Not too long ago I attended a functional medicine conference, and the attendees were entitled to receive a free stool analysis.  Although I can’t say I enjoyed the collection process (especially since this required three different stool samples collected on different days), I was curious to see what the comprehensive stool panel results showed.  Fortunately I tested negative for pathogenic bacteria, yeast, and parasites.  And most of the other markers looked great, which of course made me very happy.  However, even though I hadn’t been experiencing any digestive symptoms, I had some positive markers for inflammation.  Fortunately the markers that are commonly high in inflammatory bowel disease looked good, although I was still surprised to see some of the other inflammatory markers on the high side.

You might wonder why I’m sharing this story with you.  Well, the main reason is to demonstrate that it is possible to have inflammation yet not experience any overt symptoms.  Another reason is to demonstrate that I’m not perfect, as while I eat a pretty good diet overall, I admittedly had been indulging more than usual prior to collecting the stool samples.  Not to make excuses, but I traveled a lot in 2015, and I probably gave in to too many temptations. And while it’s a little bit embarrassing to admit this, I thought it was a good idea to share this experience so that you realize that it’s not only a challenge to eat well when trying to restore one’s health when dealing with a thyroid or autoimmune thyroid condition, but it’s also a challenge to eat well when trying to maintain a state of wellness.

Is It Possible To Eat Too Many Healthy Foods?

When I was a teenager and young adult, there were certain foods I ate on a regular basis that I thought were healthy, but I eventually learned that this wasn’t the case.  A few examples include pasta, whole wheat bread, and soy chicken nuggets.  Of course now I have a pretty good idea of which foods are healthy and unhealthy, but one thing to be aware of is that you can eat too much of a healthy food.  For example, in the second half of 2015 there is no question that I ate too many nuts and too much dark chocolate.  Yes, I did eat some foods worse than these (i.e. pizza), and this probably was a factor as well.  But I don’t want you to overlook the fact that eating an excess of other foods that have some health benefits can also cause problems.

So was overindulging in nuts and dark chocolate a potential factor in my inflammation?  I’m honestly not sure, and I did mention earlier that I ate other foods far worse than nuts and dark chocolate.  For example, I attended my younger sister’s wedding in August of 2015, and Italian food was served.  And while we did put in a request for gluten free pasta, I ate a cannoli that definitely wasn’t gluten free.  Speaking of which, if anyone has a gluten free cannoli recipe please feel free to share it with me in the comment sections below!  I wish I can say that the cannoli was the only bad thing I ate, but the night before I also had some pizza at a Brooklyn pizzeria.  And while I ordered a gluten free pizza, I admittedly was naughty and also had some regular pizza.  Of course even gluten free pizza isn’t considered to be healthy, especially when you consider some of the ingredients used by many restaurants.  But eating pizza is even worse from a health perspective when it’s loaded with gluten (no matter how delicious it might be…and believe me, that Brooklyn pizza tasted amazing).

In last week’s blog post I spoke about gluten, and whether someone should avoid it even if they don’t feel bad upon eating it and/or don’t experience any improvement in their symptoms upon avoiding it.  I usually don’t feel bad when eating foods with gluten, but this doesn’t mean that it’s not having a negative effect on my health.  If you read last week’s blog post, you’ll recall that I mentioned that gluten apparently causes an increase in intestinal permeability (a leaky gut) in everyone, and not just those with Celiac disease or a non-autoimmune gluten sensitivity.

Do YOU Have Gut Inflammation?                                   

After reading this post, I’m sure there are some people who are wondering if they have gut inflammation.  The truth is that many people have gut inflammation and are unaware of it.  You of course can test for some general inflammatory markers through the blood such as high sensitive c-reactive protein (hs-CRP), or erythrocyte sedimentation rate (ESR).  Just keep in mind that negative findings don’t necessarily rule out inflammation.  While you can do a comprehensive stool analysis like I did, such testing can be expensive.  If you are eating gluten and/or dairy on a regular basis then this can be problematic.  But even if you are gluten and dairy free but are eating a lot of nuts, seeds, grains, and legumes, then these might cause inflammation when eaten in excess.  And so rather than spend a lot of money on additional testing, it might be best to just minimize your consumption of these foods for awhile and see if your health improves.

