Last Friday I was on Facebook Live doing a presentation on testing the adrenals [1], but for those who prefer reading the information I’m giving a summary in this blog post. I’ll be focusing on 3 different types of adrenal testing. Although in the upcoming weeks a lot of the material will focus on Hashimoto’s thyroiditis to celebrate the release of my new book “Hashimoto’s Triggers”, which will be released on March 5th, this information on adrenal testing will benefit those with hyperthyroidism and Graves’ Disease as well.
Why Should You Test The Adrenals?
When I was diagnosed with Graves’ Disease, I didn’t think stress was a factor. I always considered myself to have good stress-handling skills, and so you can imagine how surprised I was when an adrenal saliva panel revealed that I had depressed cortisol levels and a depressed DHEA [2]. This was my first lesson on how you can’t go by symptoms when determining the state of your adrenals. The pattern I had is referred to by many as an “adrenal fatigue” pattern, and while I can’t say that I felt awesome while I had Graves’ Disease, I can say that fatigue wasn’t one of my primary symptoms.
Some healthcare professionals don’t recommend adrenal testing because they assume that all people have adrenal imbalances. I argue that this is a reason why everyone should do adrenal testing. It would be one thing if everyone with an adrenal imbalance had the same pattern, but this isn’t the case. As I mentioned earlier, when I was dealing with Graves’ Disease both my cortisol levels and DHEA were depressed. However, many others will have elevated cortisol levels. And while there is some overlap between treating someone with elevated cortisol levels when compared to depressed cortisol levels, the treatment isn’t exactly the same.
Healthy Adrenals Are Necessary For Healthy Sex Hormones
In the past I wrote a blog post entitled “The Negative Impact of the Pregnenolone Steal [3]”. The pregnenolone steal is also known as the cortisol steal, and what this means is that the body prioritizes the production of cortisol at the expense of the sex hormones. As a result, someone who is dealing with prolonged chronic stress not only is likely to have an adrenal imbalance, but there is a very good chance that some or all of their sex hormones (i.e. progesterone, estrogen, testosterone) will be deficient.
In this scenario, many doctors who dispense bioidentical hormones would recommend these to the patient. However, the real problem isn’t with the sex hormones, but instead is with the adrenals. I’m not suggesting that all sex hormone deficiencies are due to adrenal imbalances, but the truth is that the majority of sex hormone imbalances can be corrected by improving the health of the adrenals.
Can You Take Adrenal Supplements Without Doing Any Testing?
Even though I’m discussing the importance of adrenal testing in this blog post, the truth is that many people take adrenal support supplements without doing any testing. For example, I commonly see people randomly taking adaptogenic herbs such as ashwagandha [4], rhodiola, and eleuthero. Others will take nutrients such as vitamin C and the B vitamins to support the adrenals. And while taking these without testing might not do you any harm, you want to be cautious about taking other supplements without knowing what type of adrenal imbalance you have.
For example, if you have elevated cortisol levels then you wouldn’t want to take licorice root or an adrenal glandular, as these are best taken when someone has depressed cortisol levels. Similarly, phosphatidylserine is best taken if someone has elevated cortisol levels [5]. And while I don’t commonly recommend DHEA to my patients, when I do recommend it I’ll make sure that the person has low DHEA levels. This might sound like common sense to some people reading this, but you’d be surprised how many people I’ve seen over the years who were taking supplements and/or hormones that didn’t fit their adrenal pattern.
While I’d be cautious about taking adrenal supplements without any testing, anyone can of course incorporate lifestyle changes to help improve their adrenal health. In fact, in order to have optimal adrenal health it is necessary to eat well, do a good job of managing stress, and to get sufficient sleep. These are factors that everyone can and should work on. In fact, working on these diet and lifestyle factors is even more important than taking supplements.
3 Types of Adrenal Testing
What I’d like to do next is discuss three different ways to test for the adrenals:
1. Blood Testing. Many medical doctors, including just about all endocrinologists, never do any adrenal testing. The exception is if they suspect that someone has adrenal insufficiency in the form of Addison’s disease or Cushing’s syndrome. Those medical doctors who do test the adrenals usually utilize blood testing. In most cases they will order a morning cortisol, and perhaps test the DHEA.
Adrenocorticotropic hormone (ACTH) is a pituitary hormone that can also be tested for in the blood. It stimulates cortisol production, and if someone has a condition such as Addison’s disease they will usually see depressed cortisol and increased ACTH, while with Cushing’s syndrome, both cortisol and ACTH will usually be increased. An adrenal tumor frequently presents with increased cortisol levels and a decreased ACTH.
While blood testing isn’t completely useless, there are a few reasons why you shouldn’t rely on this type of testing for determining the health of the adrenals. First of all, blood testing doesn’t look at the circadian rhythm of cortisol, and the reason for this is because this almost always involves a single blood sample. As I’ve discussed in past blog posts and articles, cortisol follows a circadian rhythm, as it should be at the highest level in the morning, and gradually decrease throughout the day. While someone can conceivably visit a lab multiple times in a single day to see what cortisol looks like at different times, this a major inconvenience, which is one of the main reasons why it usually isn’t done.
