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Hormone Replacement Therapy – StatPearls – NCBI Bookshelf

Posted: February 6, 2023 at 12:48 am

Continuing Education Activity

Hormone replacement therapy (HRT) is supplementing women with hormones that are lost during the menopausal transition. To relieve the symptoms associated with menopause, conventional HRT includes an estrogen and progesterone component to mimic hormones created by the human ovary. Estrogen therapies are numerous, and include those indigenous to the human ovary, for example, estradiol and estriol. Other estrogenic compounds include conjugated equine estrogen (CEE), the most commonly prescribed estrogen in the United States. They are not identical in their effect on the human body but share the same FDA indications. This activity describes the indications for hormonal replacement therapy and highlights the role of the interprofessional team in managing patients with postmenopausal symptoms.

Objectives:

Identify the different formulas of hormones for replacement therapy.

Describe the adverse effects and contraindications of hormonal replacement therapy.

Summarize the indications of hormone replacement therapy.

Explain interprofessional team strategies for improving care coordination and communication to ensure the safe use of hormonal replacement therapy and improve outcomes.

Hormone replacement therapy (HRT) is supplementing women with hormones lost during the menopausal transition. To relieve the symptoms associated with menopause,conventional HRT includes an estrogen and progesterone component to mimic hormones created by the human ovary.

Estrogen therapies are numerous, and include those indigenous to the human ovary, for example, estradiol and estriol. Other estrogenic compounds include conjugated equine estrogen (CEE), the most commonly prescribed estrogen in the United States. They are not identical in their effect on the human bodybut share the same FDA indications, according to thePhysicians Desk Reference.[1][2][3]The indicationsfor menopausal issues include:

Treatment of vasomotor symptoms of menopause

Treatment of genitourinary syndrome of menopause ( previously known as vaginal and vulvar atrophy)

Prevention of osteoporosis

A progestogen is a term used to include not only progesterone made by the human ovarybut also progesterone-like substances, also known as progestins. A woman who desires HRT andhas an intact uterusmust have a progestogen with estrogen to protect her uterus from endometrial hyperplasia or malignancy. Estrogen alone will cause the endometrial lining to grow. Progestogens stabilize the lining from proliferating abnormally. It is assumed that if a woman has had a hysterectomy that she no longer needs a progestin. Progesterone, however, is different as it can provide symptom relief from sleep disturbance and mood instability, and increasing evidence supportthat it offers tissue protection to the breast.[4][5][6]

FDA-approved indications for progestogens include:

Amenorrhea, either primary or secondary

Assisted reproductive technology treatment

Endometrial hyperplasia

Dysfunctional uterine bleeding

There arenumerous estrogen and progestogen choices, and they may be administrated orally or transdermally either through cream, patch, vaginal inserts, or subdermalpellets. Each route of administration has unique benefits and risks.

Oral Estrogen: Any estrogen administered orally results in increased activated protein-C resistance, increasing the risk of ablood clot. Oral estradiol also induces thehepatic formation of matrix metalloprotease 9, which decreases the formation and rupture of atherosclerotic plaque.

Transdermal Estrogen: Bypasses the hepatic metabolism that produces activated protein-C resistance, and the risk for blood clotting is negated.

Progestin administration is usually via the oral route, although a few are available in combination with estrogen in patch forms. Progesterone is available in an oral form that can also be used vaginally for non-FDA-approved uses.

Specializedpharmacies make compounded estrogen and progesterone creams, sublingual troches, and vaginal inserts, but these are not FDA approved and are not included in this article.

When studying the potential adverse effects of HRT, the most referenced information in the United States comes from the Women's Health Initiative (WHI).[7][8][9]

WHI Trial

This was a multifaceted trial, including two double-blind, placebo-controlled, randomized trials of postmenopausal hormone therapy.[10]

The first arm included CEE at 0.625 mg per day with medroxyprogesterone acetate (MPA) 2.5 mg per day. The second arm studied patients who had prior hysterectomies and treated with CEE 0.625 mg only.

HRT and the Breast

The CEE/MPA arm was discontinued earlier than expected due to an increased incidence of invasive breast cancer of 24% (HR=1.24). The CEE-only arm was not discontinued early, completed in 2004, and extended follow-up of patients has continued for 11.8 years. CEE use for 5 to 9 years is associated with a statistically significant reduction in breast cancer by 23% (HR=0.77). Those in the CEE arm also had decreased mortality from breast cancer by 63% compared to those not on CEE, and 38% fewer died from all other causes after breast cancer was diagnosed.

