Most people reading this probably have heard of a leaky gut.  But many people don’t truly understand what causes a leaky gut, how to determine if they have it, and how to heal their gut.  Many people just assume they have a leaky gut, and then will attempt to repair their gut by drinking bone broth and/or taking gut repair supplements.  In the past I have written numerous articles and blog posts on leaky gut syndrome, but since a leaky gut is something that impacts those with Graves’ disease and Hashimoto’s I’ve decided to put together an updated blog post that focuses on five things you should know about a leaky gut.

1. According to the triad of autoimmunity, everyone with Graves’ disease and Hashimoto’s has a leaky gut.  The triad of autoimmunity involves a genetic predisposition, an environmental trigger, and an increase in intestinal permeability, which is also known as a leaky gut.  It’s common to work with an autoimmune thyroid patient who wonders if they have a leaky gut, although according to this theory, EVERYONE with any type of autoimmune condition has a leaky gut, at least initially.  In other words, according to this theory a leaky gut is one of the three factors necessary for autoimmunity to develop, but this doesn’t mean that a leaky gut can’t be healed.  In fact, in order to reverse the autoimmune component it is necessary to find and remove the environmental trigger and heal the gut.

2. Gluten causes a leaky gut in everyone.  Speaking of environmental triggers, recent evidence shows that gluten causes a leaky gut in everyone.  This is a very good argument for everyone with Graves’ disease and Hashimoto’s to avoid gluten while restoring their health, and to also try to your best to avoid it after you have achieved a state of remission.  I was diagnosed with Graves’ disease in the fall of 2008, and I achieved a state of remission in 2009.  And while I avoid gluten most of the time, I can’t say that I’ve been 100% gluten free since restoring my health.  So if gluten causes a leaky gut in everyone, why haven’t I relapsed?

There are a few potential reasons for this.  First of all, I do minimize my exposure to gluten.  Second, I’m pretty sure that I don’t have Celiac disease or a non-gluten sensitivity.  So while gluten causes a leaky gut in everyone, in my case it wasn’t the direct trigger of my Graves’ disease condition.  A third reason is luck, as if I were to overindulge in foods with gluten for a prolonged period of time, and at  the same time I was exposed to a certain environmental trigger, then there is a very good chance I would relapse.  So every time I’m exposed to gluten I’m playing with fire.  And to be honest, there is a risk even with a single exposure to gluten.  So in no way am I encouraging anyone to consume gluten after getting into remission.

By the way, I think another reason why I haven’t relapsed is because I do a lot of other things to maintain a healthy state.  Even though I’m not perfect with the diet, I eat well most of the time.  And just like most people, I deal with a lot of stressors, but I’m confident that I do a good job of dealing with them, as I block out time for stress management each day, and I also make sure to get sufficient sleep each night.  In addition, I’m always doing things to reduce my toxic load, including doing a 21-day liver detox a few times per year, as well as infrared sauna therapy a few days per week.  Don’t get me wrong, as there is always room for improvement, but it’s also important to understand that perfection isn’t necessary to maintain a state of wellness after achieving a state of remission.  If this were the case then everyone would eventually relapse.

3. Leaky gut testing is available.  Some people aren’t aware that there is testing available to find out if you have a leaky gut.  One option is the lactulose-mannitol test, which is a urine test that requires someone to swallow a sugary solution of lactulose-mannitol.  Lactulose is a larger molecule, and therefore it’s poorly absorbed in someone who has a healthy gut.  As a result, if someone who does this test has high levels of lactulose in the urine then this usually indicates that they have an increase in intestinal permeability.

Cyrex Labs also has a leaky gut test.  The name of the test is the Intestinal Antigenic Permeability Screen, also known as their Array #2.  This tests for a few different antigens associated with a leaky gut, including actomyosin, occludin/zonulin, and lipopolysaccharides.

I used to recommend leaky gut testing frequently, most commonly the Array #2 from Cyrex Labs.  And there are times when I still recommend this test to my patients, but in most cases I assume that the person has a leaky gut.  And there are a few reasons why I take this approach.  First of all, according to the triad of autoimmunity, everyone with Graves’ disease and Hashimoto’s has a leaky gut.  Second, when I used to recommend the Array #2 more frequently I found that most people did test positive.  And when someone tested negative I would wonder if the results were accurate since everyone with an autoimmune condition has a leaky gut, at least according to the triad of autoimmunity I mentioned earlier.

