Recently I interviewed Dr. Aimee Duffy, as she discussed how to optimize the health of your adrenals. If you would prefer to listen the interview you can access it by Clicking Here [1].
Dr. Eric Osansky:
With me, I have Dr. Aimee Duffy. We are going to be chatting about the adrenals. I am going to give Dr. Duffy’s bio, and then we will chat about adrenal health, tying it into thyroid health. Dr. Duffy is the #1 bestselling author of Normal Doesn’t Have Side Effects. She is an award-winning speaker of Harvard Club in Boston, CNN, NASDAQ, New York City Bar Association, and the Philadelphia College of Physicians. Dr. Duffy has shared the stage with Martha Stewart, Suzanne Somers, Ice-T, and Dr. Oz. She is a frequent podcast guest and expert guest on ABC, NBC, CBS, and FOX Network TV shows. Thank you so much for joining us, Dr. Duffy.
Dr. Aimee Duffy:
Absolutely. I’m so excited to be here. Thanks.
Dr. Eric:
So excited to have you. Why don’t we go ahead and start off by discussing your background? How did you get into functional medicine?
Dr. Aimee:
Sure. I love to tell stories. That’s the best way people like to hear information as well. When I was younger, I absolutely loved babies. They were my favorite thing in the whole world. I had all the Cabbage Patch Kids with all their clothes and accessories. I became a babysitter at the early age of 11. I wasn’t allowed to stay alone with the babies, but I would go over to neighbors’ houses and play with the babies while moms were doing their thing.
Over the course of the next several years, I developed a great relationship with one of the families that I babysat for. They invited me when I was 17, a senior in high school, to be in the delivery room when their next baby was due to be born. That was really my first experience. I had never dealt with anything like that before. I was there. I got to see the whole thing. When that baby came out and was put on Mama’s chest, I thought this is the coolest thing ever. I want to be a doctor and do this. I am going to deliver babies. That was in high school.
I went through college and med school. I became the doctor that delivered babies. Over the course of my years, I have delivered over 1,000 babies. It’s been an amazing experience. What I found though was that when you’re not delivering babies, in that line of care, you’re doing a lot of women’s health and GYN-type stuff.
Early in my career in medical school residency, there was a lot of talk about hormones. The Women’s Health Initiative came out. There was lots of scary information about the concerns associated with hormone replacement. I found myself in these conversations with women. “What should I do about these hormones? Do I need to get off what I’m taking? I feel horrible. You have to fix me.” “Well, we have these hormones, but we’re hearing they have a lot of negative things. My job is to do you no harm, so I don’t know that’s the best option for you.” We didn’t have a good solution for that. Get stuck between a rock and a hard place of having horrible symptoms or risk the negative side effects. I didn’t think that was a good place for anybody to be, myself in trying to help these patients, or them having to make that decision on their own.
I started doing a lot more research and reading about hormone therapies. I came across this idea of bioidentical hormone therapy that I had never heard of in medical school or residency. That was like Alice in Wonderland, where she goes into the tiny door, and it opens up, and it’s this amazing world of beauty and knowledge. Where did this come from? Why aren’t we talking about this more?
When people first think about bioidentical hormones, they are thinking about estrogen, progesterone, and testosterone. Really, this is where we’re rolling into adrenals. Cortisol is a hormone. Thyroid is a hormone. Are there ways we can test, understand what’s going on with a patient, and then evaluate it in a better way to help them get back to normal again? Ultimately, that’s what our goal is.
I started with these patients who were really feeling miserable, whether they were having classic hormone symptoms, but they are also fatigued, they can’t lose weight, their hair is falling out, their libido is horrible, or they’re having painful intercourse. Their gut is a mess. They didn’t even think that was something they needed to talk to the doctor about because they are so used to having gut issues. That is where I started to really find the results: when we could test those patients, see what their issues were, and respond more naturally. That is where my book Normal Doesn’t Have Side Effects comes from.
When we are getting things back to normal in terms of hormone levels, be it the sex hormones or thyroid, people really start to feel better. You don’t have to worry about all those side effects. We are doing it in a more natural way. That’s really what started my process: going through the steps to get to those types of patients. Now, that’s the type of patient that I see in my practice for the most part. That’s where we get started.
Dr. Eric:
Always want to try to address the root cause of the problem, which of course we both do. There is a time and place for hormone therapy as well. Now that we have some of your background, why are the adrenals important to our health?
Dr. Aimee:
If people hear about adrenals, they don’t really know what that means, but there is a lot of chatter in advertisements for supplements about cortisol and stress. I must have high cortisol levels because I’m so stressed out all the time. What I have found over the course of my 15+ years doing this in practice is the adrenals are your stress hormone, but they are also really important for other things, like your immune system. They’re anti-inflammatory.
