Adrenal Thread

[SPE]

I have a couple of questions for you guys, Chris and SWALE:
1) My pre-treatment thyroid results were TSH 2.27 (.35-5.5), FT3 3.1 (2.3-4.1), Total T4 6.5(4.5-12). This was also before I started testosterone replacement, as my Total T was low. Unfortunately I was dieting at the time as well. BOTH could have an impact on my thyroid function, right?
2) My AM Cortisol was a little low at 17 and my DHEA was also VERY low. Could fixing these alone improve my thyroid function?
3) It seems that the adrenal function is often overlooked here. Could you clarify how important this is and how to interpret ranges and results?

Also, SWALE any comments are appreciated! I know you treat high cortisol with PS, but how do you determine what is high? From what Chris has said, normal cortisol for men is often above the upper limits.

Thanks Chris

[marianco]

I believe that when you seek to balance one neurotransmitter/hormone system, you have to also examine and balance the rest. They are all closely connected in their functions. From a mental health point of view it is important to optimize functioning in the neurotransmitter/hormone systems involved in reproduction (e.g. estrogens, testosterone, progesterone), adrenals (e.g. cortisol, DHEA, norepinephrine, epinephrine, dopamine, etc.), thyroid, pancreatic (e.g. insulin), besides the brain-involved neurotransmitter/hormone systems.

For example, in order for the thyroid hormone activity to function, adequate serotonin is necessary.

One of the important functions of testosterone is to limit adrenal activity - essentially to quell the stress response so that it does not rage on uncontrollably. Testosterone both causes a reduction of ACTH production from the pituitary, and directly reduces adrenal activity - both reducing the production of cortisol. Testosterone, by also increasing brain dopamine production, causes a reduction in norepinephrine production from the locus ceruleus. Norepinephrine is a signal for stress.

A high cortisol is one indicator of the amount of stress a person is experiencing and is trying to cope with - unless one is dealing with an adrenal disease state such as Cushing's Syndrome. Another would be high norepinephrine levels.

If anything, I think the best ways to reduce such stress include: 1) behavioral and environmental interventions to reduce stress, 2) increasing serotonin to help provide a buffer against the perception of stress - i.e. things hurt emotionally less, 3) optimizing testosterone level to control the adrenal stress response. When these don't work, other measures - often other psychiatric medications - are used. Improving the brain's ability to produce GABA, for example, is one of the alternatives - GABA being an inhibitory neurotransmitter than can help induce calmness - which is modulated using anxiolytic and other medications.

I am not sure that limiting adrenal output is necessarily the best thing to do because that also limits a person's ability to generate energy and get the body ready to respond to stress. The adrenal glands are like a car's transmission, where the brain is the engine. If the transmission is regulated, then the cars ability to accelerate when needed may be compromised. I think it would be better to reduce the stresses that necessitate increased adrenal output in the first place - before the adrenals fatigue.

Adrenal fatigue is a highly important condition to treat. It is a very common condition in our highly stress-filled lives. Adrenal fatigue is like having a transmission that is broken or is stuck in neutral. Pressing the accelerator pedal accomplishes nothing - which is what people with adrenal fatigue feel - the inabilitiy to generate energy on-demand.

Adrenal fatigue is most easily determined using saliva tests of DHEA and Cortisol levels done multiple times in one day. This is more sensitive than the blood tests. Adrenal fatigue can be evidenced also by low DHEA, low Cortisol, low progesterone levels. Hypothyroidism often occurs with Adrenal fatigue - possibly from the resulting impairment in production of neurotransmitters necessary for thyroid function, such as serotonin.

[1cc]

Marianco,

Thank you for an excellent post.

[SWALE]

Mariqanco--Do SSRI's increase T4 to T3 conversion (outside of their ability to through stated purpose of reducing stress for the patient)?

SPE--That is not a low cortisol level.

Hypothyroidism is linked to adrenal fatigue in that the adrenal glands have been trying to, through stress hormone production, make up for the lack of thyroid. Once the adrenals burn out, then both are left in a deficient state.

This is also why adrenal function must be evaluated first prior to treating the deficient thyroid. An uncovered adrenal deficiency could literally kill a patient if thryroid supplementation is initiated first.

[SPE]

Originally Posted by SWALE

Mariqanco--Do SSRI's increase T4 to T3 conversion (outside of their ability to through stated purpose of reducing stress for the patient)?

SPE--That is not a low cortisol level.

Hypothyroidism is linked to adrenal fatigue in that the adrenal glands have been trying to, through stress hormone production, make up for the lack of thyroid. Once the adrenals burn out, then both are left in a deficient state.