When examining evidence from European studies which usually use estradiol derivatives rather than CEE, and non-MPA progesterone or progestins, the conclusions are vastly different and unequal. Transdermal estradiol alone increased the risk of breast cancer by 10%, but estradiol with progesterone decreased the risk of breast cancer by 10%.

HRT and the Heart

In the WHI CEE/MPA arm, the overall incidence of coronary heart disease (CHD) increased by 24% over five years of use, with the most substantial elevation in risk within the first year, with an increase of 81% (HR=1.81).[11][12] This evidence requires cautious interpretation due to the following:

The average age of the patient treated in this study was 62 years. In women who started on therapy within ten years of menopause, there was a risk reduction of CAD of 11% (HR=0.89), but this was not statistically significant.

In those women who continued CEE/MPA for over six years, the risk of CAD dropped by 30% (HR=0.70).

These risks do not apply to estradiol and progesterone based treatments. Basic science studies show several mechanisms through which estradiol (not CEE) is cardioprotective. These include stabilization of atherosclerotic plaques, reduction of carotid intima-mediathickness (CIMT), and decreasing coronary artery calcium (CAC) scores. Numerous subsequent studies both in Europe and the United States show that cardiovascular disease and death are prominently reduced when HRT commences within the first four years of the menopause transition. The "Timing Hypothesis" refers to the theory that when starting HRT closer to the time of the menopausetransition, a cardiovascular benefit is seencompared with later initiation.

HRT and Risk of Stroke[13]

Stroke incidence increased in both arms of the WHI trial by 31% in the CEE/MPA arm, and 39% in the CEE arm.

Studies using oral estradiol are conflicted, showing a similar stroke risk, but the incidence of fatal stroke is unchanged.

HRT and the Risk of Venous Thromboembolism (VTE)

VTE, comprised of deep venous thrombosis and pulmonary embolism, was increased by 2-fold (HR= 2.06) in the WHI CEE/MPA arm.

Transdermal estradiol does not confer the same thromboembolic risk, as is evidenced by numerous European studies. The ESTHER study from France showed an overall risk of 0.9 for ablood clot, which is a decreased risk.[14] Subsequent studies looking at other transdermal estradiol doses and routes confirm these findings, with at least a null effect for blood-clotting risk.

Contraindications for oral or transdermal estrogen-based therapies include:

Known, suspected, or history of breast cancer

Known or suspected history of other estrogen-basedcancer, i.e., uterine cancer. Women who have had a hysterectomy and have no remaining evidence of disease are still candidates for HRT

Activedeep venous thrombosis (DVT) or a history of DVT or pulmonary embolism (PE)

History of blood clotting disorder, the most common being Factor V Leiden mutation carriers

Active or history of arterial thrombotic diseases such as myocardial infarction or stroke

Chronic liver disease or dysfunction

Migraine with aura

These contraindications do not apply to transvaginal based estrogen therapies, as the serum concentration of estrogen from this route is extremely low. The North American Menopause Society (NAMS) has recommended that the black-box warning that applies to conventional HRT not be applied to transvaginal estrogen treatments.

Hormone levels of estradiol and progesterone are not traditionally measured for monitoring purposes. Instead, the relief of menopausal symptoms and the absence of adverse effects signify an adequate medical response.

Adverse side effects may include:

No scientific evidence links HRT with significant weight gain.

HRT, including androgen therapies such as testosterone, should be monitored with serum testingbut is not considered conventional HRT.

Patients undergoing menopause require management from an interprofessional team that also includes the pharmacist and nurse. To improve patient outcomes, clinicians should not empirically prescribe hormone replacement therapy. These hormones correlate with a variety of adverse effects, including an increased risk of breast cancer, stroke, heart disease, and deep vein thrombosis. The duration of treatment of these hormones should not be more than a few years, and close monitoring is required. If the female has mild symptoms of menopause, then education should be provided about the benefits and harm of these hormones. The pharmacist should consult with the prescriber on the exact agent and dosing, while also examining the patient's medication record. Nursing needs to be very aware of signs of adverse events, and monitor closely on subsequent visits, alerting the clinician of any concerns. This interprofessional team approach will drive the best outcomes with HRT. [Level 5]

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Natural hormone replacement therapy: How it works – Medical News Today

Posted: February 6, 2023 at 12:48 am

Some people may have concerns about the potential side effects of conventional hormone replacement therapy (HRT). As such, they may be interested in trying natural, plant-based options.

