Functional Endocrinology 101: Assessment of Adrenal, Thyroid and Reproductive Hormones as a Starting Point in Treatment
Fatigue, slow metabolism and insomnia associated with hormone changes are by far the most common complaints that bring patients to Naturopathic Doctors. Unpacking the “why” behind these symptoms can take time as underlying causes are different for each patient, but understanding a patient’s individual endocrine balance from the start of treatment remains of the utmost importance for a clinician. In diagnosing adrenal imbalance, subclinical hypothyroidism, early menopause, estrogen dominance, testosterone deficiency and other easily-identifiable conditions, supports may be put in place right away. Though endocrine supports are not the end of treatment (there are good reasons that endocrine imbalances occur), it is possible to begin improving the quality of life of the patient while underlying causes are being investigated and treated. What’s more, stabilizing endocrine imbalance creates more stable conditions for successful treatment of underlying causes.
Comprehensive Laboratory Evaluation of Adrenal function, Thyroid Function and Reproductive Hormones
A thorough assessment of endocrine function includes:
- A salivary analysis of adrenal function: this includes a 4-point circadian measure of cortisol levels and other adrenal hormones including DHEA and 17-OH progesterone. Salivary levels of insulin are collected within the same panel to understand influence of cortisol on insulin resistance (more on this later).
- A full thyroid panel, whether or not the patient uses thyroid hormone already: this includes a TSH, Free levels of Thyroxine (T4) and Thyronine (T3), thyroid peroxidase and thyroglobulin antibodies as assessment of auto-immunity and Reverse T3 as marker of “thyroid resistance”. This information is interpreted in the context of the adrenal function above as the adrenal glands have immense influence on thyroid function. Understanding pure and simple hypothyroidism vrs. Auto-immune hypothyroidism (as in Hashimoto’s thyroiditis, a very common condition) influences treatment strategy.
- Levels of reproductive hormones including estradiol, estrone, progesterone and free and total testosterone, taken on day 21 of the menstrual cycle for pre- and peri-menopausal women; free and total testosterone for men.
Cortisol is the Epicenter of Endocrine Balance
Of the above assessment, the circadian secretion of cortisol is arguably the most important insight into a patient’s metabolism. This is due to cortisol’s critical role in regulating inflammation of the immune system. Many of the factors that cause endocrine imbalance revolve around inflammatory processes such as chronic infections, toxic exposures, cardiovascular disease and severe stress. “Inflammation” is the immune system’s response to these physiologic stressors. (This is an important concept to understand, as we are taught that infections make us sick, when really it is the immune system’s inflammatory response to the infection that makes us sick.) When inflammation is high, the adrenal glands will increase production of cortisol in order to help control an inflammatory response that may otherwise get out of control. So, in understanding a patient’s individual cortisol levels we can also deduce how much inflammation and physiologic stress is occurring in their system. High cortisol means high inflammation. Low cortisol means long history of inflammation that has depleted the adrenal glands. We call this adrenal fatigue.
Cortisol is often demonized by the weight loss community, but it is important to keep in mind that cortisol is only trying to help. High levels of cortisol over long periods of time cause insulin resistance and weight gain, particularly in the abdomen as well as hypothyroidism. This is because the adrenal glands are trying to protect us from starving by slowing down our metabolism (this ancient adaptation allowed our ancestors to survive famines). High levels of cortisol cause us to sleep poorly. This is because the adrenal glands do not want us to go into a deep sleep when there is perceived danger. High levels of cortisol change the balance of hormones for both men and women, prioritizing survival over reproduction. Hence, men with high levels of cortisol will often have low levels of testosterone, causing depression, lack of focus, low muscle mass and poor libido. Women with high levels of cortisol will often have progesterone deficiencies causing estrogen dominance, infertility and early onset of menopause. The examples of how high cortisol is detrimental to our well being go on, but cortisol is just doing its job of protecting us. The key to lowering cortisol is lowering inflammation and for this, we have to have identify and remove the irritants to the immune system.
Functional Endocrine Interventions
Because it takes time to diagnose and treat underlying causes of inflammation, it can be a very good strategy to start correcting hormone imbalances from the start of treatment. Common functional medicine interventions include:
Thyroxine-containing thyroid supports
We now know that high inflammation —> high cortisol —> poor thyroid function. One of the ways that cortisol slows down the thyroid is by preventing the conversion of thyroxine (the weaker of the two thyroid hormones) to thyronine (the more physiologically active form of thyroid hormone). Hence, thyroid supports that contain T3 or thyronine are more likely to have clinical benefit for the patient’s fatigue, metabolism, brain fog and other hypothyroid symptoms. Thyroxine-containing therapies include Liothyronine/Cytomel, a synthetic T3 replacement that can be prescribed to accompany Levothyroxine/Synthroid and desiccated thyroid which contains both of the thyroid hormones in a glandular form. These medications are available by prescription only and must be monitored by a knowledgeable healthcare practitioner who is accustomed to working with T3 therapies.
Pregnenolone is the precursor to all adrenal and reproductive hormones and can be used in adrenal fatigue or circadian rhythm imbalance to provide “building blocks” to a tired endocrine system. DHEA is often neglected by a stressed endocrine system when cortisol production is prioritized and can be important for women as a precursor to testosterone. Both of these are available over the counter at most health food stores and on line, but it is still recommended to use them only when diagnostic findings support their use and under the guidance of a practitioner who frequently prescribes them
This type of progesterone is much different than what is found in birth control pills and progestin implants such as Depoprovera and progestin-containing IUDs such as the Mirena. While progestins look very different from human progesterone and for this reason cause side effects of weight gain, acne and irritability, bioidentical progesterone is virtually identical to human progesterone. Bioidentical progesterone can be used to replace the progesterone deficiency created by excessive inflammation, and can be a useful tool for heavy menstrual cycles, infertility, anxiety, insomnia, migraine headaches and endometriosis.