RHR: The Right and Wrong Way to Treat Hormone Imbalance


This RHR episode is about how to address male and female hormone issues.  This is a question I get a lot, but I realize I haven’t really specifically addressed it either on the blog or in the podcast, so that’s what we’re going to do in this new, shorter podcast format.  Let us know what you think about these new shorter segments in the comments.

In this episode, we cover:

2:55 The right and wrong way to treat hormonal problems
8:48 What you need to know about taking hormones
12:13 5 critical systems every hormone treatment program must address


Full Text Transcript:

Steve Wright:  Hey, everyone.  Welcome to another episode of the Revolution Health Radio Show.  This show is brought to you by ChrisKresser.com.  I’m your host, Steve Wright from SCDlifestyle.com, and with me is integrative medical practitioner and New York Times bestseller, Chris Kresser.  How are you doing, man?

Chris Kresser:  Steve, I’m pretty good.  How are you?

Steve Wright:  I’m bouncing back from a well-deserved cold that I got.

Chris Kresser:  Oh, right.  Yeah.  I recently had one of those that Sylvie brought home from her preschool.  It’s one of the joys of having a young child in preschool.

Steve Wright:  Gotcha.  Yeah, I don’t have that problem yet, but I have the joy of still not understanding the respect I need to give my body with sleep levels and travel and trying to run a business.

Chris Kresser:  Yeah, that’ll do it, too.

Steve Wright:  Well, we’re going to change up the format today and do kind of a shorter segment that’s very focused in.  What’s our topic?

Chris Kresser:  Our topic is how to address male and female hormone issues.  This is a question I get a lot, but I realize I haven’t really specifically addressed it either on the blog or in the podcast, so that’s what we’re going to do today.

Steve Wright:  All right, awesome.  Well, before we get into that, I want to let the listeners know that if they haven’t signed up for ChrisKresser.com membership, well, there are already 99,442 people that have joined, so I think you’re missing out and you should totally hop over there and join in.  And when you do, what Chris has done is he’s gone and aggregated all the content that he’s put together over the last few years including a 30-part email series and all of his best tips and tricks including audio seminars and eBooks on various topics and symptoms and diseases that you might be dealing with.  So if you haven’t signed up yet for ChrisKresser.com membership, definitely head over there and check that out.  There’s going to be some sort of symptom guide or disease guide.  Whatever you’re dealing with, he has something in there for you.  Get that, and that will help you with your health.

Talking about hormones, Chris, before we get into hormones, what kind of breakfast did you eat today?

Chris Kresser:  I had some plantains fried in a little bit of expeller-pressed coconut oil, and I had some bacon and some eggs and some raw sauerkraut, so pretty straight forward this time.

Steve Wright:  Nice.  Very nice.

Chris Kresser:  Good, though.

Steve Wright:  Yeah.  OK, well, let’s kind of set the table.  Most people, I guess, we’re going to assume are eating paleo at this point, and they’re having some hormone issues.  How do we go and begin to correct these or even understand what’s going on with them?

The right and wrong way to treat hormonal problems

Chris Kresser:  This is going to be applicable to anybody regardless of whether they’re eating paleo, but let’s say that a nutrient-dense, real food diet, including paleo, is a great starting place but not necessarily the solution in all cases.  The most important thing that I want to get across as context for this discussion is that there are two different models of endocrinology, which is the branch of medicine that deals with hormone issues.  There’s the replacement model of endocrinology and the functional model of endocrinology.  The replacement model is basically measuring what’s low and replacing it.  So you go to the doctor and they measure your hormones.  Let’s say you have low estrogen and progesterone, and they give you estrogen and progesterone to replace those and bring those levels back up.  That’s the replacement model.  The functional model is different.  It is concerned with determining the underlying cause or source of the problem and addressing it at that level, and then once you do that, the hormones basically take care of themselves because there are basic systems in the body that are required for proper hormone function, and if you make sure those systems are functioning well, then the hormones will usually be in balance and at optimal levels.

An example of this might be low testosterone in men.  The typical approach, again, is if you go to the doctor, they test your testosterone levels, they’re low, and they give your testosterone to bring the levels back up.  But one of the problems with that is what if the cause of the low testosterone symptoms or the symptoms that are being attributed to low testosterone is actually aromatization of testosterone into estrogen?  This is something that’s quite common in men dealing with andropause, which is also known as “manopause,” a much catchier term.  Male menopause, so to speak.  What happens is with insulin resistance, an enzyme called aromatase gets up-regulated and that increases the conversion of testosterone to estrogen, which in men is not a good thing.  So if you take more testosterone in that situation, that could actually just lead to higher levels of estrogen because the testosterone is getting converted into estrogen.  That’s just one example of how this can play out and why it’s so important to focus on the underlying causes rather than just using this replacement model that has become kind of the de facto approach in treating hormone issues in conventional and even in alternative medicine.

Steve Wright:  Are there some groups of people where the replacement model is the right call?  I’m sure you and I are always going to lean towards trying to get to the root cause, but is there merit there for a certain group of people?

Chris Kresser:  Well, let’s put it this way:  Sometimes it’s necessary to replace hormones, but there’s never a case where you would only use the replacement model.  Let’s just say that the functional model is always the best choice, but within the functional model, sometimes replacement is part of the treatment program.  Does that make sense?

Steve Wright:  Totally.

Chris Kresser:  So we’re still addressing the underlying causes to the extent to that’s possible, but in some cases addressing those underlying causes may not be enough to fully address the problem.  A great example of that is in people with Hashimoto’s thyroiditis, an autoimmune thyroid disease that can cause hypothyroidism.  What happens there is the body attacks the thyroid gland and destroys thyroid tissue, and thyroid tissue is where thyroid hormone is produced.  And at least as far as we know, once the thyroid tissue is destroyed, it doesn’t come back, so if you’ve had Hashimoto’s for many years before it was diagnosed and before you took any steps to reverse it, it’s possible that you’ve lost so much thyroid tissue that you don’t any longer have the capacity to produce adequate amounts of thyroid hormone internally.  So in those cases, taking supplemental or replacement thyroid hormone such as Synthroid or Armour or Nature-Throid or any of the “bioidentical” replacements is necessary and beneficial because the benefits of thyroid hormone are so great and thyroid hormone is so universally needed in the body that the benefits of replacing it with medication far outweigh any potential side effects of that medication.  So that’s one example where replacement would be part of any kind of functional plan that involves addressing the underlying causes.