This article outlines the different types of natural HRTs, along with their potential benefits and risks. It also provides some alternative methods for treating hormonal problems and offers advice on when to see a doctor.

Hormone replacement therapy (HRT) is a therapy that doctors may prescribe to treat hormonal imbalances or depletion, particularly following menopause.

Natural hormone replacement therapy (HRT) uses hormones derived from plants to treat hormonal conditions.

There are two main types of natural HRT: Bioidentical HRT, and traditional natural HRT.

Bioidentical hormone replacement therapy (BHRT) treats hormonal imbalances and depletion using synthetic hormones derived from plant estrogens.

Doctors refer to bioidentical hormones as hormones with the same molecular structure as ones that the human body produces naturally.

Most BHRTs contain plant hormones that mimic the following:

There are two types of BHRT. They are:

The manufacturers of bioidentical hormones claim that custom-compounded BHRTs have fewer side effects and associated health risks than conventional HRT medications. However, there is no scientific evidence to support these claims.

Traditional natural HRTs involve consuming plants or supplements containing compounds that may alleviate hormonal symptoms.

Some plants and supplements that people may take to treat hormonal symptoms include:

Typically, people take natural HRT to treat the following conditions:

According to the FDA, there are no established benefits of taking BHRT medications over conventional HRT medications.

Despite the manufacturers claims, the FDA also indicate that there is no evidence that BHRT medications help prevent or treat the following conditions:

The FDA has since corrected most false statements and claims about BHRTs efficacy in treating the above conditions.

Despite this, some doctors, pharmacists, and drug companies still promote misinformation about the benefits of BHRT.

However, a 2015 study in the Journal of Clinical Oncology suggests that BHRT may help reduce symptoms associated with cancer treatments, though research is ongoing.

According to the FDA Office of Womens Health, conventional hormone therapies may not be safe for people with a history of the following medical conditions:

To date, no credible, large-scale scientific studies have investigated the potential adverse health effects of BHRT. The FDA state that there is no evidence suggesting that BHRT medications carry fewer health risks than conventional HRTs.

Risks include:

It is also tricky for doctors to track side effects linked to BHRT medications because symptoms may take years to develop.

The FDA also state that compounded BHRT medications tend to carry greater risks than non-compounded forms.

Because pharmacists mix compounded BHRT medications, the FDA cannot approve them for quality or consistency. They also carry health risks because the precise dosage and formulation depend on a pharmacists precision and accuracy. As such, it is not possible to guarantee their safety.

It is important to note that pharmacists and drug companies are not obliged to report any side effects associated with compounded BHRT medications.

The chemicals in non-compounded BHRT may also cause side effects. These chemicals may differ across medication types and brands.

The FDA do not regulate natural supplements, meaning their quality, purity, and overall contents vary between brands and batches.

Some commonly recommended supplements for hormonal imbalances may cause side effects, especially if a person takes them incorrectly. These side-effects may include:

People should also consider that some supplements may interfere with certain medications. As such, a person who is taking any kind of medication should talk to their doctor before taking any supplement.

People should take BHRT medications according to the instructions of their doctor or pharmacist.

A person should take any natural supplements according to the packet instructions. However, they should only take such supplements after approval from their doctor.

BHRT medications are available as either oral or topical medications in the form of creams, lotions, and gels.

People typically take oral BHRT medications daily, ideally at the same time each day. People using topical BHRT products may need to apply them several times a day. A person should read the medication label for specific instructions.

According to the FDA, a person should take all forms of hormone therapy at the lowest effective dose for the shortest possible time.

Several alternative treatment options can help a person manage the psychological and physical symptoms associated with hormonal imbalances and depletion. We outline some examples below:

Some people may require prescription medications to ease symptoms of hormone depletion, such as:

The following complementary therapies may also help to alleviate hormonally-induced symptoms of depression:

The following lifestyle changes could help to prevent or treat symptoms of hormonal imbalances or depletion.

