker of poor prognosis in cardiac patients and might represent a determinant factor directly implicated in the evolution and prognosis of these patients. “

To the contrary, hypothyroid patients are not seeking “high doses of T3?. Instead, they seek an amount of NDT that removes their symptoms of hypothyroidism, improves their temperature and metabolism, results in a strong heart and good blood pressure. When we achieve all the latter, we’ve noticed our free T3 in the upper quarter of the range, and the Free T4 around mid-range…and we have no symptoms of excess (if iron and cortisol is also corrected).  It’s all the result of adequate, physiologic doses for replacement, not high doses of NDT with its inherent direct T3.

We are NOT stimulant addicts or drug-seekers, and find that offensive. We are only seeking to replace what our thyroids are not giving us, and to regain a non-hypothyroid state as a result.

We are seeking human decency, wisdom and open-mindedness from our physicians. You would not deny a diabetic patient replacement with the hormone insulin, so why would you deny a person without adequate thyroid function all the right hormones, including the T3 hormone which is critical for every cell in the body to function properly? This seems cruel and unusual treatment in my book, and does NOT correlate with the “first, do no harm” portion of the Hippocratic oath!

7) Regarding the idea that patients are full of “bitter, angry, contentious discourse.”

Do try to understand how it feels to live in a body with a damaged or under-functioning thyroid and to have a doctor replace your missing thyroid hormones with nothing more than a storage hormone. We do not see healthy thyroids only producing a storage hormone. Living life without adequate thyroid hormones (particularly direct T3- the “active” thyroid hormone which every living cell in your body needs to function properly) leaves patients frustrated.

Additionally, put yourself in our shoes when you proclaim us “normal” based on a pituitary hormone, in spite of the fact that we continue to have hypothyroid symptoms. The latter test has repeatedly failed to correspond with how patients feel and function on a daily basis.

Imagine being held to a medication such as Synthroid, which then leaves you with inadequate thyroid hormones to obtain functional levels of daily living, optimal heart function and optimal hormonal balance. Imagine living your life in pain, depression, and with high blood pressure and cholesterol, with inadequate adrenal function, and all your sex hormones thrown off balance simply because your doctor is not open-minded or educated enough to grant you the use of natural desiccated thyroid which can make those symptoms disappear (in the presence of good iron and cortisol). Imagine being unable to get out of bed in the morning due to severe unrelenting fatigue and being unable to think properly due to brain fog caused by lack of thyroid hormones. Imagine missing out on the joys of life, and family, and being a functional member of society, simply because your doctor would not allow you to try a better form of medication. Would you not be upset with your physician if you knew there was a simple solution, yet you were repeatedly brushed off, symptoms ignored, and told to go on with living your half-life and to just “deal with it?”

8) Regarding the idea that Natural Desiccated Thyroid has not worked for some patients

Janie Bowthorpe has compiled several reasons why NDT doesn’t seem to works based on over a decade of reported patient experiences: http://www.stopthethyroidmadness.com/ndt-doesnt-work-for-me Can that many patients and their important experiences be unworthy of your open-mindedness and investigation?

In conclusion, I hope that you will read all the above with a more open-mind and rethink your stance on the use of Natural Desiccated Thyroid hormone. It is a proven safe and effective form of treatment for over 122 years and counting. Your patients are counting on YOU to do what is right!

Sincerely,

Dawn Lawson, RN

Hashimoto’s and Graves patient for over 28 years, Post Total Thryoidectomy 2012. Happily out of heart failure and OFF BP and Cholesterol meds, OFF Cholesterol meds since June 2013- when my thyroid doctor put me on Natural Desiccated Thyroid.

View the original article here

Here we go again, thyroid friends: Endocrinologists wear their pointed DUNCE hats.

Here we go again, thyroid friends: Endocrinologists wear their pointed DUNCE hats.

Ah me.

Ever heard of Clinical Thyroidology?

It’s a physician-targeted publication by the American Thyroid Association (ATA). The ATA states they are the “leading organization devoted to thyroid biology and to the prevention and treatment of thyroid disease through excellence in research, clinical care, education, and public health.”

And a recent Letter to the Editor in the December 2013 publication of Clinical Thyroidology only underscores why so many thyroid patients report that they…

avoid Endocrinologists like the plague for the treatment of their hypothyroidism. can hardly contain their disgust about Endocrinologists they have seen!

