Human Chorionic Gonadotropin in Pain Treatment
Thanks to the revelation that Dodger baseball star Manny Ramirez used—and is now suspended for the use of—human chorionic gonadotropin (HCG), this compound is now known to the general public. It is now common knowledge that HCG can enhance athletic performance.
HCG is also a new, emerging treatment that appears to have great potential as an adjunct to opioid pain treatment. Adverse publicity involving anabolic steroids has already caused most of them to be removed from the commercial market and thus depriving physicians and patients of beneficial treatment options. Unfortunately, the Ramirez fiasco has the potential to tarnish the image of HCG and cause it to be restricted for medical uses.
Due to the HCG sports controversy and despite very early clinical experience, we want to let practitioners know that HCG is starting to be used as an adjunct in severe, chronic pain patients. Use in pain patients is a far cry from its use to enhance athletic performance. To alert practitioners to HCG’s potential, some of my preliminary clinical experiences with HCG are reported here. To date it appears quite beneficial, safe and easy to administer. Some females with low testosterone serum levels have greatly benefited from its use.
Why Has HCG Entered Pain Practice?
Over a year ago, Practical Pain Management published articles about the emerging use of hormonal treatments, including HCG, in pain practice.1 Hormone therapy in pain patients is now being used for replacement—particularly of testosterone and cortisol. HCG stimulates the production of testosterone, progesterone, estrodiol, and thyroid—all of which should bring obvious benefits to some pain patients.2-4 HCG may also achieve pain reduction through neurogenesis and tissue healing.
What Is HCG?
Human chorionic gonadotropin derives its name from the fact that it was originally believed to be only produced in the placenta during pregnancy. Indeed, the common at-home pregnancy test is based on the finding of HCG in female urine. It is now known, however, that it is also produced in the pituitary of males and females of all ages.2-4 Chemically, it is made up of two amino acid sub-units. One of the units contains amino acid sequences that are essentially identical to FSH (follicle stimulating hormone), LH (luterinizing hormone), and TSH (thyroid stimulating hormone).2 Consequently, HCG, when given, stimulates the testes, ovary, thyroid, and adrenal to produce testosterone, thyroid, estradiol, progesterone and related compounds. It is this pro-hormone stimulation that gives HCG multiple clinical uses. Severe chronic pain patients who must take opioids develop multiple hormonal deficiencies that may be ameliorated by HCG’s hormone-stimulating properties.
The other sub-unit of HCG has some biologic activities that may also assist pain patients. It increases cyclic adenosine monophosphate (cAMP) and nitric oxide (NO).4 cAMP is known to be a critical element in tissue production and growth while NO has important intracellular and intercellular regulatory functions. NO is known to increase blood flow. HCG receptors are found throughout the body, so this finding validates that HCG has a much greater biologic role than simply maintaining a placenta in pregnancy.4
Although considerable mystery about the physiologic effects of HCG remain, it is clear that the combined effects of hormonal stimulation and enhanced tissue growth through cAMP and NO production make HCG a compelling compound for clinical trials in severe, chronic pain patients. Note that HCG must be injected since it is apparently digested if taken orally.
How Is It Produced?
One of the myths about HCG is that commercial products come from animal urine. The most commonly used HCG product in the United States is produced and distributed by Abraxis Pharmaceutical Products. The only HCG product listed in the 2009 Physician’s Desk Reference (PDR) is Ovidrel® produced by EMD Serona Inc. Ovidrel® is in a prefilled syringe. The former is marketed in a 10cc vial containing 10,000 USP units and its package insert lists the production source as urine from pregnant women. The latter obtains its HCG from a cell line which comes from hamster ovaries. Both products are FDA approved and are marketed only after high level scientific straining and sterilization techniques have been used. It is highly recommended that pain practitioners only obtain or prescribe American-manufactured HCG that is distributed through, local American pharmacies and suppliers; refrain from purchasing any product from unknown internet sources or from out of the country. There is a large clandestine Mexico-Canada trade comprised of so-called HCG products which are unknown, non-standard, and which have questionable sterility and potency issues.
The popular press refers to HCG as a female fertility drug. This is only partially correct. The fact is that it has multiple U.S. Food and Drug Administration (FDA) approved indications. The HCG insert from Abraxis Pharmaceutical Products lists three indications:
- Prepubertal cryptorchidism;
- Hypogonadotropin (pituitary deficiency) hypogonadism; and
- Induction of ovulation and pregnancy in anovulatory women.
“HCG stimulates the production of testosterone, progesterone, estrodiol, and thyroid—all of which should bring obvious benefits to some pain patients.2-4 HCG may also achieve pain reduction through neurogenesis and tissue healing.”
Patients who require high dose opioid therapy and who develop hypogonadism as evidenced by a low testosterone serum level, qualify for indication No. 2. Opioids are known to suppress the pituitary gland producing a hypogonadotropin state.1 It was this indication that first attracted the author to its possible benefit in pain patients.
In addition to the package insert indications, HCG is used “off-label” for other purposes (see Table 1). It is emphasized that there are few clinical studies or reports involving HCG. Its most widespread use has probably been weight control. This has been controversial. Some observers don’t believe there is much weight loss with HCG, but it is reputed to cause slimming apparently due to muscle building at the expense of fat reduction. This belief is unproven.