Of course there is always the possibility that someone initially had a leaky gut but then took the necessary steps to heal it.  So for example, in some people gluten is the sole leaky gut trigger, and if someone has eliminated gluten from their diet, yet hasn’t found and removed the “direct” autoimmune trigger, then conceivably this can cause someone to have a normal leaky gut test, even in the presence of positive autoantibodies.  Stated differently, it’s possible to remove the “leaky gut” trigger and heal the gut, yet still have elevated thyroid antibodies if the “direct” environmental trigger hasn’t been removed.

4. A leaky gut can lead to multiple food sensitivities.  I’m not a big fan of food sensitivity testing, but there are times when I have had patients order a food sensitivity panel.  And it’s common for those who have a leaky gut to have many different food sensitivities.  The good news is that healing the gut usually will help to resolve most, if not all of the food sensitivities.

5. In order to heal your gut you need to follow the 5-R protocol.  The five components of the 5-R protocol include 1) remove, 2) replace, 3) reinoculate, 4) repair, and 5) rebalance.  It is imperative to remove the leaky gut trigger, and while this may sound like common sense, I commonly see people focusing on replacing, reinoculating, and repairing before they find and remove the factor that caused the leaky gut.  Admittedly it can be challenging at times to find the leaky gut trigger, and while you can incorporate the different “Rs” of the protocol simultaneously, you won’t heal a leaky gut if you don’t remove the factor that is causing it.

So how can you find the leaky gut trigger?  I talk about this in great detail in my book Hashimoto’s Triggers, and the same process of finding and removing triggers also applies to those with Graves’ disease.  While many times testing is necessary to find your leaky gut trigger, this isn’t always the case.  For example, if gluten is someone’s sole leaky gut trigger, then simply eliminating gluten can allow someone’s gut to heal.  If taking a course of antibiotics were the leaky gut trigger, then of course you removed the trigger as soon as you stopped taking the antibiotics.

Sometimes it’s not so simple, and testing may be necessary to find your leaky gut trigger.  And even if testing isn’t necessary to detect your “leaky gut trigger”, it very well might be necessary to find your “direct trigger”.  If this is confusing to you then I’d recommend reading my blog post on the triad of autoimmunity.  It’s also important to keep in mind that someone can have multiple leaky gut triggers.  So for example, if someone is eating gluten and has a gut infection, both of these can cause a leaky gut, and thus both of these “leaky gut triggers” would need to be removed in order for the gut to heal.

So let’s summarize this blog post.  According to the triad of autoimmunity, everyone with an autoimmune condition has a leaky gut, which of course would include those with Graves’ disease and Hashimoto’s.  Although gluten isn’t a “direct” environmental trigger in everyone, it does cause a leaky gut in everyone.  A leaky gut can also cause multiple food sensitivities, and while leaky gut testing is available, it’s not something that I commonly recommend to my patients.  Finally, in order to heal your gut you need to remove the leaky gut trigger, which is the first “R” of the 5-R protocol.

Methimazole (brand name Tapazole), is commonly prescribed to those who have hyperthyroidism and Graves’ disease.  In most cases it is effective in reducing thyroid hormone levels, and while it’s not doing anything for the cause of the problem, it can help to prevent someone from receiving radioactive iodine (RAI) or thyroid surgery while the underlying cause of the condition is being addressed.  However, not everyone is able to tolerate Methimazole, and if someone has a negative reaction to Methimazole, there is a good chance the endocrinologist will recommend RAI or thyroid surgery.

Methimazole, along with other thionamide-derived antithyroid drugs, have been used for over half a century.  A common starting dosage is 20 mg per day, although if someone has a more severe case of hyperthyroidism then larger doses might be prescribed (i.e. 40 mg/day).  Most endocrinologists will recommend Methimazole for 12 to 18 months, assuming the person isn’t experiencing any severe side effects, or other problems, including elevation of the liver enzymes.

As for how Methimazole works, it inhibits an enzyme called thyroperoxidase, which is important in the synthesis of thyroid hormone.  It specifically inhibits the metabolism of iodide and the iodination of tyrosine residues, which in turn prevents the synthesis of both T4 and T3 (1).

Potential Side Effects of Methimazole

Here are some of the side effects people can experience when taking Methimazole (2) (3):

• Changes in taste
• Dizziness
• Hair loss
• Headaches
• Hives
• Itching
• Joint pain and swelling
• Nausea
• Rashes
• Vomiting

More serious side effects include the following (3):

• Blood in your urine or stools
• Clay-colored stools
• Dark urine
• Fever
• Jaundice (yellowing of the skin or eyes)
• Loss of appetite
• Severe blistering, peeling, and red skin rash

Two Additional Complications Associated With Methimazole

Agranulocytosis.  This is a term used to describe a severe reduction in the production of white blood cells. This is more likely to affect those who take high doses of Methimazole.  Some patients with agranulocytosis will present with signs and symptoms of an infection, including a high fever and a sore throat (4).