Anyone experiencing symptoms of a hormonal change or imbalance should see a doctor as soon as possible. Early intervention may help prevent complications.

People should also see a doctor if their condition does not improve while taking a medication or herbal supplement, or if they experience side effects associated with these treatments.

There are two main types of natural hormone replacement therapy (HRT):

Some experts do not think that BHRTs are any safer or more effective than traditional HRT medications.

People should be aware that certain medications and supplements can cause side effects and interact with other medications.

As such, a person who wants to try natural HRTs should talk to their doctor about the potential risks and benefits of doing so.

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Dear Annie: Im worried about my sisters use of diabetes injections to drop a few pounds – OregonLive

Posted: February 6, 2023 at 12:43 am

Dear Annie: Im worried about my sisters use of diabetes injections to drop a few pounds  OregonLive

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Diabetes Drug Mounjaro Expected To Be Approved For Weight Loss Soon: What To Know And How It Compares To Similar Drugs – Forbes

Posted: February 6, 2023 at 12:43 am

Diabetes Drug Mounjaro Expected To Be Approved For Weight Loss Soon: What To Know And How It Compares To Similar Drugs  Forbes

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Alcohol: Some People Have Higher Risk Of Heart Attack, Diabetes And Stroke More Than Binge Drinkers Signs Youre At Risk – Revyuh

Posted: February 6, 2023 at 12:43 am

Alcohol: Some People Have Higher Risk Of Heart Attack, Diabetes And Stroke More Than Binge Drinkers Signs Youre At Risk  Revyuh

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As a Transgender Man, Testosterone Shots Made Me Feel Reborn

Posted: February 6, 2023 at 12:39 am

Welcome to Testosterone HQMen's Health's guide to the exciting, complicated, and revolutionary world of testosterone. For everything you need to know about T, click here.

I REMEMBER EXACTLY what my first shot was like. I was terrified as the nurse at the Mazzoni Center in Philadelphia handed me the syringe. She had carefully instructed me on how to inject the testosterone, extracting the viscous liquid from the vial, then pinching my skin below my abdomen. I stared up at her, asking, Are you sure? She smiled at me and assured me I could do it. So I did, and with that moment, my life changed in every way possible.

Truthfully, the hesitation was from the unknown. Being born biologically female, I certainly had no experience with testosterone, and how it would specifically affect me and the rest of my body. However, what I did know is what made me feel good, what made me feel like myself, and that made the decision to begin transitioning far easier. The well-educated doctors at the Mazzoni Center have been with me every step of the way.

Each week, I inject .35 mL of testosterone subcutaneously. After three years, its just a part of my routine. Initially, I was still unsure of myself doing my shot alone, but over time I became more comfortable with the process. Prior to all of this, I did my research. I looked at the experiences of other transmen, and reached out in several instances to gain further insight. What I gathered was that while there were some general similarities, each individual had a different experience, simply because of their journey.

My protocol for taking testosterone was personally tailored to me. This is why I was fortunate to have worked with the medical professionals at The Mazzoni Center. They analyzed my anthropometric measurements, medical history, and future goals, both physical and emotional. My doctor wrote a prescription for me that would allow my body to transition in a safe and healthy manner. Since beginning hormone replacement therapy three years ago, the amount of testosterone has never changed. The human body does not work well under extreme conditions or wide-ranging fluctuations. We are more adapted to gradual and consistent change, which is exactly how my testosterone protocol was designed.

The support, or at least a consultation with an affirming medical team or provider, is essential before making any type of medical change. I would never suggest that anyone do this alone. There are dangers in taking too much, and the amount you take is dependent on environmental factors and characteristics, such as age and body composition. Additionally, I know several transmen who wanted to transition at a slower pace, and "microdose" testosterone. Taking less testosterone in this way is not dangerous, but changes will happen at a noticeably slower pace. The nice thing about this process is that you can transition in a way that aligns with your personal goals and health needs.

I realize now that as humans, our instinct is to look for comfort from who and what we know. However, that is not a definitive truth. That is our observation, our perspective, which can lead towards a path of false representation. So, through my own observations, I took what information I could to benefit my scenario, and surrendered the rest to another mans path. Several individuals, such as Cody Harman, Nikias Tomasiello, and Logan Dub, provided positive support through their social platforms, and were kind enough to answer my questions and address my concerns. I began to realize that I was surrounded by many others, simply looking to connect with the inner vision of themselves. The start is summoning up the courage to make connections, reaching your hand out and knowing that someone will grasp it.