This is also why adrenal function must be evaluated first prior to treating the deficient thyroid. An uncovered adrenal deficiency could literally kill a patient if thryroid supplementation is initiated first.

This is what happened to me. My cortisol was never checked before starting thyroid meds. I ran into alot of trouble about 3-4 months into it with bad anxiety and literally crashing everyday between 1-5pm.

[1cc]

Originally Posted by SPE

This is what happened to me. My cortisol was never checked before starting thyroid meds. I ran into alot of trouble about 3-4 months into it with bad anxiety and literally crashing everyday between 1-5pm.

The best and most accurate way to measure cortisol is with a Saliva test, as marianco mentioned. Blood cortisol is not accurate at all.

[SPE]

Originally Posted by 1cc

The best and most accurate way to measure cortisol is with a Saliva test, as marianco mentioned. Blood cortisol is not accurate at all.

My next step in a few weeks is an ACTH Stim test, measuring cortisol, ACTH, and DHEA. I'm pretty sure he'll put me on something like Cortef after seeing the results.

[1cc]

Originally Posted by SPE

My next step in a few weeks is an ACTH Stim test, measuring cortisol, ACTH, and DHEA. I'm pretty sure he'll put me on something like Cortef after seeing the results.

If you do Saliva, then you won't need an ACTH stim test.

[ASaxon]

My understanding was that the gold-standard cortisol test is a 24-hour urine cortisol/creatine test. I've read posts that saliva testing can be tricky depending on when exactly you take it and what you've recently put in your mouth. Plus, the higher variability of that test seems to be in question by some endos so I've rarely heard any doctor want to use it over a 24-hour urine test except as a screen to rule IN a cortisol problem. It's probably good at detecting people that have very high, or very low, cortisol levels but maybe not as good as a 24-hour urine when someone may be closer to the normal range.

I have no professional exp other than reading about it and talking to a few endos about it. Obviously it's not a bad first test but I'm not sure how conclusive it is when it results in near normal levels. It certainly is cheaper and less of a hassle. I ended up having a 24-hour urine myself because I wanted to be sure.

[SPE]

Originally Posted by 1cc

If you do Saliva, then you won't need an ACTH stim test.

As I understand it, the ACTH Stim is THE FINAL say wrt adrenal issues. It measures how your body reacts under stress with cortisol. If the response is low, then your response to stress is low. Individuals with cortisol levels in the normal range as identified by a saliva test, could have very poor responses to stress and therefore feel bad. This is also adrenal insufficiency.

[marianco]

Originally Posted by SPE

As I understand it, the ACTH Stim is THE FINAL say wrt adrenal issues. It measures how your body reacts under stress with cortisol. If the response is low, then your response to stress is low. Individuals with cortisol levels in the normal range as identified by a saliva test, could have very poor responses to stress and therefore feel bad. This is also adrenal insufficiency.

The problem of using blood tests such as serum cortisol and ACTH-stimulation is in the interpretation and design. The tests are often designed to look for extremes such as in Addison's Disease and Cushing's Disease. It is more difficult to interpret for disorders that involve small changes from the average.

As another example, often the "normal range" for TSH (thyroid stimulating hormone) is between 2.0 to 5.0. The problem is that this norm was arrived at without excluding people with hypothyroidism. Thus the numbers are skewed. Using the normal range, a TSH under 5.0 would be thought of as being normal and not hypothyroid. But that is not the case. If the Free T3 and Free T4 are checked, often such a person would be hypothyroid. As a result, I use a TSH of > 2.0 to determine hypothyroidism - verifying it wiht the Free T3 and Free T4. In other words - the TSH is essentially useless in determining hypothyroidism. It would be best to just check Free T3 and Free T4.

When it comes to hyperthyroidism, the TSH is also not very useful. It often a TSH near zero stirs alarm when no alarm need be there. The TSH is the brain's idea of how much thyroid hormone activity there is. It is not necessarily how much thyroid hormone is actually there - because there can be a disconnect in disease states. A truer measurement of hyperthyroidism is the Free T3 and Free T4.

[marianco]

Originally Posted by SWALE

Mariqanco--Do SSRI's increase T4 to T3 conversion (outside of their ability to through stated purpose of reducing stress for the patient)?

I corrected my note - removing that reference. Mea culpa - I shouldn't write when I'm tired.

Thyroid function and serotonin activity are highly linked. Both need to be addressed to optimize function.