When we talk about the pandemic that we have been living in, and everyone being so stressed out, their cortisol levels are not normal. That could be affecting their ability to fight off infection and immunity. Not having the appropriate stress response, it starts to mess with your brain. You have to think about what the adrenals are supposed to do in the first place, so you can understand why if they are not working right, what the consequences could be.
When you wake up in the morning, your cortisol levels are high. It’s time to wake up. The sun comes up. You’re ready to go. Over the course of the day, your cortisol levels go down. Let’s imagine that at 1pm, you get chased by a saber-toothed tiger. You would have a fight or flight response. Your cortisol and adrenaline go way up. You’re able to outrun the tiger. Run fast, jump high, lift heavy things. You won’t stop and go to the bathroom and eat a snack. If you sprain your ankle, your body is smart. It doesn’t want to let you feel that pain, so you can keep running. Otherwise, if you stop, you won’t make it. That adrenaline is really important for our survival.
In that scenario, maybe you find a cave. You outrun the tiger. You catch your breath for 20 minutes. You go back to your home, and everything’s fine. You rest a little bit that afternoon, and you go back to normal.
What happens where we are now, fast forwarding from caveman days to here, is we have so much stimulation, starting with setting an alarm clock and turning on lights before the sun comes up in the morning to getting in the car to dealing with your schedule. Especially now with our smart phones, we have constant notifications all the time interrupting us. It may not necessarily be stress although everybody knows what stress is. That stimulation constantly throughout the day. Driving in your car, it’s not relaxing. You have to be on alert all the time. Your cortisol levels are always a little bit higher. You get home and turn lights on. Even though the sun is going down, we are not calming down. We have screens in front of us. We are not sleeping well. We call that “tired and wired” when you’re exhausted throughout the day but are not getting adequate sleep.
What I tend to see more in my practice is low cortisol. We have really used up all the reserves. What the adrenals are supposed to be doing, we have asked them to work so hard over time. We are running a marathon uphill without ever taking any breaks. That starts to lead to what we call adrenal dysfunction. It used to be called adrenal fatigue, and a lot of people understand that. It’s an imbalance in that pattern of high in the morning, low at nighttime. The signals from your brain start getting confusing. The brain is telling you, “I am being chased by a tiger, but you are not responding.” That gets really confusing. When there is really something stressful going on, like you get sick, or you do have an injury, then the signals are all messed up, and you are not able to recover appropriately.
What happens more so indirectly from cortisol dysfunction and adrenal fatigue is that it doesn’t allow us to do the things that we know we need to be doing to maintain our health. When you’re tired all the time, you are less likely to exercise appropriately. You’re not getting adequate sleep when your cortisol levels are cattywampus.
One of the most common symptoms that I see is carbohydrate cravings. You tend to crave salt and sugar because your brain is saying we need energy from somewhere, especially later in the day. We tend to go back and forth between this salty snack, this sweet snack. Margaritas are a favorite because they are both salty and sweet. Then we are frustrated. “I want to eat healthier, but I tend to crave these things.” Then we start rationalizing, “I have a busy day. I’m tired. I am just going to order pizza tonight.” We are not able to get over that hump and do the adequate lifestyle management things that we need to do. These people become overweight.
It starts to affect other hormones. There is definitely a connection between the adrenals and thyroid. There is also a connection between adrenals and progesterone; that’s a big one. Other hormones, too. Everything starts to fast forward. I see women who are going through menopause or feeling menopausal earlier, late 30s, early 40s because their cortisol levels are tanking, and it’s messing up the whole hormone connection there. There is some direct correlation with adrenal dysfunction and health, but it’s more indirectly because it’s not allowing us to maintain healthy habits. We start to get overweight diabetes. We are going to have blood pressure issues. More high cholesterol. It just goes on and on from there.
Dr. Eric:
We mentioned low cortisol. When I dealt with Graves’, I did a salivary test, and that definitely showed my cortisol levels were in the tank. My DHEA was low. I don’t know if you commonly see that, too.
Dr. Aimee:
Absolutely.
Dr. Eric:
For those listening, DHEA is also an adrenal hormone. It sounds like it’s not just emotional stressors, but also you mentioned the importance of diet when it comes to adrenals.
Dr. Aimee:
Right. The other thing that I talk about with adrenals, and I mentioned the stressors from the outside in terms of either work stress, home stress, finances, time management, we have all these stressors. A lot of people are taking care of elderly family members who are sick, and that’s a big stressor on life, those sorts of things. Everybody understands what stress means from the outside.