The first changes were my body temperature. I used to be cold most of the time, but I noticed that my core temperature began to feel almost hot. I suddenly was operating like a self-heated furnace!

Hair growth took a bit longerit was probably around six months before I noticed differences there. I was ecstatic! I will never forget that moment and the friend I shared it with immediately. I was also fully aware of the thickening of my vocal cords, which altered my voice.

There were some changes that really surprised me, such as the change in my facial structure, and the noticeable increase in my bone density. I remember visiting my chiropractor, who I had not seen since before transitioning. As he worked on my face and neck, he told me that my bone structure felt more defined. In my head, I imagined that I would change in the stereotypical way, enhancing my masculinity and general physical construct, but not to that detail. These types of changes really excited me. I felt reborn, figuratively speaking, and I guess I was in a way.

Some changes I noticed would hit me suddenly. Others came with the territory, such as altering my hair and wardrobe. I loved changing my wardrobe, and buying the clothes I liked, rather than the ones I thought I "had to have" based on my perceived societal constructs of gender norms. For me this experience was liberating on so many levels. All of these changes, in every manner that they appeared, were small celebrations, reminders that I did it; I was living in the truth, and no one could take that from me.

What I had not thought about were the changes I would face from a social and emotional place. Certain physical and emotional challenges scared me. I had to relearn how to behave socially in the world as a man. And, from a physical standpoint, I knew that just because I was taking testosterone did not mean that I would suddenly take on the figure of a man. I still had underlying body dysmorphia, present from my past, and working through that was challenging. Taking on the male gender norm from a social standpoint was also a large task for me. I had lived my life as a female for many years, and taking on new responsibilities as a man was daunting to say the least.

I had to recognize that testosterone could potentially make me more aggressive, or change the way in which I react to the environment around me. Thankfully, I did not notice aggression in this way, but I did notice confidence and a boost in self-esteem. This was not only due to hormone replacement therapy, but the validation I felt in aligning my internal identity with my external frame. My presence felt stronger, and intuitively, I began to trust in who I was as a person.

Admittedly, when I started transitioning, I worried about regretting my decision. This is not something I could take back, or "reverse," and naturally, that made me question myself. However, what I know is that I would have regretted living a lie more. That is also something I could not take back.

Additionally, I found it important to remind myself that just because I was taking testosterone and was changing my life in a positive way, my life would not be perfect. Testosterone did a lot for me, but it did not take away my limitations, past failures or regrets. I am still the same person, but an expanded version of who I was. I still struggle just like everyone else. Testosterone is not perfection, nor does it slow time. It is not an emotional cure for what keeps you up at night. For me, it was how I found the part of myself I believed could not exist.

Testosterone had allowed me to take on a new identity, one that felt whole, complete. I now look upon the last three years of my life through a lens of pride. It takes courage to change the course of your life, especially when you feel alone. It takes bravery to fight against the stream that channels you to a set course. I made a choice to start testosterone, and I know that was the right choice.

Bari Glassman is a graduate student at Immaculata University studying Dietetics, and he intends to combine his passion for nutrition, and fitness, with his interest in cultural diversity, as a future professional practice.

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Male hypogonadism – Diagnosis and treatment – Mayo Clinic

Posted: February 6, 2023 at 12:17 am

Diagnosis

Early detection in boys can help prevent problems from delayed puberty. Early diagnosis and treatment in men offer better protection against osteoporosis and other related conditions.

Your health care provider will conduct a physical exam and note whether your sexual development, such as your pubic hair, muscle mass and size of your testes, is consistent with your age.

Your provider will test your blood level of testosterone if you have signs or symptoms of hypogonadism. Because testosterone levels vary and are generally highest in the morning, blood testing is usually done early in the day, before 10 a.m., possibly on more than one day.

If tests confirm that you have low testosterone, further testing can determine if a testicular disorder or a pituitary abnormality is the cause. These studies might include:

Male hypogonadism usually is treated with testosterone replacement to return testosterone levels to normal. Testosterone can help counter the signs and symptoms of male hypogonadism, such as decreased sexual desire, decreased energy, decreased facial and body hair, and loss of muscle mass and bone density.