Steve Wright:  Gotcha.  Now, when you’re using some sort of – like, you mentioned testosterone – supplementation, is this true with all hormones, but there are some hormones I know for sure, like testosterone, where when we give them exogenously, say there’s not a tissue damage concern, actually the body will then down-regulate its own internal production, which kind of offsets the purpose, right?

What you need to know about taking hormones

Chris Kresser:  Yeah, and that’s a great point.  That’s exactly one of the risks with taking hormones over a long period of time, as you pointed out, Steve.  The way that the body regulates hormone production is through a process called negative feedback.  We have glands in our brain, particularly the pituitary gland, that monitor levels of hormones in the body, and this is true whether you’re talking about thyroid hormone or estrogen or progesterone or testosterone or whatever.  Let’s say that your thyroid hormone levels are low.  Well, the pituitary as the control tower that monitors these hormones will pick up on that, and it will send out larger amounts of thyroid-stimulating hormone, which then acts on the thyroid to produce more thyroid hormone.  The converse is also true.  If you have high levels of thyroid hormone in your blood, the pituitary will see that and it will send out less thyroid-stimulating hormone in order to make less thyroid hormone because it sees that there’s already too much in the blood.

So what happens when you take exogenous – which just means supplemental from outside of your body – hormones?  Well, the levels of those hormones go up in the bloodstream and then your pituitary gland sees that and it reduces your own internal production of that hormone.  Now, that may not be much of a problem when you’re taking that hormone because the hormone is coming into your body from outside, and even though you’re not making as much, you’re still getting what you need by taking it.  But there’s another problem that happens when you have chronically higher levels of hormone in your blood, which is that the receptors for those hormones get down-regulated.  That means that a given amount of hormone in your blood will actually have a lesser effect because the receptors aren’t sensitive to that hormone anymore.  So you can develop this hormone resistance problem, and I’m sure a lot of women or men who’ve taken supplemental hormones have experienced this.  What happens is the dose that they started on that was effective at first becomes no longer effective as that hormone resistance develops, and they have to continue to take higher and higher doses to get the same effect.  That’s a problem that develops over time.

Let’s just say that there are some cases where hormone replacement is necessary, and at the same time, we want to do everything we can to address the hormone imbalances without using additional hormones if possible.

Steve Wright:  Yeah, I’ve even seen some studies on, like, hydrocortisone where that feedback mechanism happens in days, where it starts to shut down internal cortisol production.

Chris Kresser:  Yeah, and we talked about cortisol resistance on a previous podcast.  It’s really fascinating.  Some of the research suggests that what we’re calling adrenal fatigue syndrome is often not related to high cortisol or low cortisol or even cortisol rhythm problems, but instead it’s more caused by cellular resistance to the hormone cortisol.

Steve Wright:  Yeah, so we have all these feedback loops.  How do you begin to make sense of this for, say, a woman who’s having some PMS issues and some stuff going on?

5 critical systems every hormone treatment program must address

Chris Kresser:  I’m going to break it down.  There are five critical systems that you need to focus on in order to ensure optimal hormone production and balance, and this is true whether you’re male or female and regardless of what the hormone is that we’re talking about.  I’ll name these five systems now, and then we’ll talk about them in a little bit more detail.  The idea is that before you even start to fiddle around with taking hormones, you need to make sure you have these things dialed in.  In some cases, it’s fine to take some additional hormone while you dial in these things, but you should never take hormone without focusing on these things as well.  The systems are blood sugar, adrenals or hypothalamic-pituitary-adrenal axis or HPA axis is two, number three is the gut, number four is detoxification/liver and gallbladder function, and number five is essential fatty acid balance.  Let’s talk about them in a little more detail.

The first is blood sugar regulation.  Now, insulin resistance, which is often a problem with blood sugar issues, affects hormones in several different ways.  Insulin surges can up-regulate aromatase, which I mentioned earlier, and aromatase is an enzyme that converts testosterone into estrogen.  In men, what you often see is a normal or low normal testosterone level but a high estrogen level, and this is commonly seen in andropause or “manopause,” and in order to fix it, you really have to address the insulin and blood sugar issue because the problem isn’t low testosterone, per se, although the symptoms are caused, in a sense, or are reminiscent of low testosterone symptoms.  The problem in this case is insulin resistance.

Now, in women, the way that insulin resistance or high insulin tweaks hormones is that it up-regulates an enzyme called 17,20-lyase, and this increases the production of testosterone and leads to PCOS, which is the number one cause of infertility, and it also causes thinning of the hair or hair loss in the scalp, facial hair growth, weight gain, depression, and a whole bunch of other nasty symptoms.  And as a side note, PCOS, I think, is a more common cause of hair loss in women than hypothyroidism.  Even though when a woman is losing hair the first thing a lot of us will think about is hypothyroidism, often PCOS, increased production of testosterone and/or inflammation are to blame there.  What’s interesting is that not only do testosterone levels go up with insulin resistance in women, but estrogen levels can also go up because 17,20-lyase converts DHEA, which is an adrenal hormone, into the estrogen-testosterone pathway, so all of the hormones in that pathway go up, including estrogen, but testosterone goes up more proportionately, which is why you see the PCOS symptoms.  But estrogen going up suppresses FSH, which is a pituitary hormone that acts on the ovaries, and that suppression of FSH is actually what causes infertility in that particular pattern.