What’s the solution to get rid of gut inflammation?  Well, it of course depends on the cause of the inflammation.  If someone is sensitive to gluten and they eat even a small amount of it then this can result in inflammation.  On the other hand, not everyone with gut inflammation is sensitive to gluten.  In fact, some people who avoid gluten still have gut inflammation.  Other foods can cause inflammation, along with other factors such as an infection, and even chronic stress.  Taking certain nutrients and herbs can also help to reduce gut inflammation, such as fish oils, probiotics, and turmeric.  However, if the cause of the inflammation isn’t addressed then these natural anti-inflammatory agents aren’t going to be as effective.

In summary, many people have gut inflammation but are unaware of it.  And while some people with gut inflammation experience overt symptoms, this isn’t always the case.  Eating foods that contain gluten and dairy causes inflammation in a lot of people, but eating too many healthy foods such as nuts, seeds, grains, and legumes might also lead inflammation in some people.  While you can do some testing to confirm or rule out inflammation, regardless of the findings you of course want to eat a healthy diet, try not to overindulge in certain foods, and do a good job of managing your stress.

Many people with thyroid imbalances, and especially those with an autoimmune thyroid condition such as Graves’ Disease or Hashimoto’s Thyroiditis, can benefit from avoiding gluten.  It’s very common for my patients who go on a gluten free trial to tell me how much better they feel.  Sometimes the changes in their symptoms are dramatic, and some people even experience a dramatic reduction in their thyroid antibodies upon avoiding gluten.  However, not everyone feels better when avoiding gluten.  And so the goal of this blog post is to discuss what approach you should take if you don’t feel any improvement in your symptoms upon avoiding gluten.

Just as a side note, while growing up, gluten was part of my regular diet.  I would have cold cereal for breakfast (i.e. Fruit Loops, Apple Jacks, etc.).  I ate plenty of bread, cookies, and other foods loaded with gluten.  In addition, I  grew up in Queens New York, which has a bagel store on almost every corner, and there are also plenty of pizza places and bakeries.  And so I had plenty of gluten as a child and teenager, and I must admit that if gluten was as healthy as vegetables I would be eating gluten-based foods all of the time!  Sure, I feel great after having my green smoothie for breakfast, and I don’t mind eating steamed broccoli, but if bagels and pizza were just as healthy I’d be eating these foods every day.  And yes, I know there are gluten free versions of these, but they still aren’t as healthy as whole foods.

So now that you are aware of my secret obsession with bagels and pizza (more so pizza than bagels), let’s talk about what you should expect to happen when you avoid gluten.  If you are symptomatic should you experience an improvement in your symptoms within a few days or weeks of going gluten free?  Should you notice an improvement in your blood tests upon removing gluten from your diet?  It really does depend on the person, as if someone has a gluten sensitivity, or a condition such as Celiac disease, then they will usually feel better upon avoiding gluten.  However, not everyone experiences overt symptoms even when they are gluten sensitive, and some people even have silent Celiac disease (1) (2) (3).  Admittedly most of the cases of silent Celiac disease seem to be present in children and adolescents, but adults can have this as well.

How Can You Tell If You Have A Gluten Sensitivity?

There are basically two ways to tell if someone has a gluten sensitivity…by symptoms or through testing.  Of course if you experience symptoms when eating gluten then this is a clear sign to avoid it.  The problem is that not everyone experiences overt symptoms when consuming gluten, and so the lack of symptoms when consuming gluten doesn’t necessarily rule out a gluten sensitivity.  Also, keep in mind that foods that contain gluten are typically high in FODMAPs, and so if you have problems with gluten and other high FODMAP foods then there is a chance that gluten sensitivity isn’t the issue, but you might have small intestinal bacterial overgrowth instead.  If you aren’t familiar with FODMAPs then I would read the blog post I wrote entitled “Should People With Thyroid Conditions Follow a Low FODMAP Diet?”

As for testing, while this can help to detect a gluten sensitivity problem, a negative finding doesn’t rule out a sensitivity to gluten.  For example, if someone gets a Celiac panel which measures the antibodies to gliadin and transglutaminase and the test results are negative, this doesn’t mean you can’t be sensitive to other proteins of gluten which aren’t tested.  Cyrex Labs has the most comprehensive test for gluten that I know of, but while it tests for many of the markers of gluten, it doesn’t test for all of them. In addition, if someone has depressed immunoglobulins then this can result in a false negative result.