Elevated liver enzymes.  This is more commonly associated with Propylthiouracil (PTU), but over the years I’ve had numerous patients with hyperthyroidism whose liver enzymes were elevated when taking Methimazole or Carbimazole.  You might want to check out an article I wrote entitled “How To Decrease Elevated Liver Enzymes In Hyperthyroidism and Graves’ Disease“.  In the article I discuss when you should be concerned about elevated liver enzymes, and some strategies to decrease them.

What Alternatives Are There To Methimazole?

As I mentioned in the opening paragraph, if someone is unable to take Methimazole, it’s common for their endocrinologist to recommend radioactive iodine or thyroid surgery.  However, there are three treatment options you should consider before getting your thyroid gland ablated or surgically removed:

Option #1: Try to get a prescription for Propylthiouracil (PTU).  The downside of PTU is that it can be harsher on the liver than Methimazole, and approximately 50% of those who are unable to tolerate Methimazole will also be unable to tolerate PTU.  That being said, it still might be worth giving PTU a try, as while it might produce similar side effects as Methimazole, there is also a chance that you might be fine taking it, and at the very least it can buy you some time while you are trying to address the underlying cause of your condition.

Option #2: Consider natural antithyroid agents.  Many reading this know that when I was diagnosed with Graves’ disease I didn’t take antithyroid medication.  Instead, I took an antithyroid herb called bugleweed to manage my hyperthyroid symptoms.  Although bugleweed isn’t always potent enough to lower the thyroid hormone levels, it’s definitely worth a try before resorting to extreme treatment methods such as RAI and thyroid surgery.  It’s also important to mention that the quality of the herb is important, and you should consider taking a stronger extract ratio.  For more information on bugleweed and other herbs that can help manage the hyperthyroid symptoms, I would read a blog post entitled “Which Are The Best Herbs For Managing The Symptoms Of Hyperthyroidism & Graves’ Disease?”.

Option #3: Low dose naltrexone (LDN).  This option should be considered for those people with Graves’ disease, and not other types of hyperthyroid conditions (i.e. toxic multinodular goiter, subacute thyroiditis, etc.).  Naltrexone is an FDA-approved medication, and it was discovered that low dose naltrexone (LDN) has immune-modulating effects that can benefit many people with autoimmune conditions.  While there are no studies I’m aware of that specifically show that LDN can help people with Graves’ Disease, over the years I have had some people with Graves’ disease successfully use LDN to manage their symptoms while addressing the underlying cause of their condition.

If LDN can modulate the immune system and effectively manage the hyperthyroid symptoms, then why don’t I recommend it more frequently to my patients with Graves’ disease?  There are a few reasons for this.  The main reason is because while it’s not harsh on the body like Methimazole, it’s also not as effective in managing the hyperthyroid symptoms.  I also find bugleweed to be more effective than LDN.  And if someone has an elevated resting heart rate due to high thyroid hormone levels, then it’s important to get the thyroid hormone levels down as soon as possible.

Another reason why I don’t commonly recommend LDN to my patients is because it can be challenging to get a prescription.  Unfortunately most endocrinologists aren’t open to prescribing LDN, and many aren’t even aware of the benefits regarding its immune-modulating effects.  However, recently I’ve had a few patients get a prescription remotely by working with a medical doctor online at www.ldndoctor.com.  The way this works is that you schedule a consultation with a medical doctor, and they will write a 6-month prescription for LDN.  I must warn you that I don’t personally know any of the LDN-prescribing doctors, although so far the feedback from my patients have been positive.

Another website to check out is www.ldnscience.org, where you can find a local doctor who prescribes LDN.  The upside is that you not only can search for a doctor who prescribes LDN in the United States, but in other countries too.  The downside is that there are some locations that don’t have an LDN-prescribing doctor.  For example, I live right outside of Charlotte NC, but as of writing this blog post, the closest doctor who prescribes LDN practices approximately 2 hours away.  However, if I was facing either radioactive iodine or thyroid surgery I would gladly drive a few hours to get a prescription for LDN, although I also would consider scheduling a consultation with someone through www.ldndoctor.com.

Which Option Should YOU Choose?

If you had a negative reaction to Methimazole and are currently facing a situation where your endocrinologist is pressuring you to receive radioactive iodine or thyroid surgery, you might be wondering which of these three alternatives to consider.  It’s not an easy decision to make, as while I listed PTU first, this doesn’t mean that you can’t try a natural approach such as bugleweed.  And even though I gave a few reasons why I don’t initially recommend LDN to my patients with Graves’ disease, you might decide to start with this option.