What a lot of people don’t understand is the stressors that are happening on the inside. That is where we deal with diet and gut. If we are eating and ingesting or being exposed to things that your body looks at as foreign or a threat, so any kind of chemical, all of our standard American die that is full of chemicals right now; medications you might be taking. We can’t control 100% the air we breathe and the water we are drinking. Now our insides are being exposed to these threats. It really sends the exact same signal to your adrenals. The brain is not delineating between that tiger chasing me and I just ate something like gluten. That is a very popular one. I just ate the McDonald’s McMuffin or something like that (I don’t know what it’s called now). If you eat that, your body goes, “What is this thing? It looks like a threat.” It will send all those same signals as if we are being chased by that tiger.
Those internal stressors are affecting your adrenals just as much as the outside stressors. You may not recognize that. People go, “Man, I ate that, and now I don’t feel good.” Maybe they don’t notice it at all, but later, they feel really tired, or they are having some aches and pains in their joints because of the reaction they had to the food they ate earlier that day or in previous days.
When you think about diet, what do I need to do to support my adrenals? There really isn’t an adrenal diet if you want to think about it that way. You need to think about what are the foods I am going to put in my body that are going to help heal and fuel my body and restore it as opposed to the foods that will be a threat? When you are ready to sit down and eat something, you are holding it in your hand, is this going to be fuel and restorative for me, or is it going to cause more stress to my body?
Dr. Eric:
Most people know what foods they should eat and what they shouldn’t eat, to some extent. Some people classify whole wheat pasta as being healthy. Like you said, there is gluten in that. There are other foods people might think of as being healthy. We know refined foods and sugars are not good for us. Unhealthy oils, like canola oil and seed oils like sunflower seed oil and peanut oil. Definitely agree most functional practitioners (hopefully all…) agree that people should be eating whole healthy foods, plenty of vegetables, and avoiding those refined sugars, unhealthy oils. There is no specific adrenal diet. There are books on adrenals that talk about diet. Everybody is different.
You mentioned adrenals can have an effect on thyroid health as well as the sex hormones, especially progesterone. Can you get deeper into how that has an impact?
Dr. Aimee:
In both scenarios, there are different things that happen. Sometimes it’s hard as practitioners even to figure out which one is driving the bus. People come to see me all the time,” I was diagnosed with hyperthyroid. I am on Synthroid. Maybe I felt better for the first month, or never really felt better although they told me my labs were better, but I still have all these symptoms.” Ok, what’s going on there?
For me, that’s a great place to look at other things, like hormones and adrenal function. Even though their labs say their thyroid levels are okay, they still have all the same symptoms. There is definitely a communication between the adrenals and the thyroid. It’s not really easily defined in my opinion as a direct, if you have low cortisol, you will have hypothyroid. It doesn’t always work that way.
I’m sure you’ve talked about this in your podcast before, but to take the inactive thyroid hormone and convert it to the active thyroid hormone. There is an ability to take the inactive thyroid hormone, which we call T4, and convert it to active thyroid hormone, which is T3, that hits your receptors and does the work. It takes an appropriate amount of cortisol to do that. There is a lot of other factors that go into that. It’s not a direct thing. If you don’t have enough cortisol, if your body is under stress, it won’t be able to make that conversion. In your blood work, your thyroid may look okay, but if your thyroid hormone is not getting to your tissues, then you won’t feel the response to those symptoms. There is definitely a connection there between adrenal and thyroid.
In the hormone section, if you look at the steroid hormone pathway, they all start with cholesterol. There are different signals that move it down. This is biochemistry 101 that I was awful in in medical school. Now I use it every day, which is crazy. You have progesterone. Right below that, you have cortisol.
What I typically see in my practice is women who are pre-menopausal, so they are under 50. Let’s just make it easy that way. If they start to have hormone-related symptoms, like night sweats, more irritability, irregular periods, weight issues, “Something is up with my hormones. Can I be in menopause already? It’s too early.” They’re 41. Usually, what happens is it’s the adrenal dysfunction, the low cortisol that starts to pull progesterone down because our body’s #1 job is to keep us alive. We are all about survival first. If you can’t run from that tiger, then you won’t make it. It doesn’t matter if you have the progesterone there to procreate because progesterone is important for helping you ovulate and prepare the uterine lining for baby and pregnancy. That’s where libido comes from, too. If your cortisol levels are low, it starts to pull your progesterone down, and you start to have hormone-related symptoms. That is really coming from the adrenal dysfunction.
In other women, we see them when they are 53/55, and they are like, “Man, I was feeling great until I hit menopause. Boom, all these symptoms showed up.” That is probably more the hormone changes that turned around and affected their cortisol levels. You can see it in two different places, but there is definitely a connection between those hormones.
