Cortisol & DHEA

Cortisol and DHEA are two of the most important hormones produced by the adrenal gland. They are considered “stress hormones.” When you are under stress (whether emotional, physical, or psychological), the adrenal glands start producing cortisol and DHEA. Therefore levels of these two hormones will increase. This helps our bodies cope with the stress. However, if the stress become prolonged or chronic, the adrenal glands start to get fatigued, and eventually the hormone levels will start to fall, and we may begin to show physical, emotional, and psychological signs of chronic stress.



Cortisol

Overview

Cortisol, or hydrocortisone, is a natural hormone produced by the adrenal gland, a small gland that sits on top of each kidney. It is the main hormone among a whole family of hormones known as steroid hormones. Some people do not produce enough cortisol to provide for their body’s needs.

The adrenal glands are a major component of the body’s natural defense against stress, including any type of injury (including surgery), infection, or emotional, physical or psychological stress. Repeated stress, infections, or chronic illness can deplete the body’s adrenal reserves, and the ability to produce adequate amounts of cortisol is affected.

Furthermore, adrenal hormone is necessary to maintain adequate blood sugar. People with low adrenal reserve experience rapid drops in blood sugar (hypoglycemia) during stress because there is not enough cortisol to maintain sugar levels. In response, the body starts producing and secreting adrenaline, which raises blood sugar but also causes anxiety. Therefore, people with low adrenal cortisol are more prone to flare-ups of temper, nervousness or shaking, palpitations, irritability, difficulty concentrating, salt cravings, sleep disturbances, fear of situations that are even moderately stressful, and can have panic attacks, fatigue, feel cold, and may have depression.

The adrenal glands also play a key role in reproductive function. Women with low adrenal output can have skipped or irregular menstrual periods, unusual menstrual bleeding, and are at greater risk for miscarriage or infertility. Because of changes in the functions of the ovaries, women can also have increased facial hair or acne.

During infections, the adrenal glands normally increase their output to double or triple the amount of cortisol in the blood to help fight the infection. During a viral infection, adrenal hormone is necessary to suppress inflammation—people with low reserves are more prone to higher fever and body aches. Therefore, people with low adrenal reserve may have increased susceptibility to colds and infections, more prolonged infections, and are more prone to allergies and arthritis.

Like persons with low thyroid function, people with low adrenal reserve benefit from taking cortisol pills to make up for what the body is not producing. The normal average daily production of cortisol is 30-40 mg (milligrams). If you have adrenal insufficiency you may be producing only 15-20 mg per day. Taking an additional 5-20 mg of cortisol a day can support the adrenals and improve health and well-being.

The big misunderstanding is that cortisol is the same as Prednisone (or similar high-strength steroids, such as Medrol). Such medications, while useful in select medical conditions, provide cortisone far in excess of the normal physiologic needs of the body, and long-term use is associated with serious side effects and medical complications, including: high blood pressure, weight gain and bloating, immune suppression, osteoporosis, fungal infections, and a tendency towards diabetes and stomach ulcers. Furthermore, within a short period of time, medications like Prednisone actually can shut down the body’s normal hormone production. These potential side effects have no relationship to low-dose cortisol treatment!

Low-dose treatment with cortisol replaces only what your body is not producing. In fact, even if your cortisol production is normal, an additional 5-20 mg of cortisol will not cause any appreciable side effects. Cortisol is actually 5 times weaker than Prednisone, so 40 mg of Prednisone would be like taking 200 mg of cortisol! Furthermore, unlike Prednisone, cortisol has very short life span in the body. In other words, it gets cleared out of the body before it has a chance to do any harm.

Many patients respond to proposed cortisone treatment by expressing fears about how dangerous it is-- “My mother took it and it gave her ulcers, puffed out her face, and put a hump on her back!“ Be reassured that cortisol is completely different from Prednisone and used very differently.

Can cortisol levels be tested? Yes, but the “normal” laboratory values are so broad that the test often misses people with subtle or moderate adrenal insufficiency. For example, the standard laboratory range for cortisol is 8-22. However, anything under 14 would be considered adrenal insuffiency, in spite of it being in the “normal” range. Because cortisol is so safe, sometimes the best “test” is simply beginning a trial of taking cortisol (based on your symptoms and physical exam, of course).