So hopefully you realize that it can be challenging at times to determine if someone has a gluten sensitivity, as while a positive test result usually confirms a gluten sensitivity, a negative result doesn’t necessarily rule out problems with gluten.  If one has overt symptoms when consuming gluten and/or tests positive for a gluten sensitivity then there is no question that they should avoid gluten.  But if they don’t experience negative symptoms, and if the testing reveals no gluten sensitivity, then it’s not clear if they should avoid gluten.  And this is one reason why many healthcare professionals will have all of their patients who have a chronic health condition avoid gluten.

“Can I Get Into Remission If I Continue To Eat Some Gluten?”            

At this point you might still be wondering if you can restore your health if you continue to eat gluten.  The answer is “maybe”.  In my experience it is possible for some people with Graves’ Disease and Hashimoto’s Thyroiditis to restore their health, even if they don’t completely avoid gluten.  While some natural healthcare professionals will disagree with this, and while I do encourage my patients to avoid gluten while following a natural treatment protocol, I have had some patients continue to eat gluten and still get into remission.  This doesn’t mean that they were eating large amounts of whole wheat bread and pasta on a daily basis, as they were still eating very healthy, but they didn’t completely avoid all sources of gluten.

With that being said, it does appear that gliadin, which is one of the proteins in gluten, causes an increase in intestinal permeability in everyone, even those who aren’t sensitive to gluten (4).  What this means is that gluten causes a leaky gut in everyone.  And while this study did show that those people with active Celiac disease and a non-autoimmune gluten sensitivity had a greater increase in intestinal permeability, those who didn’t have Celiac disease or a non-autoimmune gluten sensitivity still experienced negative effects on the intestinal barrier when consuming gluten.

However, some people are hesitant to avoid gluten if they don’t feel worse upon eating it, or if they don’t notice any positive changes in their symptoms upon eliminating it.  The problem is that you can’t always go by symptoms alone, and it is impossible to predict who will do fine when continuing to consume gluten.  And so there are basically two options for those who are looking to restore their health, yet don’t experience any negative symptoms when eating gluten (or don’t feel better upon eliminating it).  One option is to continue to eat gluten while following a natural treatment protocol and see how you progress.  If you choose this option I still would try to minimize your consumption of gluten, and if you are eating mostly whole foods then it’s easy to accomplish this.

A second option is to play it safe and completely avoid gluten.  This always leads to questions such as “is it okay to have a tiny amount of gluten?”, or “what if I’m 99% gluten free?”  This once again depends on the person.  Some people make an effort to go gluten free, but either intentionally or accidentally get exposed to small amounts of gluten.  And if they don’t have Celiac disease or a non-autoimmune gluten sensitivity then they probably will do fine.  On the other hand, if they have a gluten sensitivity they will continue to have gut inflammation even when consuming small amounts of gluten, and as a result they probably won’t improve.

What Should You Do If Avoiding Gluten For A Prolonged Period Of Time Doesn’t Help?

I’ve come across people who have gone gluten free for six months or longer without any improvement in their symptoms or thyroid blood tests/antibodies.  Isn’t this an obvious sign that they aren’t gluten sensitive?  Well, when this is the case there is a good chance that gluten isn’t the primary trigger.  However, keep in mind that there can be multiple triggers.  For example, someone can have a gluten sensitivity that is causing inflammation, but the main trigger is an underlying infection.  And so avoiding gluten might have helped with the inflammation, but since the main trigger (the infection) was still present, the person didn’t notice much of a difference with their symptoms when avoiding gluten.

It’s a no-win situation, and so you might as well just throw in the towel and munch on some donuts or muffins, right?  The truth is that I’m not against some people eating gluten on an occasional basis…after they have restored their health back to normal.  Although I try to eat a healthy diet most of the time, I’d be lying if I told you that I was completely gluten free 100% of the time.  Gluten should admittedly be avoided, just like alcohol, and while I don’t drink alcohol, I do occasionally indulge in foods that contain gluten.  I’m not suggesting that everyone is able to eat gluten after they restore their health, as there definitely are people who need to completely avoid it.  And next week I’ll be releasing a blog post which might suggest that I should completely avoid gluten altogether, even though I feel fine when I consume it.

In summary, while many people feel better upon avoiding gluten, not everyone who eliminates gluten from their diet notices an improvement in their symptoms and blood tests.  When this is the case, it is tempting to want to go ahead and eat gluten on a regular basis, but just remember that the lack of symptoms, and even a negative test result doesn’t rule out a gluten sensitivity.  While some people might be fine eating small amounts of gluten while trying to restore their health, others won’t do well.  As a result, I think it’s a good idea for everyone to go on a gluten free trial, although this doesn’t mean that everyone needs to completely avoid gluten on a permanent basis.