That’s the story with blood sugar, and so taking steps to address blood sugar dysregulation, like eating real food, avoiding flour and sugar and industrial seed oils, adjusting your carbohydrate intake based on your blood sugar response, doing high intensity strength training and not sitting as much, getting enough exercise, making sure you’re getting enough sleep and managing stress – all the things that we normally talk about in terms of addressing blood sugar – are important here, of course.

Steve Wright:  Is there any sort of supplement that could be universally talked about for these people as well?

Chris Kresser:  There are definitely supplements.  Some of the compounds in cruciferous vegetables can help reverse some of the issues that we’ve just discussed here, so upping your cruciferous vegetable intake from a food-based perspective is helpful.  DIM can help in some studies, although in others it doesn’t.  There’s mixed research on it.  It can help reduce the conversion of testosterone into estrogen, and most of the bigger supplement companies, Designs for Health, Pure Encapsulations – the better brands that we’ve talked about – have a formula for dealing with aromatization in men, which is where testosterone gets converted into estrogen, and also dealing with this 17,20-lyase problem in women where testosterone and estrogen production goes up.

The second problem is HPA axis dysregulation, which is also referred to as adrenal fatigue syndrome.  I think this and the next problem we’re going to talk about, the gut, are probably the two biggest issues with hormone imbalance.  Pregnenolone is the mother of all hormones.  It’s the precursor to all of the different adrenal and sex hormones that are produced in the body, and the enzyme that converts cholesterol into pregnenolone – so cholesterol is the precursor to pregnenolone, and that’s why cholesterol is so important in the body.  We’ve talked about this before, and I don’t want to go too far down this tangent, but really low cholesterol can be a problem for hormones because, as I said, cholesterol is the precursor to pregnenolone, and pregnenolone is the mother of all hormones in the body.

Anyway, the enzyme that converts cholesterol to pregnenolone is limited, and it requires a lot of ATP, which is cellular energy.  It’s an energy-intensive process.  That means that the amount of pregnenolone we can make in the body is limited, and there’s something called the pregnenolone steal that I’m sure many of you have heard of, which describes a process where the majority of the pregnenolone that we produce on a daily basis is channeled into cortisol production, and this happens when we’re under a lot of stress because cortisol is one of the hormones that’s involved in the stress response.  So if you’re not sleeping well, you’re not managing your stress, you’ve got a lot of stuff going on in your life, and/or you have gut infections or you’re eating a poor diet or you’re dealing with any kind of chronic illness/injury/pain problem, that’s going to create a stress response in the body, and that in turn will divert pregnenolone into that cortisol pathway, and it takes it away from the DHEA pathway, and the DHEA pathway, if you go down that road, that’s where estrogen and testosterone are produced.  So if you have low DHEA levels on a lab, that’s often a sign of pregnenolone steal, and getting back to the replacement model, if you just give that patient more pregnenolone, it can actually make things worse because it just channels more raw material into that cortisol pathway.

The solution in this case is that you have to decrease stress physiology, so you have to address the underlying causes of the stress, whether it’s a gut infection or poor diet or lack of sleep or emotional/psychological factors.  You have to also address blood sugar issues because that can be a stressor on the body.  Insulin resistance can lead to elevated cortisol levels, and high cortisol levels can lead to insulin resistance.  And of course, you need to do all of the other things that we’ve talked about at length to manage stress, so making sure you’re getting enough sleep, doing some regular stress management, addressing any gut issues or any other chronic health issues that are causing a stress response in the body.

I think this is the thing that’s so hard for all of us to do.  You mentioned it in the beginning of the show, Steve.  It’s something I still struggle with.  Despite the fact that I’m keenly aware of how important it is and I take steps to manage it pretty regularly, it’s still something that I struggle with.  But what I can tell you in doing a lot of testing, treating well over a thousand patients now with these kinds of problems, almost every man or woman with a sex hormone issue, like in women they either have low progesterone and estrogen dominance or excess testosterone or men with low testosterone, I can tell you that virtually every single one of these patients that I’ve treated had an underlying HPA axis issue.  So I can’t emphasize this enough.  You have to address the adrenal side because if your pregnenolone levels are low or they’re getting diverted into cortisol because of stress, you just will not have enough raw material to make the sex hormones, and that can lead to infertility, it can lead to menstrual cycle issues, mood imbalances, low libido – all the classic hormone symptoms.

Steve Wright:  That’s the exact same thing that I’ve seen, and this piece right here seems to be the one complete neglection from the replacement model that seems to torpedo that model the most, in my opinion.

Chris Kresser:  Absolutely, and it’s the hardest thing to change, you know?  I’ve noticed that dietary changes, you know, they’re challenging for people, but a lot of people have an easier time doing that than making the changes to deal with stress management.

The next area of focus is the gut, and again, this is right up there with the HPA axis in terms of its importance.  Impaired gut function can mess with hormones in several different ways, so if you have a parasite or a fungal overgrowth or dysbiosis or leaky gut, that causes inflammation.  Inflammation suppresses the function of the hypothalamus and the pituitary in the brain, which produce the stimulating hormones, and then it also suppresses the function of the adrenals and the ovaries and the gonads in men that produce the actual hormones.  Inflammatory cytokines can also cause hormone resistance, which we talked about just now, where the levels of hormones may be fine but the receptors on the cells aren’t sensitive to those hormones, so you end up getting the same symptoms.  Dysbiosis has been shown to increase the activity of something called beta-glucuronidase, which reverses hormone conjugation in the liver, which means that you get a recirculation of deconjugated hormones like estrogen back into the circulation, and that can cause estrogen dominance.  Dysbiosis also increases the production of certain downstream estrogen metabolites like 4-OH and 16-OH, which are proliferative.  That means that they actually can contribute to breast and prostate cancer, and dysbiosis decreases the production of 2-OH, which is protective against those conditions.  I mean, this is just a tiny sliver of the ways that gut issues can affect hormone production.  We don’t have time to go into all of it, but suffice to say that healing your gut is a really crucial part of addressing hormone problems.