One of my favorite things to talk about, and I’m going off on a tangent a little bit, is the connection between thyroid issues and estrogen. In post-menopausal women, why do women get thyroid disease more than men? It’s more rare in men. Oftentimes, we are seeing it in this older group. I have heard patients tell me all the time, “My doctor told me it’s normal for women to have low thyroid. They put me on my medicine. They didn’t talk about why or where that’s coming from.”
Estrogen is really important to help regulate the little protein called thyroid hormone binding globulin that carries the thyroid hormone around in your blood and delivers it to where it’s supposed to go. If you have low estrogen, it’s counterintuitive, but it increases that thyroid hormone binding globulin. It increases the carrier. All your thyroid hormone gets stuck to that, and it’s stuck to this protein and not being delivered to the tissues.
When women start to go through menopause, and their estrogen levels go down, they have less available thyroid hormone. Even if maybe their thyroid is actually producing what it’s supposed to produce, it’s not getting to where it needs to go. When people are frustrated, “I still have thyroid symptoms even though I’m taking this medication every day. Do I need a higher dose?” you need to look at that bigger picture and think, “Are we out of balance from a hormone perspective, whether it’s progesterone or estrogen affecting the thyroid and adrenals?” They all communicate together beautifully.
That’s why I love doing saliva testing. You get a really nice picture of what your cortisol levels are, estrogen, progesterone, DHEA, testosterone. It’s like putting music notes on a page. You can see how they all dance and work together and start to create a better balance there. Of course, thyroid normally is tested in blood. We don’t do saliva testing for thyroid. But you have that side by side. You can start to see the connection there in how all the hormones work together. In my opinion, you really can’t put blinders on and say we are going to deal with your thyroid and not look at the other parts of that hormone cascade picture.
Dr. Eric:
Just to repeat what you said: If you have low estrogen, that will increase the thyroid binding globulin. You will have less free thyroid hormones in the bloodstream. You need healthy adrenals to have healthy estrogen. If you have low adrenals, it’s common to see low estrogen and low progesterone. Like you said, there is an interrelationship, but that is where the adrenals tie in as well. There are other things that relate to having healthy estrogen levels as well. I’m glad you brought up that thyroid/estrogen relationship. Thank you for doing that.
A couple of questions I have. How about high cortisol? You see mostly low cortisol, but I’m sure you see some high cortisol. I know I do when I do saliva testing for example. Obviously, with an acute stress situation, we’ll see cortisol rise. But then there is that middle stage. I’m sure you’re familiar with the three stages of adrenals.
Dr. Aimee:
Definitely. I can see some high cortisol. Because I see so many people with cortisol levels that are low, I’m not saying that you can’t have high cortisol, but I’m usually questioning my interpreting of that. There is some triage there. What was going on that day? Did you have any surgery lately? Have you been on any kind of steroids? Do you do a Flonase for allergies every day? It’s so rare to see high cortisol that I want to make sure that’s actually real. Sometimes I will repeat the test again because if it doesn’t fit their clinical picture, that may not make sense.
The reason it’s so important to connect those two and determine if it’s real is our treatment approach is very different. They may have similar symptoms. For people with high cortisol, they are going 120 miles an hour, so they will be tired from that. They may still have fatigue and difficulty sleeping and things like that. You want to be able to make sure that is really what is going on because our treatment for high cortisol is going to be more telling the brain, “I’m not being chased by that tiger.” We use more calming herbs. L-theanine is a great one for that. Things that will help your brain turn off. My goal there is definitely supporting a symptom, but it’s more trying as much as we can to prevent them from getting worse and going into that low cortisol/adrenal fatigue stage.
Just like I made the connection from low cortisol, you need cortisol. Too much cortisol is also not good. It overwhelms the system. You will still probably see some dysfunction from a thyroid perspective as well. Again, it’s not a direct, if somebody has high cortisol, they will have high thyroid. If they have low cortisol, they have low thyroid. But they do talk to each other and connect.
Dr. Eric:
I agree with you in that if cortisol is very high, it’s a good idea to ask the patient on that day of collection if anything crazy was going on. I remember once, I had a specific patient, where their morning cortisol looked good, but in the afternoon, there was a spike. The last two cortisol levels on the saliva test looked okay. I asked her if anything was going on that day. She said she was studying for a test around lunchtime, which coincided with the saliva sample she took around that time. That makes sense.