Thyroxine, also known as T4, is the primary thyroid hormone secreted by the thyroid gland.  This hormone is low or depressed in those people with hypothyroidism, and it is usually elevated in those with hyperthyroidism.  Although the focus of this post will be on T4, triiodothyronine (T3) is another thyroid hormone.  And because most T3 is produced via the conversion of T4 into T3, if someone has low T4 levels then they usually will have low T3 levels, although there are exceptions.

Before talking about some of the factors which can cause low T4 levels, I’d like to briefly discuss how thyroid hormone is manufactured.  Because if you understand how it is formed then you will also understand some of the things which can lead to lower thyroid hormone levels.  The thyroid follicles are cells in the thyroid gland, and this is where thyroid hormones are produced.  You get iodide from the diet, which travels through the bloodstream to the thyroid follicular cells, which in turn takes up the iodide with the help of something called a sodium-iodide-symporter.  Thyroid peroxidase is an enzyme which plays an important role in iodination, which involves the oxidation of iodide ions to form iodine atoms.

Thyroxine contains four iodine atoms, which is why it’s referred to as “T4”, and these iodine atoms attach to a tyrosine molecule.   And as you might have guessed, triiodothyronine contains three iodine atoms, which is why it’s referred to as “T3”.  There is also thyroglobulin, which is synthesized by the thyroid follicular cells, and this acts as a substrate for the synthesis of T3 and T4, and also stores inactive forms of thyroid hormone.  So what’s important to understand is that iodine and tyrosine are important for the formation of thyroid hormone, and thyroid peroxidase and thyroglobulin also play important roles.

Hopefully you have a better understanding of how thyroid hormone is formed.  Now I’d like to go ahead and look at seven reasons why you might have low T4 levels:

1. Hashimoto’s Thyroiditis.  This is an autoimmune condition which involves the immune system attacking the thyroid gland.  The immune system specifically attacks thyroglobulin and/or thyroid peroxidase, which in turn is what results in low or depressed thyroid hormone levels.  Although many people with Hashimoto’s don’t have low T4 levels, since most medical doctors don’t do anything to address the autoimmune component, the immune system will continue damaging these structures of the thyroid gland, and as a result, over a prolonged period of time most patients with Hashimoto’s will eventually have low T4 levels.

What’s The Solution To This Problem?  The goal is to address the autoimmune response.  The most important factor is to try to detect and then remove the autoimmune trigger.  While doing this you should do things to reduce inflammation and increase regulatory T cells, which I discussed in a separate blog post entitled “Regulatory T Cells and Thyroid Autoimmunity“.

2. Iodine Deficiency.  Since iodine is necessary for the formation of thyroid hormone, it should come as no surprise that an iodine deficiency can result in low T4 levels.  But how can you determine if you have an iodine deficiency?  The most accurate way of testing for iodine seems to be in the urine.

What’s The Solution To This Problem?  If someone has an iodine deficiency then the obvious goal should be to correct it.  However, not everyone does well when taking iodine, especially many people with Hashimoto’s Thyroiditis, and so if you test positive for an iodine deficiency and are thinking about supplementing with iodine, you do need to be cautious.  This is especially true if you are thinking about taking high doses of iodine, but it can also be a problem in some people even in small doses.  For those people with Hashimoto’s, many times it is best to restore the health of the immune system before taking iodine.

3. Dysregulation of the HPT Axis.  When talking about the formation of thyroid hormone earlier, I didn’t talk about the role of the hypothalamus and pituitary gland.  These both play an important role in the signaling of thyroid hormone.  Most people are familiar with thyroid stimulating hormone, which is also known as TSH.  TSH is released by the pituitary gland, which tells the thyroid gland to produce more thyroid hormone.  However, the hypothalamus communicates with the pituitary gland, and so if there are problems with either the hypothalamus or pituitary gland then this in turn can cause problems with the thyroid gland.

What’s The Solution To This Problem?  If someone has dysregulation of the hypothalamic-pituitary-thyroid (HPT) axis, then the goal should be to improve the health of the HPT axis.  Adaptogenic herbs can help to accomplish this, with ashwagandha perhaps the most well known herb which can have a positive effect on the HPT axis.  Taking glandulars to support the hypothalamus and pituitary gland can also help in some cases.  However, while taking adaptogenic herbs can help, stress causes dysregulation of the HPT axis, as well as the hypothalamic-pituitary-adrenal (HPA) axis, and so improving your stress handling skills is essential.