For older men who have low testosterone and signs and symptoms of hypogonadism due to aging, the benefits of testosterone replacement are less clear.

While you're taking testosterone, the Endocrine Society recommends that your health care provider monitor you for treatment effectiveness and side effects several times during your first year of treatment and yearly after that.

Oral testosterone preparations have not been used for treatment of hypogonadism because they can cause serious liver problems. Also, they don't keep testosterone levels steady.

One Food and Drug Administration-approved oral testosterone replacement preparation, testosterone undecanoate (Jatenzo), is absorbed by the lymph system. It might avoid the liver problems seen with other oral forms of testosterone.

Other preparations you might choose, depending on convenience, cost and your insurance coverage, include:

Gel. There are several gels and solutions available, with different ways of applying them. Depending on the brand, you rub the testosterone into your skin on your upper arm or shoulder (AndroGel, Testim, Vogelxo) or apply it to the front and inner thigh (Fortesta).

Your body absorbs testosterone through your skin. Don't shower or bathe for several hours after a gel application, to be sure it gets absorbed.

Side effects include skin irritation and the possibility of transferring the medication to another person. Avoid skin-to-skin contact until the gel is completely dry, or cover the area after an application.

Injection. Testosterone cypionate (Depo-Testosterone) and testosterone enanthate are given in a muscle or under the skin. Your symptoms might waver between doses depending on the frequency of injections.

You or a family member can learn to give testosterone injections at home. If you're uncomfortable giving yourself injections, member of your care team can give the injections.

Testosterone undecanoate (Aveed) is given by deep intramuscular injection, typically every 10 weeks. It must be given at your provider's office and can have serious side effects.

Gum and cheek (buccal cavity). A small putty-like substance, gum-and-cheek testosterone replacement delivers testosterone through the natural depression above your top teeth where your gum meets your upper lip (buccal cavity).

This product, taken three times a day, sticks to your gumline and allows testosterone to be absorbed into your bloodstream. It can cause gum irritation.

Testosterone therapy carries various risks, including:

If a pituitary problem is the cause, pituitary hormones can be given to stimulate sperm production and restore fertility. A pituitary tumor may require surgical removal, medication, radiation or the replacement of other hormones.

There's often no effective treatment to restore fertility in men with primary hypogonadism, but assisted reproductive technology may be helpful. This technology covers a variety of techniques designed to help couples who have been unable to conceive.

Treatment of delayed puberty in boys depends on the underlying cause. Three to six months of testosterone supplementation given as an injection can stimulate puberty and the development of secondary sex characteristics, such as increased muscle mass, beard and pubic hair growth, and growth of the penis.

Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this condition.

Having male hypogonadism can affect your self-image and, possibly, your relationships. Talk with your health care provider about how you can reduce the anxiety and stress that often accompany these conditions. Many men benefit from psychological or family counseling.

Find out if there are support groups in your area or online. Support groups put you in touch with other people with similar challenges.

Although you're likely to start by seeing your family doctor or other care provider, you might be referred to someone who specializes in the hormone-producing glands (endocrinologist).

Here's some information to help you get ready for your appointment.

Make a list of:

For male hypogonadism, some questions to ask your provider include:

Don't hesitate to ask other questions.

Be prepared to answer questions about your condition, such as:

Sept. 29, 2021

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City of Vacaville Introduces Next Generation to Biotechnology and Advanced Manufacturing – Financial Post

Posted: February 6, 2023 at 12:06 am

City of Vacaville Introduces Next Generation to Biotechnology and Advanced Manufacturing  Financial Post

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Is Incyte Corporation (INCY) Stock at the Top of the Biotechnology Industry? – InvestorsObserver

Posted: February 6, 2023 at 12:06 am

Is Incyte Corporation (INCY) Stock at the Top of the Biotechnology Industry?  InvestorsObserver

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Where Does Catalyst Pharmaceuticals Inc (CPRX) Stock Fall in the Biotechnology Field After It Is Down -3.88% This Week? – InvestorsObserver

Posted: February 6, 2023 at 12:06 am

Where Does Catalyst Pharmaceuticals Inc (CPRX) Stock Fall in the Biotechnology Field After It Is Down -3.88% This Week?  InvestorsObserver

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