The next or number four issue is proper detoxification.  A while back I wrote a series called Paleo Diet Challenges and Solutions, which is now available as an eBook where I go into some considerable detail on the importance of detoxification, and one of the main things that I was talking about in that series and now eBook is that the liver and gallbladder play an important role in clearing excess hormone from the body.  Defects in hormone detox can cause hormones to be only partially metabolized, and I just gave an example of that with beta-glucuronidase and the recirculation of estrogens back into the blood and how that can cause estrogen dominance.  Partially metabolized hormones compete for receptor sites with active hormones, but when they bind to the receptors, they don’t have the same effect, so they actually block the receptors from the active hormones, and that ends up throwing off proper negative feedback that we talked about before, which is the way that hormones are regulated in the body, and the end result is you get a patient with symptoms of hormone imbalance but relatively normal labs or a patient that’s extremely sensitive to any drugs or supplements.  I’m sure you’ve seen people like this, Steve, where whatever supplement or drug you give them, they just react extremely.

Steve Wright:  Yes.  Yeah, it’s definitely a growing number of people.

Chris Kresser:  A growing issue, right, and there are some genetic mutations that predispose people to that, but those mutations generally won’t be activated epigenetically unless there’s some kind of issue here with impaired detox pathways.  Of course, the key here is to make sure those pathways are functioning well and to reduce the toxic burden that we’re exposed to.  We’re exposed to toxins in food, of course, with the standard American junk food diet, the flour, the seed oils, the excess sugar, the chemicals, preservatives, and things that are increasingly used in processed and industrially refined foods, but there are also environmental toxins like BPA and phthalates and the many other chemical agents that are introduced into our environment every year with very little regulation or concern for safety.  So using natural skincare and cosmetic products, shampoos, soaps, natural home cleaning products – all of this can help reduce the toxic burden and give our detox pathways a little bit of a break.  And then there are a lot of things that we can do to improve detox capacity, like improving our methylation status, improving our glutathione levels, etc., and I talk about that a little bit more in the eBook.

The last concern for hormone balance is fatty acid balance.  Fatty acids are precursors to compounds called prostaglandins, and prostaglandins, in turn, modulate hormone receptor sites and our response to hormones.  We’ve talked in the past, and if you’ve read my book or you’ve been following my blog for any length of time, you know that excess omega-6 fat can lead to a number of different problems, and one of the problems that this can cause is altered hormone receptor function.  Too much omega-6 and not enough omega-3, the long-chain omega-3’s like EPA and DHA, essentially ends up driving the production of prostaglandins that are proinflammatory.  So you have not enough omega-3 and too much omega-6, that leads to an inflammatory environment, but if you get sufficient amounts of omega-3 by eating cold-water fatty fish or taking fish oil, EPA and DHA, that promotes the conversion of the prostaglandins into less inflammatory substances or pathways.  And then EPA and DHA, the longer-chain omega-3’s, also improve insulin sensitivity and glucose tolerance.

What you’ve probably noticed with all five of these systems is they’re important to focus on in their own right, but they all are also interacting with each other.  Blood sugar problems can lead to adrenal and HPA axis issues and vice versa, gut issues can cause adrenal and HPA problems, and having chronic so-called adrenal fatigue can definitely make it more likely that you’re going to have gut issues.  Inflammation from fatty acid imbalance can affect the gut and the adrenals and blood sugar.  It just goes on and on.  If we put these five points on a piece of paper and we just started drawing lines between them, it would become like a big web, and that’s really the point of this show, this particular episode, that these are the five fundamental areas that you need to focus on to maintain proper hormone balance, and any approach you do, whether you’re taking replacement hormones or not, should include this focus.

Steve Wright:  Awesome.  Well, I love laying that content out.  I know that there are going to be a lot of questions in the comment thread because we didn’t dive into each one, and I think that’s going to be the beauty of these short formats, that we can let the listeners sort of ask some follow-up questions here about each one of these five areas and let us know, Chris, if we need to dive into each one in more detail.  Out of all the five, what’s the one that’s being missed the most by practitioners out there that the patients need to really, really educate themselves on?

Chris Kresser:  It’s hard to say because there is some difference from person to person, but I think the HPA axis issue is probably paramount.  But then if we ask what’s the thing that’s being missed most in terms of adrenal stuff, it’s the gut.  So as I said earlier, I’d have to say there’s a tie for first place with the gut and the adrenals.

Steve Wright:  Gotcha.  Awesome.  Well, we’ve kind of hit our limit for this show, so I want to thank everyone for listening.  Chime in in the comments like I said about this kind of a shorter format more in depth.  Let us know what you think about it and what questions you have about this current episode.

Chris Kresser:  All right, thanks for listening, everyone, and talk to you soon!

Like what you’ve read? Sign up for FREE updates delivered to your inbox.

  • I hate spam too. Your email is safe with me.

Comments Join the Conversation

  1. Charmaine says

    When I saw a Naturopath in 2009, I was eating vegan, obese, dealing with migraines and mood swings and general fatigue. Amongst many supplements and a few lifestyle modifications, she recommended seed cycling.

    I am not good at taking things daily, so I never completed the seed cycling protocol properly. I overhauled my diet to be Paleo in 2013 and had tremendous benefit, including reducing BMI, no migraines, less mood swings, but have an increase in androgens (DHEA-s) and a diagnosis of PCOS. I think I began to see PCOS manifesting in 2007 that eventually made me go to the naturopath. Currently I’m prioritizing seafood for balancing omegas while reducing poultry. I’m wondering if seed cycling while I’m increasing my omega 3 would be beneficial. Or perhaps you can post studies debunking seed cycling.