Dr. Aimee:
I had a story like that real early on. When you’re first learning about this stuff, you have to learn from somebody else. I would do all these saliva tests and call the lab to ask about this particular person. It took some time to learn it. This person, I remember it was the same thing. It was a 2pm spike or something like that. Everything else looked normal or what I expected. After several questions and conversations, I found out that she was putting some sort of steroid spray or cream on her dog every day. It was that time of day. “I always put it on at lunchtime.” She didn’t connect that when she is putting this steroid cream on her dog, that would affect her saliva test. Once we figured that out, we did it the right way without exposure to that, and it came out okay.
The other thing that’s really important, and we should do this with all of our tests, is if the clinical picture doesn’t fit with what you expect the pattern to be, then that’s another reason for questioning. Again, I’m expecting somebody, when they fill out their intake form, or we’re having conversations, that their adrenals are going to be tanked. Then it’s not. Whether it’s high or even when cortisol is normal or appears normal, the way they are describing their symptoms, I would have expected them to be flatlined. Even then, I might say, “Tell me about that day. Was it a super stressful day?” In some patients, their norm may be really low, but the stress of that day increases their cortisol enough to make it go into the normal range.
That becomes the art of this medicine: Even though this test looks normal, this doesn’t fit the clinical picture. That happens in thyroid, too. This person has every single symptom of thyroid dysfunction, yet their thyroid levels look totally normal. That’s a little bit different. It’s not a direct relationship to what was going on that day, but it makes you start thinking, what else is creating those symptoms or the inability of the thyroid hormone to get where it needs to go? That should prompt you to look more directly into adrenals and gut health, too. If your gut is not happy, then you’re not absorbing that thyroid hormone that you’re popping into your mouth every day, and it’s not doing its job.
Dr. Eric:
Good point. You want to look at the whole picture and take into consideration the test. That’s also why we do a health history to get other information. Sometimes we need to dig deeper. Maybe do a comprehensive stool panel or other tests. Thanks for pointing that out.
Getting back to the adrenal testing. You do saliva testing. I’ve done saliva testing for years. Why do you do saliva testing over blood tests? I know the answer to that, but for those listening who figure, “Why can’t I just go to a LabCorp or Quest or somewhere else and get a morning cortisol?”
Dr. Aimee:
Specific to adrenals, there are two parts to that question. The first part is we talk about an adrenal pattern. I mentioned it earlier, but your cortisol goes high in the morning when the sun comes up. Over the course of the day, they go down. The sun goes down, and it’s helpful. I see a lot of patients where their morning cortisol may be pretty normal, but by the time they get to noon, they’re tanked. It’s bedtime for them. That’s why they’re complaining of all this afternoon fatigue. “I can’t stay awake at my desk. My kids drive me crazy when they get home at 5pm. I’m trying to make dinner, and they’re screaming. I feel crazy. I think I need some antidepressant or antianxiety medication” when their cortisol levels are low.
If all you do is go into a lab and get a one-time cortisol test, that’s not giving you an adequate picture of what the whole day looks like. Especially if someone is having trouble sleeping, it’s very common to see a little rise in cortisol at nighttime as you are getting ready for bed. If they are not sleeping well, rather than, again, us going down the traditional path of needing Ambien or some other prescriptive medication for sleep, if we see that their cortisol level is going up, there are certain supplements we can do to help stop that. You can get better sleep.
It’s really important in my opinion to get that full four cortisol test throughout the day to adequately see what that pattern looks like. That is step #1.
Step #2, sort of what I mentioned earlier about the stress. Let me go backwards for a second. Ideally, we want to collect the cortisol sample 30 minutes after you wake up. That’s when it should be at its peak. There are plenty of studies that show us that your peak cortisol level is going to be 30 minutes after you wake up and are ready to get out of bed. Imagine trying to wake up, get dressed, get in the car, find LabCorp, get a needle stuck in your arm, and have that test all done in 30 minutes. That’s unrealistic, but that will also be stressful. You will end up with a high or even a normal morning cortisol level that then doesn’t tell us the actual clinical picture of what’s happening throughout your day.
That’s my interpretation of why I do saliva testing for cortisol specifically. Yes, you can measure cortisol through blood. It’s accurate from the perspective of what your cortisol level is in your blood at that moment. But it’s not accurate of your personal clinical picture of what’s going on with you.
Dr. Eric:
The only way to look at the Circadian rhythm of cortisol is the saliva test or the dried urine test. I don’t know if you use Dutch testing in your practice.
Dr. Aimee:
I have a little bit. I like the saliva test better, but I do find the Dutch test helpful. That’s one of those things when you are starting to troubleshoot, and that clinical picture doesn’t fit. I have had times, and this can be a little bit confusing. This gets advanced. When somebody’s cortisol level is really low, so I’m treating them as such. I’m giving them lots of cortisol herbs or even hydrocortisone. That’s another conversation we can have. They are responding as if their cortisol level was high. They are saying, “This is really stimulating me. I can’t take this.” It’s not doing what we expect it to do.