T3 (the active thyroid hormone created from T4 in the liver by the 2D6 enzyme) desensitizes presynaptic serotonin autoreceptors - thus leading to an increase in serotonin production. Giving T3 induces serotonin production. Similarly, in hypothyroidism, serotonin production is reduced. T3 augments the effects of serotonin-increasing medications (such as the SSRIs) by the additive effect both have on desensitizing presynaptic serotonin autoreceptors.

Serotonin stimulates hypothalamic TRH production, leading to an increase in TSH production from the pituitary. Adequate serotonin production is necessary to maintain thyroid hormone levels. Increasing serotonin levels with an SSRI may thus help improve thyroid hormone production.

A caveat: Theoretically, an excess serotonin may lead to the opposite reaction. For example, excess serotonin leads to reduction in dopamine production, which then leads to increased norepinephrine production, leading to an increased stress response and cortisol production.

High levels of cortisol (which can also be caused by high stress levels, low testosterone, etc.) can directly lead to suppression of pituitary TSH secretion, and impair conversion of T4 to T3, and can impair serotonin function (by reducing serotonin receptor density, increasing serotonin uptake via increase in serotonin transporter production, and by increasing tryptophane oxygenase production in the liver - thus reducing tryptophan, the precursor to serotonin).

It may be thus important to have an idea of serotonin levels (unless one has a good clinical feel as to a patient's clinical response to assess serotonin levels - as a psychiatrist may have) by measuring urine serotonin levels. This, somewhat, correlates with brain serotonin levels, though I am still assessing this for clinical utility.

[1cc]

Originally Posted by ASaxon

It certainly is cheaper and less of a hassle.

A saliva test that takes 4 samples during the day, which is required will cost $100. A Urine analysis for Free Cortisol will cost $25. So saliva is more expensive.

The following is from the book "Adrenal Fatigue: The 21st Century Stress Syndrome" by Dr. James Wilson page 83:

Regarding Saliva Cortisol testing:

"It is the best single lab test available for detecting adrenal fatigue and has several advantages over other lab tests in determining adrenal hormone levels."

For the rest of the passage, please read the book (it's too long to type).

[marianco]

Originally Posted by 1cc

A saliva test that takes 4 samples during the day, which is required will cost $100. A Urine analysis for Free Cortisol will cost $25. So saliva is more expensive.

The following is from the book "Adrenal Fatigue: The 21st Century Stress Syndrome" by Dr. James Wilson page 83:

I heartily recommend James Wilson's book. It's a great start regarding adrenal fatigue.

Here are some costs for comparison between blood and saliva tests:

Salivatest.com/ZRTLabs
- Cortisol x 2 (AM/PM) Saliva Test $60
- Cortisol x 4, DHEA x 4 Saliva Test $150

LEF.org/Life Extension Foundation
- Cortisol x 2 (AM/PM) Blood Test $72 members, $96 non-members
- Cortisol x 1 Blood Test $39 members, $52 non-members
- DHEA-S x 1 Blood Test $61 members, $82 non-members

Sanesco.net/Sanesco International
- Cortisol x 4, DHEA x 2 Saliva Test $89

Quest Diagnostics
- Cortisol x 1 Blood Test $127
- DHEA-s x 1 Blood Test $136

The blood test give an idea, when combined with other lab tests about the presence of adrenal fatigue. One can do four blood tests in a day to get better sensitivity - but then what patient wants to get poked with a needle four times in a day?

The saliva tests - involving multiple samples in a day - are much more sensitive in helping diagnosis adrenal fatigue than an AM/PM Cortisol blood test along with a single DHEA-s.

Be-that-as-it-may, some patients cannot afford to pay out of pocket, even for a saliva test, yet they have health insurance coverage - even if it is Medicaid or Medicare. I will take whatever test I can get to help the patient.

Some patients don't have health insurance at all and are poor but not poor enough to get government health insurance. In this case, I use my clinical skills and experience to arrive at the diagnosis and treatment. With informed consent, I would treat the person if the benefits of treatment outweigh the risks - of course, if not, I would not. Medicine, most of the time, is an art. As we generally learn in medical school, 90% or more of the diagnosis is arrived at by the history and physical - when one has clinical-saavy and medical street-smarts. It certainly is nice though to get labs. It gives you clear road-signs and specific goals to achieve. Whether or not it can be done depends on the patient.

[1cc]

Originally Posted by marianco

Sanesco.net/Sanesco International
- Cortisol x 4, DHEA x 2 Saliva Test $89

Thanks for the info. This is an excellent price. The best price I could find for the equivalent was $125.