4. Tyrosine Deficiency.  You learned earlier that tyrosine plays an important role in thyroid hormone production, as the iodine atoms attach to a tyrosine molecule.  And while most cases of low T4 levels aren’t caused by a tyrosine deficiency, it’s still something to consider.  I spoke about this in greater detail in an article I wrote entitled “Tyrosine and Thyroid Health“.

What ‘s The Solution To This Problem?  If someone does have a tyrosine deficiency then they will want to increase their consumption of tyrosine-rich foods such as chicken, turkey, fish, eggs, avocados, and spinach.  Taking a tyrosine supplement might also be a good idea if one has a deficiency..

5. Iron deficiency.  As you have learned, the enzyme thyroid peroxidase plays an important role in thyroid hormone formation.  Thyroid peroxidase is a heme-containing enzyme, which means that it is dependent on iron.  And the research shows that an iron deficiency can reduce thyroid peroxidase activity, which in turn can affect thyroid metabolism (1) (2).

What’s The Solution To This Problem?  Many people are deficient in iron, and so before ruling out an iron deficiency you want to make sure to get  a complete iron panel consisting of serum iron, ferritin, iron saturation, and TIBC.  If you have an iron deficiency then supplementation probably is a good idea.  However, you also want to try addressing the cause of the problem, which I spoke about in an article entitled “Iron Deficiency Anemia and Thyroid Health“.

6. Environmental toxins.  Certain environmental toxins can potentially inhibit thyroid activity.  Numerous studies show that xenoestrogens such as BPA and flame retardants can inhibit thyroid hormone production (3) (4) (5).  Other studies also show that fluoride can interfere with thyroid gland function (6) (7).  Bromide might also have an inhibitory effect on thyroid hormone (8).  Perchlorate inhibits the uptake of iodine and can decrease thyroid hormone production (9).  Heavy metals such as mercury can also inhibit thyroid hormone production (10) (11).

What’s The Solution To This Problem?  Although it’s impossible to eliminate your exposure to environmental toxins, you of course can do things to minimize your exposure to them.  For example, you want to avoid drinking bottled water on a frequent basis, reduce your exposure to flame retardants, along with fluoride, and other environmental toxins.

7. Soy and other goitrogenic foods.  This one is controversial, as while there are studies which show that soy phytoestrogens can cause hypothyroidism (12), other studies show that this isn’t the case (13).  Other studies suggest that soy only has antithyroid effects in the presence of an iodine deficiency (14).  With regards to other goitrogenic foods (i.e. cruciferous vegetables, spinach, strawberries, etc.), there are no human studies I’m aware of which show that eating these foods inhibit thyroid activity.

What’s The Solution To This Problem?  Besides the possibility that soy has goitrogenic properties, soy is a common allergen, and most soy is also genetic modified.  And so it might be best to minimize your consumption of soy.  With that being said, some people are able to eat some organic fermented soy without a problem, although not everyone.  As for other goitrogenic foods, such as cruciferous vegetables, most people are able to eat these without a problem, although if someone has a moderate to severe iodine deficiency then it might be best to play it safe and limit your consumption of these foods.  However, keep in mind that cooking these foods will also reduce the goitrogenic activity.

In summary, there are numerous factors which can cause low T4 levels.  Hashimoto’s Thyroiditis is the primary cause of hypothyroidism.  Nutrient deficiencies can also play a role, including iodine, iron and tyrosine.  Other potential causes include dysregulation of the HPT axis, certain environmental toxins, and perhaps certain goitrogenic foods.

Adhesive capsulitis, also known as a frozen shoulder, is characterized by a painful, gradual loss of active and passive shoulder motion resulting from fibrosis and contracture of the joint capsule (1).  Although other shoulder conditions can result in similar symptoms, people with hyperthyroidism are more prone to developing a frozen shoulder.  As a result, if you have hyperthyroidism and are experiencing moderate to severe pain in one or both shoulders that isn’t due to a traumatic injury, then it’s possible that you have adhesive capsulitis as a result of your condition.

Adhesive capsulitis usually develops one of two ways.  The primary method is gradual, which usually is the case with those who have hyperthyroidism.  But it can also develop as a result of a trauma.  When it’s not caused by a trauma, it can take a few weeks or months until the pain is severe enough for the person to seek medical attention.  Sometimes they will only notice the shoulder pain initially, but over time they will realize that it’s also affecting their range of motion.

