I’m hoping you can help with this troubling case. I know we’re not covering sex hormones specifically in ADAPT, but a client of mine has some irregularities in the background. I have limited experience related to these hormones. He’s 30 years old, asymptomatic male that came to me looking to optimize health. Very active in CrossFit, is a full-time coach and participant. Many years ago, at least five years ago, he was a bodybuilder and used anabolics but has abstained since. Ran the DUTCH complete. His total DHEA came back low normal and the downstream hormones came back very low. Testosterone was 4.9, which is very low. Estrogen, progesterone were both right at the bottom of the reference range. Seems his ability to produce all these hormones still affected by his previous steroid use. Even though he’s asymptomatic, I’m thinking I still need to work on increasing DHEA and probably, more importantly, his conversion to testosterone. Any thoughts on where to start with this? Anything else I should be aware of in this type of case?

Chris Kresser:  Yeah. Good question. So I think the first thing I would do in this situation is to test serum levels of these hormones as well. Urine is generally pretty accurate but what you’re measuring in the urine is different, is not the same as what you measure in the serum. And so for example with progesterone, you’re not measuring progesterone at all. You just measuring the metabolites of progesterone because progesterone isn’t in the urine itself, and as typically the case with hormones, you’re measuring hormones that have gone through conjugation and excretion in the urine.

So with the sex hormones, especially when I see stuff that is a little wonky or weird, I will always follow it up with serum hormone levels. And if the serum hormone levels for DHEA and DHEA sulfate, which you can test separately in serum, and then testosterone, I would run total and free testosterone. And then I would run estrogen and progesterone as well. If those are all still low, then I would definitely want to move in the direction that you suggested. Didn’t mention here what his cortisol levels are.

Typically in a male if they have low, all of these other hormones are low and their DHEA is low, they’ll often have either high or low cortisol and HPA axis dysregulation. So that’s a very important place to start. Typically if someone had not been using any hormones and they had this kind of presentation, I would tend to really focus almost exclusively on the HPA axis and also addressing any other issues that could deplete B stressors basically and deplete the hormone-producing system. Because I don’t think testosterone just goes out of whack for no reason, especially in a young male. But in this case it’s a little bit different because of the anabolic use and the potential inhibition of negative feedback. And so if we assume that that may be playing a role, it doesn’t necessarily change what you’re going to do, but it may change how he responds and what the expected course is to recovery.

Because you have an exogenous factor that may have, especially if it’s five years prior and there’s still a lingering effect that may have caused some hopefully not permanent, but definitely like a downregulation of that system. So I would still look at primarily focusing on the HPA axis. Remember that supplementing with DHEA has not been shown to increase downstream hormones like estrogen, testosterone, although DHEA supplementation can be helpful, it doesn’t typically do that. And that’s, the same is true for pregnenolone. So you’d want to focus on all of these, just the rebuilding his metabolic reserve and resilience, and addressing any issues that could continue to interfere with the HPTGA axis.