  2. Gina says

    Hello! I need some advice or expertise on hormone pellet therapy and Hashimoto Thyroiditus. Diagnosed with Hashimoto 3 years ago…Levels fluctuate here and there…Just adjusted my synthroid in all 3 years … only 3 times. Seems to be in range at this time. This year in February 2015 I decided to do the estrogen/testosterone pellet therapy (for energy and memory). Everything was going great the first round of pellets. Now the second round not so good. It seems that the estrogen was too much (still climbing after 3 months) so she lowered the pellet this time and kept the same testosterone (levels were starting to taper down on that hormone). Well now my hair is just falling out so bad and just feels so different. It doesn’t fall out in the shower..only when I gently comb through…my sink becomes full of hair (full strands from the root). I take vitamins especially Biotin and use Biotin shampoo. I just had my thyroid levels ran and the Endo says they are in range TSH & T4. I had blood drawn today as I am supposed to go next week for more pellets. I am scared that something is counter acting with these hormones. My doctor doesn’t seem concerned but she is not the one losing tons of hair for the past 6 weeks, she just prescribed some water pill that blocks some andosterone or something. Just for info…..I had a hysterectomy at 29 I am now 43, all these years I was on estrodial by mouth. Please Help

    • Lezlee says

      I’ve been on pellet therapy for 1.5 years. I just don’t have a problem with it. Yes sometimes too much estrogen but it eventually evens out. I also take DIM. I also have Hashimotos thyroiditis. I take Naturthroid for it. I have several clients on pellet therapy and only one lady started losing some hair but it was from not taking her thyroid meds like her doc told her too. Then when she started taking her thyroid every day like her doc prescribed, she stopped losing her hair. There is an ebb and flow to taking bioidentical pellet therapy. It takes about a year to get it right. My OB/GYN was trained with the BioTe company. But Im sure there are nefarious clinics who sell the pellets and are not really trained in this art. And you can always just let the pellets run out and not go back if you don’t like them. You can always tell your doc that you don’t want very much testosterone if you feel that it’s the testosterone that is causing your problems. If you don’t exercise enough and sit around at a desk you are really not using up the testosterone. One of the problems with people doing pellets is that many patients go to several different docs and they get different answers to the blood work. If you have a highly trained doc that has been educated in BHRT, Pellet therapy I would go with what she says. And go get educated yourself. I have been doing BHRT since 2002 (transdermal patch). I never had to take more and more as some professionals believe about BHRT.

  3. Kumar Bandyo says

    Does anyone know of a good functional medicine practitioner in Vancouver, BC that I can refer my clients to? I need someone that specializes in hormone imbalances, thyroid issues, and both male and female issues. Someone with the same treatment philosophy as Chris Kresser or his team.

  4. Raquel says

    Chris and the moderater made a very interesting point of the growing trend of sensitivity of reacting to everything

    I have had this issue for years. It happened after a long bout with life stressors. Even health supplements seem to react funny and make me feel jittery (and or) mentally spacy. I’m sensitive to Even basics like probiotics, multivitamins, herbs, plain ole enzymes, (although I can take ibuprofen without issues which is confusing)

    Either way, I’m just flat out way to sensitive to supplements. But my liver labs are normal, even had one of those ultrasounds and showed normal.

    So… If these genetic mutations can be triggered does that mean the issue will always remain even if you improve detox pathway, methylation, etc?

  5. MO says

    Just curious as I am Hashi. All of my blood work is always normal. Saliva tests I was low on things but no one wants to treat this. My symptoms seem to be getting worse each monthly cycle that I have. My ob wants to do a hysterectomy. My fear is that it is not going to solve my symptoms due to my hashi’s. I get breast tenderness a week before, my blood sugar runs low for about 2-3 weeks. I eat the proper diet for hypoglycemia. My gut goes crazy. My stomach gets so irritated. I just want to feel halfway decent again. Any suggestions? Thanks

  6. Cynthia says

    Hi Chris.
    Your podcast really struck a chord with me. Can you please share the most important tests to get to determine if someone has any of these issues?
    I am a 37 year old female with the following chronic conditions:
    – Alternating constipation and diarrhea, IBS
    – Fatigue, wake after 9 hours of sleep not rested
    – Body Aches, specifically joints
    – Very slow recovery time from sickness
    – Dry Eyes
    – Hyper-mobility
    – PCOS
    – Endometriosis
    – Raynaud’s
    – High Hemoglobin AC1: 5.8
    – MTHFR: two copies of the same mutation identified: A1298C

    Any thoughts or connecting the dots with what could be going on?

  7. Amanda says

    This has to be the best podcast I’ve ever read! I want to print and make all my Drs read it! It’s really hard to find a good dr that understands what leaky gut is! You did a great Job encompassing all the factors and bringing it to a point or a web sort of speak! Thank you!

  8. Andrea says

    In mention of long term hashimotos is there a way (or test) to know how much of your thyroid you have left? I’m confused, as to how one knows if they need supplementation or not, or how far long your hashi’s is

  9. Daniel Borba says

    What constitutes an insulin surge? As a T1 I have to give myself exogenous insulin. Does that mean that when ever I give myself a shot my T-levels drop. Chris I would love to hear your opinion on T1D. There are a lot of us that follow your site. Many also follow Dr. Bernstein and his recommendations for a very low carb diet. After hearing your comments on the potential of an extremely high fat diet causing endotoximia and insulin resistance, I’m curious to know if you would agree with Dr. B’s recommendations for someone with T1D. A lot of us seem to do well on his diet at first but then start developing symptoms of hypothyroid. my experience and many others has been that VLC Paleo worked very well for us until it didn’t.

    • Gi says

      Hi Chris. I have recently been diagnosed with a high prolactin level. Do you know what could cause this imbalance?, and if this imbalance can cause problems?
      Many thanks.