In addition, false elevations of cortisol are common in the blood. One of the main reasons for this is because it’s common for people to get stressed out when getting a blood draw. And cortisol increases when someone is in a stressed out state.
One advantage of blood testing is that you can test for anti-adrenal antibodies. An example is 21-hydroxylase antibodies. I can’t say that I have most people test for this, and even though I once had depressed cortisol levels I personally didn’t test for these antibodies. But if someone has low cortisol levels that remain depressed over a prolonged period of time, then in this situation it would be a good idea to test these antibodies, as this might be suggestive of Addison’s disease.
2. Adrenal Saliva Testing. I’ve been recommending adrenal saliva testing to my patients for many years. The main reason I started using saliva testing in my practice is because of the success I personally had with saliva testing when I was diagnosed with Graves’ Disease. And over the years I have also seen many of my patients benefit from saliva testing. There are a few reasons why saliva testing is a good option for evaluating the adrenals. Let’s take a look at three of these reasons:
- Saliva testing looks at the circadian rhythm of cortisol
- Saliva testing is less invasive than blood testing
- Saliva testing is just as accurate as blood testing
Just as is the case with blood testing, false elevations of salivary cortisol are possible. Cortisol responds to stress, and so for example, if someone is in a stressed out state prior to collecting the saliva sample, then there is a good chance this will cause an elevation of cortisol. Based on what I just said, you might assume that it’s best to do cortisol testing in a relaxed state. And many of my patients do collect their saliva samples on an off-day from work due to this reason. However, one can argue that it might be best to test your adrenals under “normal” conditions, which means that if you are stressed out Monday through Friday due to work, but are relaxed on the weekend, then perhaps it’s best to try to test the adrenals during the week. So for example, you can collect a saliva sample upon waking up, another sample during your lunch break at work, another one when you come home for dinner, and then one right before going to bed.
I realize that for some people this isn’t practical, and truth to be told, even for those who collect the saliva samples on a more relaxed day it can still provide some valuable information. And as I mentioned earlier, it’s very common for my patients to collect their saliva samples on their off days from work. Either way, you definitely don’t want to collect the saliva samples under abnormally stressful conditions, as this is likely to result in false elevations of cortisol.
It’s also worth mentioning that many saliva panels test for more than the cortisol and DHEA. The Adrenal Stress Index test from the lab I use also tests for 17-OH progesterone and secretory IgA [6]. You can also test for the sex hormones through the saliva, and cycling women can choose to do a cycling hormone panel. This involves collecting a saliva sample every few days of one’s cycle, which not surprisingly gives more information than a single blood test taken in the second half of the cycle.
3. Dried Urine Testing. In 2017 I started “experimenting” with dried urine testing. A lot of well known healthcare professionals (i.e. Dr. Joseph Mercola) recommend this type of testing. I used myself as a guinea pig initially, and I was impressed with what I saw, which is why I started recommending it to some of my patients. This test involves urinating on test strips throughout the day, which like the saliva, allows you to look at the circadian rhythm of cortisol. It also tests the sex hormones, but unlike saliva testing, dried urine testing can also look at the “hormone metabolites”, which in some cases can be helpful.
While there can be some value in looking at cortisol metabolism through dried urine testing, perhaps the most important metabolites to evaluate are the estrogen metabolites. These include 2-hydroxyestrone (2-OH), 4-hydroxyestrone (4-OH), and 16α-hydroxyestrone (16α -OH). The reason why looking at these metabolites can be important is because having higher levels of 4-OH metabolites can potentially be a risk factor for developing certain types of cancer, while having higher levels of 2-OH metabolites can be protective.
Which Type of Testing Should You Do?
Now that you are familiar with the different ways to test for the adrenals, you might be wondering what the best test is for you. As of now I still recommend adrenal saliva testing to most of my patients. However, if someone wants to test for both the adrenals and sex hormones then either saliva testing or dried urine testing can be a good option. Dried urine testing is more comprehensive in that it also tests for the hormone metabolites. For cycling women, both saliva testing and dried urine testing offer cycling hormone panels.
In summary, I recommend adrenal testing to just about all of my patients, and the reason for this is because most people have adrenal imbalances, and people will present with different adrenal patterns. I have primarily used saliva testing in my practice over the years, although recently I started using dried urine testing on some of my patients. If someone is just interested in evaluating the adrenals then I think it’s fine to use saliva testing, and while I have also used saliva testing to evaluate the sex hormones in the past, dried urine testing has the advantage of looking at the hormone metabolites. Blood testing usually should be utilized when more serious adrenal problems are suspected, including Addison’s disease, Cushing’s syndrome, or an adrenal tumor.
Hashimoto’s Triggers Book Update: I just wanted to remind you that my new book on Hashimoto’s Triggers will be released on Monday, March 5th. It will be available in both paperback and Kindle format, and the first few days after its release I will be offering a special discount on the Kindle version, along with a few free bonus gifts for anyone who purchases either the paperback version or the Kindle version. If you would like to check out a free chapter of my book you can do so by clicking here [7].