Functional Medicine's focus on lowering cortisol may be barking up the wrong tree.

Dr. Cloutier & Stefan on Spike Shedding, Cortisol, Estradiol dosing- new lecture released. Dr. Pierre has shown us how the corticosteroids can be used safely with much less side effect profile. Namely, hydrocortisone. I think every patient should have a little bottle of 10mg tablets of hydrocortisone for flu/cold illness, especially those that get severe and prolonged illness. 

Rationale:

• Stress Response: Even in patients without adrenal insufficiency, significant illness or stress can exceed the body's cortisol production capacity, potentially leading to symptoms like fatigue, muscle weakness, or prolonged recovery time from infections like the flu.

• Acute Infections:

  • Flu or Severe Colds: For patients with severe flu symptoms or those not recovering as expected, a short course of hydrocortisone might be considered. The idea is to support the body's immune response by ensuring adequate cortisol levels, which might help in reducing inflammation and improving symptom resolution.

    • Dosing: A low dose, perhaps around 20-40 mg daily say 20-30mg in am and 10mg at noon to mimic natural increase of cortisol in AM for 2-3 days, might be trialed. 

• Post-Surgical Recovery:

  • Post-operative patients can experience significant stress. While standard care includes pain management and antibiotics, some might benefit from hydrocortisone to shorten recovery time or manage symptoms like fatigue or nausea and help with pain. 

• Chronic Inflammatory Conditions:

  • In conditions like rheumatoid arthritis or inflammatory bowel disease during acute flares, adding hydrocortisone might help manage symptoms more effectively, supporting other treatments. Patients with chronic inflammatory bowel disease and food sensitivities in my opinion are likely continuously depleting their cortisol reserves leading often to skin inflammatory syndromes like eczema. This is why at Iron DPC we try to heal the gut when the skin shows sign of stress. Hydrocortisone would work as well. The conventionalist, however, uses synthetics. 5 mg of prednisone is roughly equivalent to 20 mg of hydrocortisone in terms of glucocorticoid activity. Dexamethasone: Approximately 25-30 times stronger than hydrocortisone. Thus, 0.75 mg of dexamethasone is approximately equivalent to 20 mg of hydrocortisone! 

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• Severe Fatigue or Prolonged Recovery:

  • In cases where patients report severe, unexplained fatigue or prolonged recovery from illness, especially if other causes have been ruled out, a trial of hydrocortisone could be considered to see if cortisol supplementation aids recovery.

Understanding the HPA Axis is important for anyone who consumes a steroid. Because if you’re taking very high doses of steroids and especially if you are on them routinely you should take the precursors. 

The hypothalamic-pituitary-adrenal (HPA) axis is central to the body's response to stress, with cortisol (and its replacement counterparts like hydrocortisone) being a key hormone. Pregnenolone and Dehydroepiandrosterone (DHEA) are upstream steroids in the adrenal steroidogenesis pathway:

• Pregnenolone is the precursor to all steroid hormones, including cortisol, DHEA, and sex hormones.

• DHEA is a precursor to androgens and estrogens and has multiple roles, including immune modulation and neuroprotection.

Why Supplement DHEA:

1. HPA Axis Suppression:

   • Long-term use of corticosteroids like prednisone and to a lesser degree, hydrocortisone (if replaced in physiologic doses) can lead to negative feedback on the HPA axis, reducing the production of ACTH and consequently, the synthesis of pregnenolone and other adrenal hormones. Supplementing these can help mitigate some of the downstream effects of this suppression. 

2. Counteracting Cortisol's Effects:

   • Immune Function: While corticosteroids suppress immune overactivity, DHEA might help maintain immune function by supporting T-cell activity, potentially balancing the immunosuppressive effects of cortisol.

   • Bone Health: DHEA has been associated with bone health; supplementation will help counteract the bone density loss that can occur with long-term corticosteroid use.

   • Mood and Cognitive Function: Both pregnenolone and DHEA have neuroprotective properties. They might mitigate some of the cognitive and mood disturbances associated with corticosteroid use.

Pregnenolone is a steroid hormone produced primarily by the adrenal glands, gonads, and in smaller amounts by the brain. It is the initial and critical precursor in the biosynthesis pathway for all steroid hormones, including cortisol, progesterone, testosterone, estrogen, and DHEA. This makes pregnenolone a foundational hormone in the body's endocrine system.

Physiological Roles:

1. Hormone Synthesis: As the starting material for other steroids, pregnenolone's primary role is to be converted into various hormones that regulate numerous physiological functions like stress response, sexual function, and immune regulation.

2. Neurosteroid Activity: Pregnenolone is also recognized as a neurosteroid, functioning within the brain to modulate neurotransmitter activity, potentially influencing mood, memory, and cognitive function. It has been linked to:

   • Memory Enhancement: Some studies suggest pregnenolone can improve memory, possibly through its effects on GABA and NMDA receptors.

   • Neuroprotection: It may protect neurons from oxidative stress and promote myelin formation, which is crucial for nerve impulse transmission.

3. Inflammation and Immune Response: Pregnenolone can modulate immune responses, potentially reducing inflammation without the broad immunosuppression seen with corticosteroids.

Potential Therapeutic Uses:

• Cognitive Health: Given its neurosteroid properties, pregnenolone has been explored for conditions like Alzheimer's disease, cognitive impairment, and even in addressing symptoms of traumatic brain injury.

• Mood Disorders: There's interest in its use for depression, anxiety, and other mood disorders, where it might help by balancing neurotransmitter activity.

• Hormonal Imbalance: In scenarios where there's a deficiency in steroid hormone production (e.g., due to aging, stress, or adrenal insufficiency), pregnenolone supplementation could theoretically support hormone levels.

• Fatigue and Stress: Some anecdotal evidence and small studies suggest benefits in reducing fatigue and enhancing stress resilience, possibly by supporting cortisol production.

Functional medicine often talks about lowering cortisol. And that’s a nice thought for someone with a stress free life, but not a reality for anyone I know. So we rx DHEA and pregnenolone to support the adrenal system. We do not suggest routinely taking cortisol lowering herbals that have become popularized “mud powder” or ashwagandha, maca, rhodiola people are adding these to everything like it’s a food. Herbals are medicines and must be used for specific reasons. Perhaps we will suggest these when someone is having abnormal high cortisol at night and trouble falling asleep. Sleep is a whole other lecture I can give. But we can measure a 4 point cortisol saliva curve and see where you are. The worst is when the cortisol is low! These people are fatigued and don’t feel well. 

In summary, past age 30 we rarely see optimal levels of precursor hormones when we measure them. We have found that those who supplement hormones and take vitamins have less illness and feel better! This is what we do at Iron DPC! Prevention and optimization! 

Stefan Hartmann,

MPAS, PA-C

CEO Iron Direct Primary Care