Adhesive Capsulitis Can Be Present In Other Conditions

Although hyperthyroidism is one of the more common conditions in which people develop a frozen shoulder, there can be other conditions that lead to this as well.  This includes hypothyroidism, as well as hypoadrenalism, Parkinson’s disease, cardiac disease, pulmonary disease, and stroke (2).

The Three Clinical Phases of Adhesive Capsulitis

The literature discusses three distinct phases of adhesive capsulitis (3):

1. The freezing or painful stage.  This is what I described above, as over time the pain will increase, and both the active and passive range of motion will decrease.  This phase typically lasts between 3 and 9 months and is characterized by an acute synovitis (inflammation of the synovial membranes) of the glenohumeral joint of the shoulder (3).

2. The frozen or transitional stage.  This stage can last from 4 to 12 months, and it’s usually when the pain is the most intense and the shoulder is the most restricted.

3. The thawing stage.  This is when the pain begins to decrease and the range of motion begins to improve.  This stage can last anywhere from 12 to 42 months (3).

How Is Adhesive Capsulitis Diagnosed?

As for how adhesive capsulitis is diagnosed, it can be challenging initially.  A physical examination will reveal both a loss of passive and active range of motion (4).  Many times it is diagnosed by ruling out other conditions, such as a rotator cuff tear, a bone contusion, or osteoarthritis.

What Are The Treatment Options For Adhesive Capsulitis?

The conventional treatment approach usually will begin with either drugs or physical therapy.  Nonsteroidal anti-inflammatory drugs (NSAIDs) can help to reduce the inflammation, which in turn might decrease the pain (5) (6).  Prednisone might also benefit some people with adhesive capsulitis, although the benefits seem to be more short term (7).  Cortisone injections are also commonly used and can lead to fast pain relief and an improved range of motion (8) (9), although of course there are potential side effects as well.  Sometimes arthroscopic surgery is used for adhesive capsulitis.  But in most cases surgery should be a last resort.

I’m more in favor of using natural anti-inflammatory agents, such as higher doses of curcumin, resveratrol, boswellia, and fish oils.  However, many times these won’t result in significant relief, and when this is the case, some type of physical therapy can be beneficial.  There is some evidence that a combination of bee venom acupuncture and physiotherapy can help with adhesive capsulitis (10) (11).  For those who aren’t familiar with bee venom acupuncture, this is a type of herbal acupuncture that uses bioactive compounds isolated from bee venom, combined with acupuncture.  But “standard” acupuncture can also be beneficial for a frozen shoulder.  Manipulation of the shoulder can be beneficial (12), and possibly even manipulation of the thoracic spine (13).  And so going to a chiropractor might help, especially if you see a chiropractor that has experience working on extremities.  Low-level laser therapy might also help with adhesive capsulitis (14).

In summary, people with hyperthyroidism are more prone to developing a frozen shoulder, which is also known as adhesive capsulitis.  Most of these cases develop gradually, although sometimes it can be due to a trauma.  Adhesive capsulitis is usually diagnosed by ruling out other conditions.  Conventional treatment usually involves NSAIDs, cortisone injections, physical therapy, and in some cases arthroscopic surgery.  Although natural anti-inflammatory agents probably won’t help much, acupuncture, manipulation, and low-level laser therapy might be beneficial.

Most people with thyroid and autoimmune thyroid conditions deal with chronic stress.  In fact, I think it’s safe to say that most people in general deal with chronic stress.  And while I have spoken about cortisol in past articles and blog posts, I haven’t talked as much about adrenaline.  And so what I plan on doing in this post is to discuss some of the factors which can cause high cortisol and adrenaline, some of the symptoms associated with elevated levels, and the consequences of having high levels of cortisol and adrenaline over a prolonged period of time.  And of course I’ll discuss what you can do to naturally lower cortisol and adrenaline.

Most people reading this are aware that adrenaline is involved in the “fight or flight” reaction.  When there is a stressful situation, there will be a rapid increase of adrenaline.  On the other hand, cortisol will also increase, but it’s a slower process.  During a chronic stress situation you can have chronically raised adrenaline and cortisol levels.