Cortisol Replacement

Cortisol comes in 5 mg tablets, as a prescription medication known as Cortef. It may also be compounded in a cream by a compounding pharmacy.

Cortisol generally should not be taken in the evening or at bedtime.

Symptoms should improve within 3-4 weeks. If there are no changes in how you feel, then it is unlikely that adrenal insufficiency is the root cause of your symptoms, and the search continues to find the cause.

If you feel a little “too good,“ or if you begin to have trouble falling asleep or feel a little bloated, either the dose of cortisol needs to be decreased to a level that does not produce any side effects, or you do not need the cortisol. Your doctor will determine what the correct course of action to take is. Remember, there are essentially no risks to such a cortisol trial!

Avoid caffeine, or at most have minimal amounts, when taking cortisol. Caffeine raises adrenaline levels, which can overstimulate your body and cause anxiety reactions. Also avoid excess sugar or heavy carbohydrate diets. Both of these raise blood sugar levels rapidly, releasing a surge of the hormone insulin, which subsequently quickly lowers blood sugar and stresses the adrenal system.

It may take several weeks to notice the benefits of cortisol treatment. It is essential to get 8 hours of sleep, because the adrenals generally need that much time to replenish their reserves and “recharge their batteries.“ As you continue eating a proper diet, take the appropriate vitamin and nutritional supplements, get enough sleep, and exercising, you will begin to notice more energy, less fatigue, less anxiety, and a greater ability to tolerate stress.

DHEA

Overview

Dehydroepiandrosterone (DHEA) is the most abundant androgen (male steroid hormone) secreted by the adrenal glands (small hormone producing glands that sit on top of the kidneys), and to a lesser extent, by the ovaries and testes. DHEA can also be converted into other steroid hormones, including testosterone and estrogen. Considerable interest in DHEA has developed in recent years with reports that it may play a role in the aging process. Circulating levels of DHEA peak at age 25 and then steadily decline with age. DHEA levels in 70-year-old individuals tend to be roughly 80 percent lower than those in young adults.

Some researchers consider DHEA a possible anti-aging hormone because DHEA deficiencies in older individuals have been associated with a number of medical conditions including breast cancer, cardiovascular disease, impaired memory and mental function, and osteoporosis. In addition, population-based studies have suggested that people with higher DHEA levels tend to live longer, healthier lives than those with lower levels of DHEA. However, low levels of DHEA being linked to certain diseases does not necessarily mean that DHEA supplements will reduce the risk or improve the outcome of these conditions.

The United States Food and Drug Administration (FDA) removed DHEA supplements from the market in 1985 due to false claims about health benefits. However, since the passing of the US Dietary Supplement Health and Education Act of 1994, DHEA has made its way back on the market and its popularity continues to grow. Despite this growth and attention, support for the health claims, particularly as tested on people, is lacking. Plus, given that DHEA products are sold as dietary supplements, there is no control over their contents or the manufacturing practices of the companies that make the supplements. One independent evaluation found that the amount of DHEA in over the counter products ranged from 0% to 150% of what the content stated on the label.

Uses / Indications

Aging

Given that DHEA levels decline with advancing age, some researchers have investigated whether DHEA supplementation may slow or prevent age-related declines in mental and physical function. Preliminary results from the DHEAge study in France suggest that the hormone may slow bone loss, improve skin health, and enhance sexual drive in aging adults, particularly women older than 70 years of age. Animal studies that have shown a boost in memory for older rats taking DHEA supplements. Results from human studies, however, have been conflicting. Some studies have shown that DHEA improves learning and memory in those with low DHEA levels, but other studies have failed to detect any significant cognitive effects from DHEA supplementation. Further studies are needed to determine whether DHEA supplementation helps prevent or slow medical conditions associated with the aging process.