One of the benefits of LDN is that unlike antithyroid medication and herbs, LDN actually modulates the immune system.  However, even if LDN effectively modulates your immune system, keep in mind that it’s not addressing the underlying cause of the problem.  Of course neither is antithyroid medication or bugleweed, and so regardless of which of these three options you choose, you would still want to address the cause of your condition.  If someone has a non-autoimmune hyperthyroid condition, such as toxic multinodular goiter, then they will want to consider the first two options I mentioned.

In summary, many people with hyperthyroid conditions take Methimazole to manage the hyperthyroid symptoms.  However, not everyone with hyperthyroidism can take Methimazole, as some people experience side effects.  When this is the case you might want to look into other options, including PTU, bugleweed, and low dose naltrexone.

The last month or two I have been talking a lot about my new book “Hashimoto’s Triggers”, which was released a few days ago.  During this time I’ve had a few people with Graves’ disease ask about “Graves’ Disease Triggers”.  The truth is that while managing the symptoms of Graves’ disease is dramatically different when compared to Hashimoto’s, the process of finding and detecting the autoimmune triggers is the same with both conditions.  And many of the same triggers that are found in Hashimoto’s are also found in Graves’ disease, although some triggers are more common in Graves’ disease, and vice versa.

For example, although I discuss H. Pylori in my book as a potential trigger of Hashimoto’s, this is a more common trigger in those with Graves’ disease.  Similarly, the research shows a higher correlation between stress and the development of Graves’ disease.  On the other hand, the parasite Blastocystis hominis seems to be a more common trigger in those with Hashimoto’s.

Some people with Graves’ disease have asked if they should read my Hashimoto’s Triggers book, or if it’s best to read the book I wrote on hyperthyroidism and Graves’ disease?  The honest answer is “both”, and here is the reason.  The book on hyperthyroidism and Graves’ disease focuses on hyperthyroid conditions, and so it of course makes sense for anyone with Graves’ disease or a non-autoimmune hyperthyroid condition to read this book.  However, there is a lot of updated information in my Hashimoto’s Triggers book that isn’t in my other book.  And while some of the information is specific to Hashimoto’s thyroiditis, a lot of the information will be useful for those with Graves’ disease, as well as those with other autoimmune conditions.

For those wondering when I plan on releasing a new book on Graves’ disease, all I can say is that this is something that will happen in the near future.  It almost definitely won’t be this year since I haven’t started writing it, but I wouldn’t rule out a new Graves’ disease book in 2019.  Of course originally I was hoping to release my book on Hashimoto’s a few years ago, and so I’m sure you can understand that I can’t put a firm date on the book at this point.  But in the meantime I would not only check out my book on hyperthyroidism and Graves’ disease, but I would also seriously consider reading my new book on Hashimoto’s Triggers…especially since the electronic version is steeply discounted and I’m also offering 3 special bonus gifts.  You can check out this special offer by clicking here.

Whether you have Graves’ disease or Hashimoto’s thyroiditis, the primary key to getting into remission is to find and remove your specific autoimmune triggers.  This can be very challenging to do, which is why it took so long to write my new book “Hashimoto’s Triggers” (which is now available on Amazon).  Speaking of which, even though the title of the book may imply that it’s specifically for those who have Hashimoto’s, the truth is that the process of detecting and removing triggers is similar regardless of whether someone has Hashimoto’s, Graves’ disease, or a different autoimmune condition (i.e. rheumatoid arthritis, multiple sclerosis, lupus, etc.).  So the truth is that this book can benefit those people with other autoimmune conditions, although some of the information is specific to Hashimoto’s.

But why can it be so challenging to find your autoimmune triggers?  While there are only 4 main categories of autoimmune triggers (food, stress, microbes, and chemicals), there are numerous triggers within each of these categories.  And while I mentioned in the opening paragraph that the process of detecting and removing triggers is similar regardless of the autoimmune condition someone has, different people will have different triggers.  In addition, it’s common to have multiple triggers.

Dealing With Multiple Autoimmune Triggers

For example, one person with an autoimmune condition might have gluten and an infection as triggers.  In this situation, removing gluten alone won’t always result in a significant improvement in the person’s symptoms and/or a reduction in their autoantibodies.  As a result, the person might end up eliminating gluten and not notice any improvement in their symptoms, and on top of this their autoantibodies remain elevated, and so they conclude that the problem isn’t with gluten.  Perhaps this person even had a negative celiac panel, and they don’t realize that it’s possible to have a gluten sensitivity, even in the absence of celiac disease (called a non-celiac gluten sensitivity).