There is a phenomenon where people make cortisol and get through it really fast. It doesn’t show up as readily in the saliva test because it’s already gone. The Dutch test, doing a urine analysis, gives us the cortisol metabolites that have been through. There are some cases where you can have low cortisol on a saliva test, but it will appear high in the Dutch test. That is somebody who actually has high cortisol; they are just super fast metabolizers and getting rid of it quickly. That’s rare. I have heard of that at conferences and things. I have had probably less than a handful of patients who fit that picture. That’s where I have found Dutch testing to be helpful.
Dr. Eric:
As far as the metabolism itself, those metabolites, it’s very common with hyperthyroidism, which a lot of people listening to this have. You prefer saliva testing, and you also use saliva testing for the hormones, too. You don’t test hormones in the blood, like progesterone or estradiol?
Dr. Aimee:
What I have learned and trained in my saliva testing courses, which I now teach to other providers, there are a few parts to that. One of the parts is hormone levels change throughout the day. That has been tested in bloodwork. I have seen the studies several times, where they took two women and tested their estrogen levels every 10 minutes. It looks like an EKG machine. It’s all over the place. Collecting four samples throughout the day, taking a pooled sample and getting one number that is more accurate of what your overall day hormone levels look like, especially if you are on hormone replacement.
Whatever your hormone replacement regimen is, you want to catch a nice balance. What does the average look like rather than a one-time blood test in the morning, and you took your hormone replacement that morning before you showed up? That level will be high. Or vice versa. If you took it yesterday, and now is a sample where it might be low, so that’s confusing. Having that test throughout the day can give us a nice average level. I do like doing saliva testing for that. It’s not impossible, but it is quite difficult to be able to go to a lab four times a day and get those tests done and then average those numbers. That’s not realistic. That helps.
The second part is we talked about thyroid hormone binding globulin, which is a protein that the thyroid hormone sticks to. You have the same kind of protein for your other hormones as well. Hormones don’t usually just hang out in the bloodstream. They have to be attached to those proteins, which carry them to the receptor sites on the tissues, whether that’s your hair, skin, breast, ovaries, etc. Blood testing misses those hormones that are stuck to that protein, so you don’t get accurate levels of what hormone is actually being presented and what the tissues are being exposed to. Oftentimes, in the bloodstream, you are getting the leftovers. It wouldn’t be unusual for it to be low. That could be inaccurate. By the time it’s high in bloodwork, then it’s really high in the rest of your body. That is going to cause side effects and things we don’t want to deal with. I find saliva testing to be more accurate in terms of actual physiologic. Where are these hormones going? What is your body being exposed to?
Dr. Eric:
If someone is cycling, do you have them do one of those cycling saliva panels?
Dr. Aimee:
We can get into a topic of irregular cycles. If they can test somewhere between 18-21 days, which is basically a week before their period is supposed to start, that is when the progesterone level is going to be at its peak. After you ovulate, progesterone levels start to go up. If you get pregnant, it will keep going up. If you’re not pregnant, it starts to go back down again.
18-20 is when it should be at its peak. If somebody is low then, then it’s very likely they will be low the rest of the time, too. That is where we are focused for progesterone in particular. Estrogen does change. It peaks a little bit earlier, but we can have a nice level of what we expect it to be during that time as well.
When somebody is cycling, estrogen is probably not the issue because they are cycling, which means they still have adequate levels of estrogen. It’s looking at progesterone and the balance in their cortisol levels. I haven’t found it to be helpful. I did it in the beginning when I was first learning. There are some labs that have you do eight days throughout your cycle or 11 days. That’s just a pain in the butt for the patient to do, and it’s not very exciting for me to interpret all of those numbers and results. I try to simplify things with getting the best information. That’s what I have found to work really well. Do that test about a week before their period is supposed to start.
Dr. Eric:
Let’s talk about treatment. I know you mentioned high cortisol, you don’t see a lot of those cases, but you mentioned L-theanine. When it comes to low cortisol, you mentioned hydrocortisone. Some practitioners will give licorice root or adrenal glandulars. What approach do you take? Does it vary depending on the person?
Dr. Aimee:
Absolutely, it varies, depending on what their levels are. I have various adrenal supplements. There are so many out there that can be overwhelming and hard for me to choose sometimes. Either I have another practitioner who says, “This is working really well for me,” or a little bit of trial and error.
As a physician and a mom of four, my cortisol levels were not very good for a long time. I have tried every single adrenal supplement out there. Even treated myself for a couple years with hydrocortisone. I have personal experience on that level as well.