Adrenal Insufficiency

As mentioned earlier, DHEA is one of the hormones made in the adrenal glands. When the adrenal glands do not make enough hormones, this is called adrenal insufficiency. Women with this condition who were given DHEA supplements reported improved sexuality and sense of well-being (including decreased feelings of depression and anxiety). Only a doctor can determine if you have adrenal insufficiency and if DHEA, along with other hormones, is needed. Adrenal insufficiency can be a medical emergency, particularly when first diagnosed. This is especially the case if your blood pressure is low, which can cause you to experience dizziness or lightheadedness. Another reason to seek medical attention right away in the case of adrenal insufficiency is swelling of the ankles or legs.

Impotence

Studies suggest that DHEA supplementation may help impotent men have and sustain an erection.

Osteoporosis

Studies have shown that DHEA cream applied to the inner thigh may boost bone density in older women.

Anorexia Nervosa

Women with anorexia nervosa are at increased risk for bone fractures and can develop osteoporosis at a younger age than women without eating disorders. It has been observed that adolescents and young adults with anorexia nervosa tend to have low levels of DHEA. Some studies suggest that DHEA may help protect against bone loss in people who are anorexic.

Athletic Performance

Although DHEA supplements are widely used by athletes and body builders to boost muscle mass and burn fat, there is little evidence to support these claims. There are no published studies of the long-term effects of taking DHEA, particularly in the large doses used by athletes. Plus, the building blocks of testosterone, including DHEA, may adversely affect cholesterol in male athletes by lowering HDL ("good") cholesterol.

Lupus

Lupus is an autoimmune disorder. Autoimmune diseases are a group of conditions in which a person's antibodies attack a part of their own body because the immune system believes the body part is foreign. Studies have shown that DHEA helps regulate the immune system and may play a role in the prevention and/or treatment of certain autoimmune diseases.

A recent review of scientific literature found that DHEA supplementation may reduce the need for medications and the frequency of flare-ups, enhance mental function, and boost bone mass in women with lupus. Further studies are needed to determine whether DHEA is safe and effective for both men and women with this condition, however.

HIV

DHEA levels tend to be low in individuals infected with the human immunodeficiency virus (HIV), and these levels decline even further as the disease progresses. In one small study, DHEA supplementation improved mental function in men and women infected with HIV. However, studies have yet to demonstrate whether DHEA supplementation can improve immune function in people with this condition.

Depression

In a preliminary study of individuals with major depression, DHEA significantly improved symptoms of depression compared to placebo. However, results of this study and others conducted to date on DHEA and depression are not conclusive. The potential value of using DHEA for depression, therefore, remains unclear, and the long-term effects of taking this supplement are unknown.

Obesity

The results of studies using DHEA to treat overweight people have been conflicting. While animal studies have found DHEA to be effective in reducing body weight, studies of men and women showed that DHEA produced no change in total body weight, although total body fat and LDL ("bad") cholesterol did improve. These differences may be due to the fact that higher dosages were used in the animal studies than in the human studies (such high doses would cause intolerable side effects in people). Further studies are needed to determine whether DHEA is an effective way to reduce body weight in obese people. Until the safety and effectiveness of DHEA is fully tested, it is best not to use this supplement for weight loss.

Menopause

DHEA has gained some popularity among peri-menopausal women. They often used the supplement to alleviate symptoms of menopause including decreased sex drive, diminished skin tone, and vaginal dryness. In one recent study, DHEA supplements did raise levels of certain hormones in post-menopausal women. However, clinical studies regarding the value of DHEA for improving menopause symptoms have had conflicting results.

Those who believe in the use of DHEA claim that it relieves the menopausal symptoms described above without increasing the risk of breast cancer or cancer of the endometrium (lining to the uterus). The risk of each of these cancers may be increased with regular, prescription hormone replacement therapy. There is no proof, however, that DHEA does not stimulate these cancers as well. Women with breast cancer tend to have low levels of this hormone in their bodies. But replacement may lead to either inhibition or stimulation of growth of breast cancer cells.

Inflammatory Bowel Disease (IBD)

DHEA levels appear to be low in people with ulcerative colitis and Crohn's disease. It is premature to say whether DHEA supplements have any impact, positive or negative, on these two bowel diseases.

