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HPA Axis

I have a new client that came looking to optimize health. He’s a 30-year-old male living in Shanghai for the past few years. Very active CrossFit coach and CrossFitter, he is a former bodybuilder and during his competitive phase he did use steroids, though he stopped this over five years ago. Ran the DUTCH Complete Hormone profile, had total DHEA on the low side of normal, total estrogen and progesterone bottom of the reference range, testosterone very low, about 4.9, with 25 being the bottom of the reference range. Notified by DUTCH that there is a genetic mutation that can prevent the production of the metabolite they use to drive their testosterone measurement.” Yes, which is most common in patients of Asian descent; that is correct. And then Brandon says, “I do have a serum testosterone measurement he had done about a year ago that came back as 12.47. He is exhibiting some symptoms of low testosterone, including fatigue, weight gain, difficulty gaining muscle, but on a scale of one to five, he’s rating most of these symptoms as a one to two, with five being the highest. How would you approach this? Should I get another serum testosterone measurement? Should I be focusing on boosting conversion of DHEA to testosterone? Anything else to think of?

Dr. Amy Nett: Yeah, so I mean I would still approach this like we do almost any other functional medicine...

How do you work HPA treatment when patients are on psychiatric and/or sleep medications? This is very common. Sometimes the patient’s goal is to get off them, sometimes not.

So few questions regarding the sleep support aspect of HPA-D, specifically, when people have high cortisol at night and a disrupted rhythm. This kind of person is often dragging during the day and awake at night. Could have high or low overall cortisol. What’s best use for sleep support at night? Would you go more with 5-HTP, Kavinace, or phosphatidylserine type of product or just experiment? I guess I’m not sure how to select sleep support supplements accurately. So specifically in the case of elevated cortisol at night. Also is it bad to be on more melatonin than 0.5 to 1 mg? I have people taking higher doses up to 10 and sleeping really well and not wanting to go down. Is there any reason to try to get them down? There is one Italian study that melatonin that 10 mg helps menopausal hot flashes. So I’ve been going on the assumption it was fine to go up to 10 mg before this course. Lastly, do you find that people backfire? I have one patient who seems to go the opposite with any of the sleep support. She gets wired with a sense of tachycardia on any sleep supplements. We’ve tried every single one always with this response, yet she does have chronic insomnia. We haven’t done the DUTCH test, but I’m certain her cortisol must be elevated at night. We’ve done the best work with just lifestyle, but there are times when she really wants to have something to take especially when traveling or under stress.

Dr. Amy Nett: Okay, so let’s break this down a little bit more. Okay, so when people have trouble sleeping,...

Chris had mentioned he didn’t mind answering questions about sex hormones and DUTCH results, so I’m seeing all these markers specifically with the metabolites that I have questions about. So we have three different questions about the sex hormone portion of the DUTCH complete hormone profile. If 16-OHE1 is in the low range, would you be concerned to do anything specific about it? What about 4-OHE1? What about 2-OHE1? Is it more the levels or the ratios that we’re concerned with?

Dr. Amy Nett: Okay. So what I’m most concerned with is, what are the estrogen levels? So there are a...

For a woman, if 5-alpha-reductase is low and she has low testosterone, would you do anything specific about it? I’ve seen 5-alpha reductase come back low on all women.

Dr. Amy Nett: Interesting. So, I actually don’t see 5-alpha-reductase low on all women. I do see women with higher...

So still trying to get a hang of the DUTCH test when the patterns aren’t as clear. So Brent has a 51-year-old female patient. She was 194 pounds and now down to 183 from the last time he saw her. She’s responding to the autoimmune Paleo protocol well, previously was on a 95 percent gluten-free diet. She has less fatigue, fewer body aches, did a full workup but have only gotten the DUTCH and blood chemistry results. Some of the key findings are homocysteine of 11.

Dr. Amy Nett: Which is high because remember, we want to see a homocysteine that’s 7 or below and when...

Also curious about the low normal waking cortisol/cortisone that you see. In that case, you think supporting inflammation methylation nutrient status like detox would be beneficial. So you’re saying, would those things be beneficial specifically for the low-normal waking cortisol? In that case do you think supporting the inflammation methylation nutrient status and late detox would be beneficial with the other patterns we saw?

Dr. Amy Nett: Well, remember that the waking cortisol is a good representation of what overnight cortisol is. So if...

What is your recommendation for clients who are working out every day in very intense training and have HPA axis dysfunction? Also, they have been told that they need to slow down but they feel addicted to exercise.

Laura Schoenfeld: All right, this is another one that I see a lot in my particular niche for my nutrition...

Would you test kids on the DUTCH adrenals for cortisol?

Dr. Amy Nett: I haven’t and I think one time I had, I think twice I’ve had moms who wanted...

The diagnostics values were 13 to 24 is the range. So 15 put this patient at the bottom end of the range. And then DUTCH waking and morning cortisol and cortisone are borderline high and lab high respectively. Afternoon cortisol and cortisone normal, and the night sample was sky high, practically same value as the morning sample.

Chris Kresser: That is interesting. I mean there is a lag for, what, the DUTCH morning sample. But the waking...

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