I have adrenal supplements that I call mild, medium, and hot. Kind of like salsas. If you have that cortisol pattern that is a rollercoaster, you may be high, then low, then high, then low. It’s hard. Do I give them a more stimulating adrenal supplement or a shut down the adrenal supplement?
There are some supplements out there that are more adaptogenic. More mild, let’s just try to balance things out a little bit. That’s where coming to the brain, having some L-theanine or something calming that way can be helpful.
The medium one is that cortisol is okay in the morning but tanks later in the day. I call that the Gatorade of the adrenals. Those herbs we commonly see, like ashwagandha rhodiola. We see some other herbs there. Lots of B vitamins. The P5P.
The hot one is in addition to some of those herbs, we add some adrenal glandulars to that. There is a lot of supplements that have mixtures of adrenal glandulars as well as other herbs. Siberian ginseng is found in a lot of those supplements to get the brain working a little bit.
I play around with those. Which one depending on which the patient’s symptoms are in terms of what sort of support we can give to the adrenals. Hydrocortisone, I have used a lot in my practice. I think it’s a great tool, especially for that flatlined person.
Let me go backwards for a second. Remember when I said earlier that when you are sprinting this marathon uphill all the time, that is wearing out your adrenals. We can give you Gatorade throughout that process so you can keep sprinting. Ultimately, one of our goals in long-term treatment of adrenal dysfunction is to lower the slope. We have to start working on that stress. We have to make that hill less steep. That comes from working on outside stressors. I can’t manage your stress for you. I can’t go to your job and help you figure that out. What are some things we can do with meditation and breathing and getting you back into parasympathetic mode? There is a lot of conversation we have about that.
Also, those internal stressors. That will go back to the dietary stuff. Let’s start eating to minimize that stress on the side.
Treatment of adrenals is not just pop that new supplement, and you will feel like a million bucks. Ultimately, that is what I started doing. I had great results with that. Patients would come back six months or a year later and wonder how long they have to be on these adrenal things. It felt good at the beginning, but some of those symptoms are coming back. This should be a magic pill. If you don’t support the adrenals to heal, then those supplements are just the Gatorade that is keeping you going on that hill.
Now, hydrocortisone fits very nicely in that when somebody is literally, “I cannot get out of bed. You’re telling me that I need to eat healthy. I can’t even process that. I can’t even think about going to the grocery store. I don’t care about eating. I don’t even eat anything, and I’m still overweight. Everyone thinks I should be a skinny mini because I hardly eat. I can’t sleep. I can’t do anything. My brain is a mess.” You see a flatline cortisol. We may need to use hydrocortisone for a while. That could be anywhere from three months to two years in some patients until they can really start to recover. If they aren’t in a place where they are going to be able to do the things they need to do to start healing, we have to get them feeling better.
Hydrocortisone is bioidentical cortisol. We use it in physiologic dosing, which means that your own body normally, in a perfect world, makes about 30mg of cortisol a day. I might start with 5-10mg in the morning and another 5mg in the afternoon trying to create that normal high and low curve. It just supports the process. Then they are starting to feel better. It takes them about a week or so to notice it. It’s not like you’re popping an Adderall and running around cleaning out closets. It’s not stimulating. But they start to notice they’re less tired, and they need less of a nap or didn’t need a nap at all today. They are going through the motions of regular life.
Now we can start introducing the supplements to support the adrenals to do their job. If the brain is not sending the signal, those supplements won’t do anything. You have to get the brain back.
I tell them hydrocortisone will do three things. Help you feel better and control some of those symptoms. Let your adrenals rest a little bit. Here they are on this hamster wheel trying to run this marathon of life, and they never get a break. We have to let them rest. We are not suppressing them. That’s what prednisone does. Hydrocortisone is let’s stay on this hike, but I will carry your backpack for you for a while, so you don’t have to work so hard.
The third thing it does is it resets the brain to say, “This is what’s normal.” High cortisol in the morning. Low at night. We will do that over and over every day for 30 days, 60 days. When you take it away, the brain is like, “I need cortisol.” Send the signal. Your adrenals have rested. You have some Gatorade in there. Now everything starts to work the way it’s supposed to.
Dr. Eric:
If you were to give a summary or action steps people can take if they feel like they are experiencing problems with adrenals. You can’t always go by symptoms. Can you give them some action steps? I’m sure there are things they can do on their own with stress management and diet.
Dr. Aimee:
What I have experienced is the more knowledge people have, the more they will have power to support their own health. They will be empowered as opposed to depending on others. Of course, you might need to depend on a doctor like me or you to help you get started in that path.