The letter is based on the March 2013 study I have mentioned before, titled “Desiccated thyroid extract compared with levothyroxine in the treatment of hypothyroidism: a randomized, double-blind, crossover study.” It was done by the Department of Endocrinology at Walter Reed Military Medical Center and headed by Thanh D. Hoang, DO and associates.

The objective of the study was to investigate the effectiveness of DTE (acronym for Desiccated Thyroid Extract, which is more popularly termed Natural Desiccated Thyroid for thyroid patients) compared with L-T4 (more popularly known as T4-only for thyroid patients).

At the conclusion of the 16-week study, they found that

“34 patients (48.6%) preferred DTE therapy, whereas 13 (18.6%) preferred levothyroxine; 23 (32.9%) did not specify a preference, he said. Further analysis confirmed those who preferred DTE lost even more weight over a 4-month period.” i.e. the patients who preferred it “lost 4 lb during the DTE treatment, and their subjective symptoms were significantly better while taking DTE as measured by the general health questionnaire-12 and thyroid symptom questionnaire (P < .001 for both).”

Yet the study concludes: “DTE therapy did not result in a significant improvement in quality of life”.

And why did the study conclude there was no significant quality of life improvement? Is it possible that this study was flawed in ways they don’t understand?

Two easy answers:

We canNOT be held hostage to the TSH lab test (which the study did for those participants) if we want to find that “significant” quality of life improvement! When thyroid patients are at their very best with desiccated thyroid, they end up finding their TSH is below the so-called “normal” range, and without one iota of “hyper-like symptoms, i.e. no bone loss or heart issues”. (Hyper symptoms will only occur if there is an undiscovered or untreated cortisol or iron issue. See #4 below).We have to have optimal cortisol and iron levels with desiccated thyroid to achieve that “significant” quality of life improvement!

Back to the Letter to the Editor….

Doctors David S. Rosenthal, MD and Kenneth H. Hupart, MD proceed to present misinformed criticism and obtuse conclusions. The last part of their letter states the following…and I have bolded what I’m going to respond to:

…..Such nonphysiologic changes in serum T3 [serum T3 rose 23% and 36% in the participants] after DTE administration and resultant risks have long been known (2) and are the subject of concern (3). 

Exploring a role for DTE in the treatment of hypothyroidism with a well-designed, blinded, randomized clinical trial is laudable. However, when evaluating a therapy for a condition that affects millions of patients and for which an effective treatment already exists (4), this clinical trial should be powered and designed to detect adverse consequences. When the goal is physiologic replacement, care also needs to be exercised that normal physiology is restored. The study of Hoang and colleagues is provocative, but it does not achieve the minimum standard required to alter current clinical practice.

And my response to what I bolded:

Risks? Concern? When are the risks and concern going to be mentioned about T4-only medications—the latter which forces us to live on ONE hormone, in spite of the fact that a healthy thyroid would be making FIVE. Where is the concern about the fact that a huge body of patients worldwide have continuing hypothyroid symptoms in their own degree and kind, either at the beginning of T4-only treatment, or the longer they stay on it? To the contrary, WE have concern when our doctors repeatedly ignore or blame those clear symptoms of continued hypothyroidism on other issues!Why are you so concerned about a higher FT3?? Thyroid patients have been doing fabulously, and have seen their lives change, on desiccated thyroid for over a decade now, and especially when we find our FT3 in the upper quarter of the range. Before that, there were a good sixty years of near-exclusive desiccated thyroid use! A higher range FT3 has done nothing more than strengthen our hearts, lower our cholesterol and blood pressure, rid us of depression and anxiety, improved bone strength, helped us lose weight, taken away the need to nap, improve our gut health, given us back our lives…and so much more.Can you be SO blind as to think that T4 treatment is that “effective”? Are you that destitute of observation about the clinical presentation of your T4-treatment patients who, sooner or later, complain of depression, rising cholesterol, higher blood pressure, aches and pains, hair loss, gut problems, the need the nap, heart problems, anxiety, weight gain and more symptoms of a POOR treatment?Have you not figured out that “adverse consequences” on desiccated thyroid, or even T3-only, are related to either inadequate iron and/or a cortisol problem? Patients are so FAR ahead of you in knowledge about the problems that cortisol and iron problems can cause with desiccated thyroid…and what to do about it. Once we correct those, we SOAR on desiccated thyroid.