  10. Lezlee White says

    I have been listening to you and Robb Wolf’s podcasts since 2011 and they are great but I have no idea where you get info that if you start taking HRT that you will have to increase dosage. I have been on BHRT since 2002 and have never had to increase the the dosage. I have clients on BHRT and they have never had to increase dosage. In fact I just got tested for pellet therapy and I am at the same dose which works. I understand you and Robb read a lot of research and are pretty smart guys and you may have some pretty good ideas on the reason men and women go into andropause and menopause but according to evolutionary principles, we get old and stop reproducing for a reason and to stop us from reproducing our hormone levels drop. But what I took away from this podcast is that if only we ate a paleo diet, got 8 hours sleep, meditated and balanced this and/or a bunch of other theories on the HPA axis, etcetera, etcetera, that we would not go into menopause. I was one of those women who did all the right things, I was on no drugs, meditated, exercised, slept 8 hours a night and when it happened it was an experience I would never have wished on an enemy. If there is a woman out there that claims she didn’t have a problem with menopause, then she is still making hormones from one of her ovaries. Unless there is a more precise understanding and solution for all of us women and men who find ourselves miserable and not being able to function while doing all the “right things”, I don’t think bashing HRT (or rather BHRT) is a good idea. If you want to be educated by a Functional Medicine Doc (she is also a MD, Internist, and a Geriatric MD) who specializes in BHRT, there is one in San Francisco. Her name is Marsha Nunley. She is in her 60’s which also qualifies her as being experienced.

  11. Sheena says

    Could you be more specific about what you mean by “whatever supplement or drug you give them, they just react extremely.”

  12. Paul says

    The problem with articles like this, which are informative but also utterly confusing, is people come on asking “Chris” questions. Article after article, Chris answers like two questions, then disappears.

    Hey Chris, first, you aren’t a doctor. Why not place yourself as a hobbiest and inform folks that first you research these topics and second, list doctors who can help people.

    It is refreshing to see this type of information, and it’s good to pass along or discuss with others the complexity, but I have noticed a downtrend in comments on your blogs. My guess is people are already frustrated. Why comment if there aren’t answers?

    • Lezlee White says

      There are some websites that do provide a list of Paleo Physicians, like Primal Docs. Thats how I found mine 60 miles away. But I had to pay a price for the appts.
      The confusion and desperation that I see from the comments on this thread, Chris really does not have all the answers. And it would be impossible for him to answer all of the questions here. What bothers me is that people really depend on him for all the answers.

  13. Cheri says

    I have recently been diagnosed with stage 2/3 adrenal fatigue, and the HPA axis issue you lay out in your conversation. This after 2 years of dealing with a variety of issues including autoimmune thyroid after a perfect storm of personal family stress, removal of ovaries, and other physical issues. In the process of trying to find answers, I was also diagnosed with MTHFR. After 2 years of Paleo and 1 year of cerefolin, I sought help locally for answer to serious sleep issues. After the diagnosis of adrenal fatigue, I followed the protocol (pregnenolone drops, Adrenal support formula, etc) that was offered to me for several weeks and the sleep issues only got worsened. I am desperate for help as I’ve not slept in almost 7 weeks without waking every 1 1/2 or so throughout the night. I have searched the internet and don’t know where to turn. Can you suggest someone who could look at the expensive tests I’ve just had done and work with me to find answers?

  14. Susan says

    I’m seeing a functional doctor and she recommends that I start taking Black Cohosh, which I believe is a phytoestrogen containing herb. I’ve never taken estrogen or phyto’s before and I’m hesitant, partially because I don’t know enough about it (or really any of the “natural” hormone therapies) and also because another doctor who I see and trust has cautioned me that there haven’t been enough studies done yet to show that phyto’s are “safe” in terms of causing breast cancer, etc.

    Does Chris have any recommended reading or suggestions on this topic and understanding the benefits, risks, if any, etc?

  15. Iatrogenia says

    Chris, you recommend cruciferous vegetables — don’t these accelerate Hashimoto’s thyoiditis? Or is that a myth?

    What can be done to slow Hashimoto’s?

    • Susan says

      I just listened to the thyroid summit last week and they discussed goiteragenic (sp?) foods, ie cruciferous, vis-a-vis Hashi’s and other autoimmune conditions closely linked to thyroid issues, and I believe what they said was that modest portions were OK, but not to go hog wild and load up on them. I don’t think that Chris is suggesting massive quantities, just including them regularly in your diet.

  16. Mark says


    In A.J. Jacob’s tongue-in-cheek n=1 test of healthy life styles, “Drop Dead Healthy” (A really fun read with some interesting observations), when he was diagnosed with low-T his doctor put him on Clomid – a female fertility drug – to increase his Testosterone. At the time my doctor wanted me to start hormone therapy for my low-T. I suggested Clomid, he enthusiastically supported me. At $30/ month for generic, even though my insurance won’t pay for it (it is not currently approved by the FDA for male therapy) it was worth a try because of all the positive results in Europe. It appears to work by blocking estrogen receptors at the pituitary and hypothalamus which eventually pushes the testicles to create more testosterone. It worked very well for me and I have not really found any negative reports on it. To be fair, I am working on a more root cause approach based on this excellent article and others, but, Clomid might be a viable alternative for replacement therapy when that is indicated. Have you ever looked into Clomid? Thanks for all of your great research and willingness to share it openly, it has made my journey to a healthier lifestyle much easier.


  17. Michele says

    Hello Chris,

    I love this article. I quit grains/gluten/soy/sugar/milk/legumes/junk food and went low carb, high fat, etc. 01-2014 and my bloated stomach and intestinal pain went away immediately. Also lost a quick 10 lbs which I didn’t care about. However, my only problem is this way of life triggered something and I cannot sleep more than 3-4 hours a night and it is dragging me down. I have no symptoms of hypothyroidism unless it’s the sleep issue. I am suspecting adrenals/hormones. My minimum health care sucks and am saving to do testing thru online labs and am going to buy a glucometer at Walmart next month. Your article is very informative. Please look at my list of tests I want to do as I am able and tell me if I am missing anything that can be related to my sleep issue:
    T3, RT3, T4, RT4, TSH
    B12 (and all B’s if possible)
    Female; age 64; 5’4”, 117 lbs, partial hysterectomy age 30, hot flashes since age 40, never had any medications or hormones except I ordered online progesterone cream last week and apply 1/4t once a day starting 2 days ago. Have to use OTC sleep aids (1-1/2) each night (and have for many years) to get that 3-4 hours sleep and lately sometimes 1 mg of melatonin or SLEEP TONIGHT. Tests from 3-2014: TSH 1.44; Free T4 .73; Glucose 92; Chol 232; Trig 80; HDL 84; LDL 132; VLDL 16.0; only high things on blood tests were HGB 16.2 and HCT 48.3 and BASO% 1.5. Did the Walmart A1C $9 kit 5-2014: 5.6% Much thanks. Am looking now to locate your ebooks. Which one might address sleep problems?