Yes, there are steps you can take on your own. If you think you have adrenal fatigue, look at a list of symptoms. It’s very easy to Google this. If you look up the symptoms that you have, and it feels like adrenal fatigue, you can look at some of those supplements and say, “Maybe I need some Gatorade.” They won’t hurt you. They are pretty safe supplements to take for the most part. If our goal is to get you to feel normal again, and you don’t feel normal, then you stop taking it. If you’re feeling overstimulated, or it’s upsetting your stomach, you can stop taking it. It’s not super dangerous to take an adrenal supplement necessarily.
But if you have so many symptoms, it’s hard to be subjective. “I feel this way. I took a pill for a week, two weeks. Didn’t work. How do I feel now?” Having objective measures of what is your cortisol now? How intense is it? We talked about the different phases of adrenal fatigue. If you are so low on that spectrum, those supplements won’t do anything for you. That doesn’t mean you don’t have adrenal fatigue, and the supplement didn’t work. Your brain is not sending the signal, so it doesn’t matter what you have there.
There is some trial and error with supplements out there. You can experiment. If it makes you feel better, that gets you one step ahead of the game. Again, we have talked throughout our conversation about the importance of everything working together. You might have adrenal fatigue symptoms. Is it because your hormones are out of balance? Your thyroid’s not working?
Finding a practitioner that is like me or you that can do some more objective testing and help you understand what is going on, where is that balance. If that is overwhelming for you, you can start with the basics. Let’s get us back into parasympathetic mode. I tell my patients all the time to Google how to be parasympathetic. There is a lot of good information out there about the things I can do to get out of that fight or flight mode, out of that stress mode. It’s easier said than done.
I have been doing a lot of talking on cold water plunging. There are a lot of studies on that. If you don’t have a tank where you can throw a bunch of ice water and get into a cold water plunge, you can turn your shower cold at the end of your shower. I think that’s fascinating. Even if you don’t have adrenal fatigue, it will be helpful for you.
At the end of your shower, turn it to as cold as you can possibly manage. The colder, the better. Count to 30. Your first response will be to hold your breath. “If I have to be here for 30 seconds, I can’t hold my breath that long,” so it forces you to start breathing and exhale. You have to do that calm, big, deep breath to help your body relax while you are in that water. The more you do that, that’s a great way to force yourself into that parasympathetic mode, that calm mode. If you can mimic that throughout your day, you don’t always have to be in the shower, but you can start help managing your stress a little bit better.
Back to the diet. Whatever you want to term it, whole food diet, I tell patients all the time: The closest you can get to nature in the least steps possible, that is the diet you want to be on. Pick an apple. Hopefully it’s organic. Pick an apple, and eat it. There are no steps to prepare that apple. Protein in meat is different. You want the minimum amount of steps. Nothing added to it. Get that raw meat. Cook it however you want to cook it, and eat it. Your veggies, as much as you can, raw veggies. One step. Steam them, sauté them, roast them, whatever. Minimal steps.
When you start thinking about something like whole wheat pasta, like you were talking about, or what we think is healthy grains and carbs, we didn’t go out and pick a stalk of wheat and chew on it. Even then, when you take the wheat and grind it up into flour after drying it out, we don’t sit there and eat spoonfuls of flour. That all has to be mixed with something else. These preservatives get in there to prevent it from getting moldy and hard. There are 52 steps to get from where it came from to your mouth. That’s an easy tool to let patients start looking at foods. How many steps? Three or less, that’s your diet you need to be on. You can start there. That will make some big changes before you find a practitioner like myself or another integrative functional practitioner that does more in-depth testing.
Dr. Eric:
I do take my cold showers. Not fully cold. I alternate. I do hot, cold, hot, and then finish up with cold. I recommend those. I can’t say I do it every single time, but most of the time, I do it.
Where can people learn more about you, Dr. Aimee?
Dr. Aimee:
My own personal website is AimeeDuffyMD.com. You can find links there to my book, Normal Doesn’t Have Side Effects. Also, if you click Learn More, you can flip over to my website for Carolina Integrative Medicine, which is my practice. You can also go to CarolinaIntegrativeMedicine.com. We have lots of info about what we talked about today, maybe not in quite so much detail. Adrenals, hormones, gut health.
There is a place where you can click Work with Me, which will get you to schedule a free discovery call with my team. We will chat with you for about 15-20 minutes. What is going on with you? What are your health issues or goals? If we’re a good fit to work together, that will get you set up on our schedule to go through the labs and the consult. That’s how people find me.
Dr. Eric:
Wonderful. Thank you so much for sharing this wonderful information with the audience. I’m sure they learned a lot about adrenals and sex hormones. Appreciate you taking the time for this interview.
Dr. Aimee:
You’re welcome. I enjoyed it.