Adrenaline is known as epinephrine.  And there is also norepinephrine (noradrenaline).  Both of these are known as catecholamines.  As for how they are formed, the amino acid tyrosine gets converted into DOPA, which in turn gets converted into dopamine.  This neurotransmitter in turn gets converted into noradrenaline.  An enzyme called PNMT converts norepinephrine into epinephrine by catalyzing the transfer of a methyl group from SAMe to norepinephrine.  Both epinephrine and norepinephrine are broken down and inactivated by the enzymes catechol-oxymethyltransferase (COMT) and monoamine oxidase (MAO).  However, if someone has a genetic defect of the COMT gene or the MAOA gene then this can affect the breakdown of the catecholamines.  Fortunately there is genetic testing available to determine if someone has one or both of these genetic polymorphisms.

What Are The Causes/Symptoms Of Elevated Adrenaline?

Before talking about the symptoms of high adrenaline, it probably is a good idea to briefly mention some of the factors which can cause high adrenaline.  In addition to stress, other factors which can cause high adrenaline include not getting enough sleep, having hypoglycemia, pain, anger and fear, and being on certain medications.  If someone has high adrenaline then they can experience one or more of the following symptoms:

• Anxiety
• Elevated heart rate
• Elevated blood pressure
• Heart palpitations
• Low insulin and blood glucose
• Headaches
• Hot flashes

What Are The Causes/Symptoms Of Elevated Cortisol?

In addition to stress causing elevated cortisol levels, other factors include not getting enough sleep, inflammation, infection, blood sugar imbalances, and trauma (both emotional and physical).  Here are some of the symptoms one can experience with elevated cortisol levels:

• Memory and concentration problems
• Problems falling and/or staying asleep
• Depression
• Elevated blood glucose levels
• Low sex hormones due to the pregnenolone steal

What Are The Consequences Of Prolonged Elevations Of Adrenaline and Cortisol?

Although having elevated adrenaline and cortisol levels for short periods of time is normal under the presence of an acute stressor, if someone is dealing with prolonged chronic stress then this can not only cause the symptoms I mentioned earlier, such as anxiety, depression, hypertension, low sex hormones, and blood sugar imbalances, but it can also lead to osteoporosis, as well as cognitive impairment.

The hippocampus, which is important in learning and memory, is particularly sensitive to chronic stress and cortisol (1).  There is evidence that prolonged elevations of cortisol can compromise the hippocampus, and this can affect cognition (1) (2).

In addition, if someone has elevated cortisol levels for a prolonged period of time, this can lead to cortisol resistance.  You might be familiar with insulin resistance, which is when there is an excess of insulin, and the cells are no longer responsive to the effects of insulin.  It’s similar with cortisol, as large amounts of cortisol can result in a decreased negative feedback of the cortisol-ACTH feedback system resulting in increased ACTH secretion. This causes higher plasma cortisol and also increases the production of adrenal mineralocorticoids (3).  This not only can affect someone’s ability to handle stress, but it also can interfere with the regulation of the inflammatory process (4).

What Impact Does Elevated Cortisol and Adrenaline Have On Thyroid Health?

Cortisol seems to have a greater impact on thyroid health than adrenaline.  In past articles I have discussed how elevated cortisol levels can affect the conversion of T4 to T3.  This will result in low or depressed T3 levels, and an elevated reverse T3.  Studies show that stress can inhibit both type I iodothyronine 5′-deiodinase activity (5), as well as type II 5′-deiodinase activity (6) (7).

What Is Cushing’s Syndrome?                                  

Cushing’s syndrome is a condition which involves the body being exposed to excessive amounts of cortisol.  Although this can be caused directly by the adrenals releasing too much cortisol, it can also be caused by an excess of ACTH released by the pituitary gland, which in turn will lead to excess cortisol.  In fact, the latter problem is more common, as many people with Cushing’s syndrome have a pituitary adenoma that is responsible for the excess amount of ACTH, which is referred to as Cushing’s disease.  An adenoma is a benign tumor, and sometimes it can be difficult to diagnose.  Cushing’s syndrome can also be caused by taking an excess amount of prescription corticosteroids.

Although some of the symptoms of Cushing’s syndrome are similar to those with high cortisol, this is an extreme condition, and the symptoms are usually more severe.  Here are some of the symptoms associated with this condition (8):

• Weight gain
• Skin changes
• Menstrual irregularities
• Muscle loss and weakness
• Osteopenia or osteoporosis
• Elevated blood glucose levels
• High blood pressure
• Infections
• Dyslipidemia

As for how Cushing’s syndrome is diagnosed, in addition to having elevated cortisol levels in the blood, a urinary cortisol test might also be performed.  ACTH should also be tested, and if this hormone is elevated then a pituitary adenoma is the most likely cause of the excess cortisol release, although an ectopic source is also possible.  If cortisol is high but ACTH is normal then there might be an adrenal tumor.  Other tests commonly used include a high-dose dexamethasone suppression test, a corticotropin-releasing hormone test, and sometimes a CT scan or MRI will be conducted in order to detect the presence of a pituitary or adrenal adenoma.