    Anyone else have any ideas about my sleep issue, please reply.

    • Susan says

      If you search online for “Chris Kresser sleep article” or “C..K..sleep podcast” you will see several more.

      As a side note, I started using L-theanine 100 mg a few months ago, 3 taken hourly, starting about 3 hours before bedtime. I simultaneously began being more respectful of circadian rythyms, namely, up and outside exercising early in the morning, no computers or bright lights after dark, etc. Also, paying more attention to eat more protein early in the day and more carb at dinner, while still having balanced ancestral meals, and also trying to take certain supplements at the right time of day (ie, vitamin D early and magnesium late, etc). Overall, my ability to get to sleep and stay asleep have improved greatly, probably due to combining all of the above.

      In my experience, weight loss dramatically decreases my need from sleep and skyrockets my energy. Even though I’m not sleepy, so I sleep less, I still feel robbed of sleep. So I’m curious if that change in body mass/composition plays a role? I also wonder if going too low carb does too? Anyone know?

  18. Dr. Shabnam Das Kar says

    Chris, great podcast! I am glad to hear the voice of sanity when so much that goes on in the name of BIHT is not good medicine! You are absolutely right about addressing HPA axis dysfunction & gut first before BIHT. In fact i dont start hormone therapy unless the patient agrees to a proper Functional Medicine approach. ( Some patients come & say they want ONLY hormones!) Are you planning on more on this topic? For example the importance of the right method of measurement of hormone replacement. Zinc , B vitamins ( Estrogen replacement uses up B vitamins) , the right hormone dosage etc. In a hormone discussion i usually start with the Steroid Hormone Synthesis chart ( not the chicken-wire, but a simplified one!)

  19. maria says

    Hi Chris,
    I am wandering what you think about bcp? I came off yasmin after 5 years! it has been 12 months since I stopped and since then I have had acne. What do I need to do to help get my body back in balance and my skin back to normal? I have had blood work, my testosterone was low as well as my cortisol.
    Need your help,
    Thank you.

  20. P Lohse says

    If one has had a hysterectomy, I am guessing that, the functional method can not be used successfully. Is this the case?

  21. Jade says

    I just started supplementing bio-identical progesterone yesterday. I hesitated for months, since going off it every month caused severe migraines, which I suffer from chronically despite paleo diet. What prompted me back on the hormone is that when I did take it, I got no migraines ever for that time of the month. I got frustrated and tired of suffering and now I’m just not going to cycle off it. At least it will tide me through until I can figure out what’s going to stop it. Btw thyroid issues and migraines run in my family. I’ve had migraines for over 25 years, they go worse in my 40s and never was diagnosed with hormone or thyroid issues. I had to self-experiment because I’ve tried a lot of things in that time frame. For me, taking progesterone as a preventive is probably less damaging than all the drugs I take for frequent migraines. Is this a bad idea?

    • Debbie says

      Jade – Check into your sleep patterns for your migraines. I was having 12-15 migraine headaches a month. Changing to a Paleo dropped it down to 6 a month within 30 days. Adding back in bio-identical progesterone and e2/e3/T dropped it to 3 a month. Once I found out I have sleep apnea and got a dental appliance to deal with that, my headaches are now 1 every 3 months. That is manageable.

  22. says

    What a great podcast! It addressed my brother-in-laws testosterone issue (he def has sugar issues), my sister and nieces PCOS (sugar imbalance) and my mother’s sensitivity to medication and supplements (toxic overload and impaired detoxification pathways). These are topics I’ve come to them on before but they weren’t convinced sugar and/or detox had anything to do with their issues. This article explained things simply and concisely. Each is taking supp hormones now (eek!). I’ve shared the link to them in hopes they will have more of an understanding or at least curiosity to look more into a solution to fix the underlying cause(s) of their health issues instead of band-aiding their symptoms with more (toxic) hormones. None of them feel better! Time to try something else! Mahalo!

  23. Jen says

    Hi Chris!

    I super new to you and your website, and so grateful…can you tell me where to find your Ebook on detoxification which you mentioned here in this podcast?

    Thank you!!

  24. says

    Great podcast. I’ve been having issues with extreme agitation whenever I take testosterone, prednisone, or increase my levothyroxine. My docs don’t seem to know why this would happen. My TSH is high. So, they want me to take more levothyroxine. Is this a condition you’ve seen before?

    • Paul says

      Old Guy — that makes sense as prednisone will do that. You likely need a T3, something your body is not getting from the T4 (your thyroid hormone). Your docs are missing something glaring and fundamental. Get some Cytomel (T3). Read about it then blast your docs. Best to u

  25. says

    Great podcast. Admittedly I prefer the longer version. When you say “points that practitioners often miss,” perhaps it’s more helpful to discuss about conventional physicians separately from holistic practitioners.

    I am very curious about measuring omega-3 levels, and if omega-3 levels really means low inflammation (it probably not a direct thing, right?) vs omega-3 and GLA.

    And when you talk about insulin resistance, most people will just refer to the stardard bloodwork that usually include fasting blood sugar and HbA1c and of course they are normal. What are functional ways to decide if this issue should be addressed, in case the standard bloodworks are normal, symptom-wise and lab-wise?

  26. Gene says

    As always, the best analysis available on HPA and hormonal issues comes from Chris Kresser.

    But (sigh), now I’m more confused than ever, Chris.