This example shows why you can’t always rely on symptoms to detect your triggers.  Sure, there are some people who have experienced complete resolution of their symptoms and a normalization of their antibodies upon removing gluten, or upon following an autoimmune Paleo (AIP) diet.  But I don’t find these situations to be common in my patients.  Of course one reason for this is because many people make these dietary changes on their own, and some are able to find their food triggers without working with a natural healthcare professional.  On the other hand, other people aren’t able to successfully find and remove their autoimmune triggers.

In any case, the reason why I brought up this example is because if someone has multiple autoimmune triggers, then the obvious goal should be to remove all of them.  But sometimes not all of these triggers are detected initially, which is why you can’t conclude that food isn’t a trigger just because you don’t feel better upon eliminating it.  In the example I just gave, the person very well might have to eliminate gluten AND eradicate the infection before they see a significant improvement in their symptoms and/or a lowering of their thyroid antibodies.  On the other hand, others might experience significant symptomatic improvement just by eliminating gluten alone, even in the presence of one or more additional triggers.

How Much Testing Do You Need To Find Your Triggers?

In my book on Hashimoto’s Triggers, I talk about conservative vs. comprehensive testing.  Conservative testing involves doing some basic testing, and for many people this is sufficient to find their triggers.  On the other hand, some people need more comprehensive testing.  How can you determine if you need conservative or comprehensive testing?  Some people make this decision based on the costs of the tests, and while I can understand not wanting to spend a lot of money on testing, at the same time you also want to do what is necessary to find your triggers.

Does this mean that I’m in favor of comprehensive testing?  Not necessarily, as I actually prefer to take a conservative approach whenever possible, but if after conducting a thorough health history I feel that more comprehensive testing is necessary, then I’ll make this recommendation to the patient.  Of course regardless of whether a healthcare practitioner recommends conservative or comprehensive testing, it is ultimately up to you.  In other words, all a healthcare practitioner will do is give his or her recommendations, and then it’s up to you to decide how much testing you want to do.

I’ll also add that there are risks of doing either conservative or comprehensive testing.  For example, when I was diagnosed with Graves’ disease I personally didn’t do a lot of testing.  So I fell under the “conservative testing” category.  The risk with conservative testing is that you might not detect all of your triggers, and additional testing might be necessary in the future.  While some people are fine taking this approach, other people don’t want to take the chance.  In other words, some don’t want to rely on conservative testing, risk not finding all of their triggers, and then have to do additional testing a few months later.

Of course the “risk” with comprehensive testing is that you might end up spending money on testing that you don’t need.  For example, there are some healthcare professionals who recommend in excess of $1,000 worth of testing to all of their patients.  I’m not saying this is right or wrong, as everyone takes a different approach.  And while it can be beneficial to rule out certain triggers (i.e. infections), some people are on a very tight budget, and are therefore unable to spend a lot of money on testing.

Don’t Forget To Heal Your Gut!

Although the main focus of this blog post was to discuss triggers, it’s important to remember that while finding and removing your triggers is necessary to reverse the autoimmune component, you need a healthy gut in order to have a healthy immune system.  And according to the triad of autoimmunity, everyone with Graves’ disease and Hashimoto’s (and every other autoimmune condition) has a leaky gut.  And while in some cases finding and removing your triggers will be sufficient for gut healing, this isn’t always the case.

In my book I discuss the difference between “direct” triggers and “leaky” gut triggers, and while I won’t get into detail here about this, I will say that sometimes the direct trigger and the leaky gut trigger are the same, but at other times they can be different.  For example, the research shows that gluten can cause a leaky gut in everyone, and so gluten is a leaky gut trigger.  And while it can also be a direct trigger of autoimmunity, this isn’t the case with everyone.  Don’t get me wrong, as ideally everyone with an autoimmune condition should avoid gluten since it can cause a leaky gut, and according to the triad of autoimmunity, a leaky gut is a necessary component of autoimmunity.

Now I’d like to hear from you, as I’d like to know what you have specifically done to find your autoimmune triggers.  Please leave a comment below and let me know!

Note: by the way, for a limited time the electronic version of my book is available on Amazon for 99 cents.  In addition, for anyone who purchases either the electronic version or paperback version of my book I’m also offering 3 free bonus gifts.  For more information click here.

Last Friday I was on Facebook Live doing a presentation on testing the adrenals, 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 5^th, 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.  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”.  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, 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.  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.  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 5^th.  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.