A better way to look at the Walter Reed study

Nearly 49% preferred desiccated thyroid! That is nothing to sneeze about! It means something. It sends the beginning of the right message. And yes, it would have been a far greater percentage if those in the Endocrinology department had understood why it’s important NOT to go by the TSH, and why the participants needed to first be properly screened for their iron and cortisol levels, then property treated! And by the way, lab results have NOTHING to do with just “falling in the normal range”.

To all thyroid patients and friends worldwide:

Sadly, we all know that the majority of Endocrinologists we have seen wear Dunce hats. Of course, there are some exceptions in the Endocrinology field! We applaud those few courageous Endocrinologists who have dared to listen to our experiences and positive clinical outcomes.

But too many remain in a stubborn, dark world of their own, represented by the comments above—a mindset which only keeps us sick.

View the original article here

Investigation of thyroid patients as to how they View their doctors — not a pretty picture!

Thyroid patient survey as to how they View their doctors — not a pretty picture!

Recently, stop the thyroid madness LLC implemented a survey to discern the thyroid patient observations and opinions on medical professionals who have used. And the results of this survey alarming negative opinions of current 1,870 thyroid patients to doctors who have used.

Of course, more knowledgeable thyroid patients are not surprised by the results of this survey. But to see the answers and especially the comments made in response to questions 2-5, everything certainly points out how deep is the problem.

Up to which doctors gave the worst treatment according to patients, endocrinologists led the Pack with result of MD in second. On the contrary, given better treatment naturopaths, although they got barely 1/3 of respondents.

Comments made by patients in response to question 3 (see below "– actions that would raise patients ' opinions of doctors) were the most enlightening. They ranged from having better knowledge about T3 or desiccated thyroid, understand the lab work just the TSH, listening to their patients (frequently stated), better understanding of thyroid symptoms, stopping to tell patients to eat differently or exercise more, don't be so afraid of higher doses of NDT, understanding nutrition, stop with the labelling/mille/hubris/patronizingrespecting patients educated ... and a lot more which you can read below the # 3 on the page linked below.

Five questions with the answers of the survey were:

Question 1: how satisfied were you with the way that most medical professionals you've seen over the years have treated the thyroid problem? (Choose only one answer)

1) very satisfied – most medical professionals have helped my thyroid problems.

2) MODERATELY satisfied – some have done well; others have not done so

3) neutral-I have no opinion one way or the other

4) not satisfied – most of my experiences with doctors have been
negative when it comes to help me

Question 2: If you chose # 1 above, because you feel very satisfied about the treatment of the thyroid by the majority of medical professionals who have seen over the years? (Choose any that apply)

1) I feel much better than I did before

2) I have no symptom that I understand that I am related to hypothyroidism.

3) most of those physicians were good listeners

4) most of those doctors seem to know what they are doing.

5) most of those physicians respects my opinions and he sees me as a partner in my healthcare.

6) taxes were accessible

7) other (133)

Question 3: If you have selected 2, 3 or 4 in the first question above: which of the following actions from medical professionals would raise the cure thyroid cancer that had gotten his opinion? (Choose any that apply)

1) pay more attention to my symptoms, rather than to focus solely on laboratory results.

2) understand how to read lab results

3) being offered of natural desiccated thyroid or T3 instead of just T4

4) going more of free T3 and free T4 more symptoms, TSH

5) understand the reality of problems besides cortisol saliva test and treatment

6) understand the problem of low iron, curling iron workshops, treatment

7) being more open-minded about nontraditional therapies

8) understanding that my depression could be related to my hypothyroid State.

9) other (395)

Question 4: when you choose a thought about the types of health care professionals who have used over the years, a guy who feels he did the worst job in your treatment.

1) endocrinologists

2) MD (physician)

3) what to do (doctor of osteopathy

4) on NP (nursing)

5) PA (physicians Assistant)

6) naturopaths

Comments (122)

Question 5: when you choose a thought about the types of health care professionals who have used over the years, a guy who feels done the best job in your treatment.

1) endocrinologists

2) MD (physician)

3) what to do (doctor of osteopathy

4) on NP (nursing)

5) PA (physicians Assistant)

6) naturopaths

View the original article here