Available Forms

Most DHEA supplements are produced in laboratories from diosgenin, a plant sterol extracted from Mexican wild yams. Some extracts from wild yams are marketed as "natural DHEA." Advertisers claim that these "natural" extracts of diosgenin are converted into DHEA by the body. However, it takes several chemical reactions to convert diosgenin into DHEA, and there is no evidence that the body can make this conversion. For this reason, it is best to look for labels that list DHEA rather than diosgenin or wild yam extract. Also, it is important to select products that state it is "pharmaceutical grade."

One way to avoid purchasing a product with contaminated DHEA is to purchase it through a professional healthcare provider or in a custom compounded prescription cream from a pharmacy.

DHEA is available in capsules, chewing gum, drops that are placed under the tongue, and topical creams.

DHEA is a hormone produced in the body and is not obtained through the diet.

Dosing Recommendations

DHEA is not recommended for people under the age of 40, unless DHEA levels are known to be low (<130 mg/dL in women and <180 mg/dL in men).

Pediatric

DHEA supplements should not be used in children.

Adult

Dosages for men and women differ. Men can safely take up to 50 mg/day, but women should generally not take more than 25 mg/day, although up to 50 mg has been used for women with anorexia, adrenal insufficiency, and other medical conditions under medical supervision. DHEA is produced by the body primarily in the morning hours. Taking DHEA in the morning will mimic the natural rhythm of DHEA production. Positive effects have been noted at dosages as low as 5 mg/day and the lower the dose the better.

Precautions

Because of the potential for side effects and interactions with medications, dietary supplements should be taken only under the supervision of a knowledgeable healthcare provider.

DHEA generally is not recommended for people under 40 years of age, unless DHEA levels are known to be low (less than 130 mg/dL in women and less than 180 mg/dL in men). People taking DHEA should have their blood levels monitored every 6 months.

No studies have been conducted on the long-term safety of DHEA.

Because DHEA is a precursor of estrogen and testosterone, patients with cancers affected by hormones (such as breast, prostate, ovarian, and testicular cancer) should talk to their physician before taking DHEA.

High doses of DHEA may inhibit the body's natural ability to make the hormone and also may be toxic to liver cells. At least one case of hepatitis has been reported.

In women (but apparently only negligibly in men) DHEA gets metabolized in small amounts to estrogen and testosterone. Women should be aware of the risk of developing signs of masculinization, such as loss of hair on the head, deepening of the voice, hair growth on the face, weight gain around the waist, or acne. Notify your health care provider if any of these symptoms occur. Other adverse effects that have been reported include high blood pressure and reduced HDL ("good") cholesterol.

The International Olympic Committee and National Football League recently banned the use of DHEA by athletes because its effects are very similar to those of anabolic steroids.

Possible Drug Interactions

If you are currently being treated with any of the following medications, you should not use DHEA without first talking to your healthcare provider.

AZT (Zidovudine)

In a laboratory study, DHEA enhanced the effectiveness of an HIV medication known as AZT. However, scientific studies in humans are needed before DHEA can be used for this purpose in people.

Barbiturates

Animal studies suggest that DHEA may increase the effects of barbiturates, a class of medications often used to treat sleep disorders including butabarbital, mephobarbital, pentobarbital, and phenobarbital. However, scientific studies in humans are needed before it is known whether this same effect occurs in people and whether it is safe for DHEA and barbiturates to be used together.

Cisplatin

An animal study indicates that DHEA may increase the effectiveness of an anti-cancer medication known as cisplatin; further studies are needed to know if this effect applies to people.

Steroids

Laboratory studies suggest that DHEA may increase the effects of prednisolone, a steroid medication used to treat inflammation and other disorders. Additional research is needed to determine if this effect applies to people.

Estrogen

It is possible that DHEA may influence the level of estrogen in the body. For this reason, some women on estrogen replacement therapy may need to adjust their dosage. This should be discussed with your healthcare provider.

Source: Adapted from University of Maryland Medical Center, 2004.