If Cushing’s syndrome is due to a pituitary or adrenal adenoma, then surgery is commonly recommended.  If the pituitary adenoma can’t be identified, then partial surgery of the pituitary gland might be conducted.  If this procedure is performed then hormone replacement therapy is necessary. If someone has an adrenal gland tumor then the affected adrenal gland is usually removed. Sometimes radiation is used to shrink the adenoma.  Prescription drugs might also be used to control cortisol production.

How Can You Test For High Cortisol or Adrenaline?

Many reading this know that I prefer testing the cortisol levels through the saliva.  Although testing cortisol through the blood has some value, I prefer the saliva because it allows you to look at the circadian rhythm  of cortisol, whereas with serum testing you are relying on a single sample, which doesn’t always tell the entire story.  In addition, it’s common for false elevations of cortisol to occur when testing through the blood, and the main reason for this is because cortisol increases during stressful situations, and many people find it stressful to get blood drawn.  You can also test for the urinary cortisol metabolites, although this is something that I personally don’t do in my practice.

With regards to testing for adrenaline, although you can test adrenaline in the blood (along with norepinephrine), urine testing is more commonly used.  Usually a 24-hour urine collection is recommended.  Organic acids is another option, as this measures a metabolite called vanilmandelate, which usually increases when someone has elevated adrenaline levels.  You can also test for genetic polymorphisms of COMT and MAO-A, which help to break down adrenaline.  I’ll discuss these in a little more detail shortly.

How Can You Decrease Cortisol and Adrenaline?

1. Reduce your stress levels.  Since stress causes an increase in cortisol levels, it makes sense to do everything you can to try to reduce the stress levels in your life.  Although I realize that reducing the stress in your life isn’t always possible, what I recommend is to write down all of the major and minor stressors in your life, and  try to determine if you can eliminate some of these stressors.

2. Improve your stress handling skills.  Whether or not you can reduce your stress levels it is a good idea to do things to improve your stress handling skills.  After all, one’s perception of the stressor usually plays a greater role than the stressor itself.  In order to help accomplish this I recommend to incorporate one or more mind-body-medicine techniques such as yoga, meditation, biofeedback, or another technique.  Also consider utilizing acupuncture and massage, as these can also help with high cortisol and adrenaline levels.

3. Nutrients and herbs which lower cortisol.  Some of the nutrients and herbs which can lower cortisol include magnolia and Phellodendron bark (relora) (9) (10), phosphatidylserine (11) (12), and  ashwagandha (13) (14).

4. Nutrients and herbs which lower adrenaline.  GABA is an inhibitory neurotransmitter, and this can decrease adrenaline levels (15). GABA doesn’t seem to cross the blood brain barrier unless if it has a phenyl group attached, although you can also take nutrients and herbs which increase GABA production.  For example, both L-theanine (16) and valerian root can both increase GABA (17) (18).

5. Protect the hippocampus.  I mentioned earlier how prolonged elevations of cortisol can compromise the hippocampus.  Well, there is evidence that the herb Bacopa monniera can help to protect the hippocampus from damage (19) (20) (21).

6. Test for COMT and MAO-A polymorphisms.  Since the enzymes COMT and MAO-A help with the breakdown of adrenaline, if you continue to have chronically elevated adrenaline even after incorporating stress management and taking some of the nutrients I discussed, then you might want to do some testing to see if you have a COMT and/or MAO-A polymorphism.  While you can’t reverse these genetic polymorphisms, you can give nutritional support to help with these defects.

So hopefully you have a better understanding of the impact high cortisol and adrenaline can have on your health, and what you can do to try to lower these.  Some of the symptoms of high cortisol include anxiety, elevated heart rate and blood pressure, heart palpitations, low insulin and blood glucose, headaches, and hot flashes.  High cortisol frequently leads to memory and concentration problems, problems falling and/or staying asleep, depression, and low sex hormones.  Some of the things you can do to reduce cortisol and adrenaline include lowering your stress levels and improving your stress handling skills, and certain nutrients can also help such as relora, phosphatidylserine, ashwagandha, valerian root, and L-theanine.