    Went through an allergic reaction to a Fluoroquinolone antibiotic 2 years ago that caused C-Reactive (>10) and Cytokines to soar. So adrenals went into overdrive for 9 months, unleashing the whole list of Cushing-like symptoms (no Pituitary or Adrenal tumors) as well as a gain of 75 pounds in 10 months without changing diet or exercise. Blood sugar rose (>130 fasting despite Vegan and semi Paleo diet for a year now), Testosterone dropped (<100), DHEA fell (<35).

    Finally after a year, the adrenals gave out, and Cortisol fell to 5) began to rise, as T3 started to be consumed by the high RT3.

    Endos who just follow the “replacement” strategy cause more problems without even considering the Pregnenolone steal or complex interactions Chris mentions. So now they want to supplement with Cortef (for the adrenals), Synthroid (for the Thyroid) DHEA (for the Testosterone), and, if all this fails, Pregnenolone is in the wings. It’s HPA insanity, par excellence.

    But (ugh), now I am more confused than ever and this strategy sounds all wrong based on this interview with Chris. Unfortunately, the interview was big on possible pathway dysfunctions, but not so informative on where one goes from there. So the unanswered question becomes, how do you determine the origin of the dysfunction — what is the chicken and what is the egg in this kind of complex HPA situations?

    Seriously – Is it inflammation, high blood sugar and insulin resistance, faulty HPA receptors, Hypothyroidism, adrenal (Fatigue or episodic Cushings) dysfunction? What do you treat first and what steps do you follow to find out what to treat first (assuming you’ve done the basics like detox and Paelo)? What kind of professional do you contact to outline the steps, since most Endos and PCPs just want to do down and dirty replacement therapy and send you on your way?

    • says

      I would make an appointment with a functional doctor in your area. You can also try to make appointments with Chris (link on his webpage). Good luck to you! I can’t imagine how frustrating and helpless someone could feel in your situation.

  27. Dr. Z says

    I have found the site: NUTRI-SPEC.NET very useful in making sense of the thyroid and it’s sisters. Discerning functional imbalances and treating them for the underlying problems is key. Chris I wish you check this paradigm, I think you would understand and appreciate what Dr. Schenker has to say. Thanx for the site
    Dr. Z

  28. Maciej says

    Thank you Chriss for another great post. I was wondering what do you think about maca root in treating adrenal fatigue? Do you think in the long run it will be more detrimental than beneficial by making the person dependent on the substance and slowly raising tolerance? Or perhaps it could help the person in the beginning to make his adrenals more functional and so this way regain some of his stamina which in consequence would help with furthering the process after one stops using maca anymore?

    • Maciej says

      And one more question regarding the adrenal fatigue. What do you think about the hypothesis that daily cold showers could reset the HPA axis?
      I will be very thankful if you answer those questions.

  29. Andrea S says

    Thank you for this podcast (and all of the amazing work you do!)! It totally hit home. I am working on healing both my HPA and gut (and, although I am post-menopausal in my late 40’s, I suffered infertility with endometriosis and possibly PCOS – although never officially dx’d with PCOS likely bc it was still pretty new in the 90’s). About a year-and-a-half ago, I had a health crisis and was found to be depleted of estrogen, progesterone, and testosterone. I was under significant stress that I wasn’t managing and I wasn’t sleeping AT ALL. I have since started on bio-identicals for all three hormones. My cortisol was kind of all over the place, but there is no doubt about pregnenalone steal!

    I was also taking melatonin for sleep but have recently stopped. I still don’t sleep all that well (wasn’t when on the melatonin either) and am working on the stress management.

    I have eaten a modified Paleo (high quality dairy) for about a year and do not have issues with excess weight. I’m heterozygous for MTHFR mutations so I am cognizant of supporting my detox pathways (although I suspect I could do better with this and hopefully healing will help!).

    My goal is to restore my body’s ability to make my own hormones. But given that I’ve been on bio-identical replacements for quite some time now, how do you suggest I come off of them?

    Thanks in advance!

    • Sue Williams says

      I’m interested in your response to Andrea’s post as well. WE have very similar stories. Loved this article – so informative.

  30. Jonas says


    I enjoyed listening to this pod cast.

    I thinking of get myself tested for Testosterone, Cortisol x4 (day test), DHEA and Melatonin levels.
    Is there any other hormones that could be good to have tested (male).

    What test method do you recommend for testing those hormones? Saliva, urine or blood?
    I have read somewhere that Saliva tests are not reliable.

      • Jonas says

        I have read the saliva testing is only good for cortisol testing, but not things like Estrogen-Testosterone.
        Could anyone please help me understand what is happing?
        The day/days after I have done strength training, I get more aggressive, easily irritated and in a bad mood. I don’t like myself and how I feel. That never happens when I do cardio training.
        Thus anyone have similar problem or can explain what is happening?

  31. James says

    So I’ve been on “bioidentical” testosterone cream for a minute and I’m not thrilled with the results. I have mad problems with my gut and possibly liver (?) which are no doubt the roots of my endocrine imbalances, but my attempts to fix said problems failed when I became dangerously underweight. Is it possible to wean oneself off hormone replacement therapy even after developing resistance? Am I boned? I really don’t want to become unable to produce any testosterone.

    • Chris Kresser says

      Yes, it’s usually possible to titrate off of them. It can be difficult and take a long time if you’ve been on them for years, but if it’s been weeks or months it’s usually not too bad.

      Focusing on the gut/liver will be key.

      • Kristy says

        I was on hormones pellets and let them wear off (Testosterone and Estrogen), with Progesterone cream. I am now very ill and anxiety is through the roof. Doctors can’t figure it out. I recently started bleeding and had a uterine polyp removed and had been put on prometrium for the bleeding before removal of the polyp. I now again have stopped the prometrium and just keep going down hill. Any suggestions? Thank you.

        • Lezlee White says

          There is a reason why females lose the ability to produce hormones. It’s to stop you from reproducing. It is a natural occurance. Paleo does not cure menopause. The reason why some women don’t have a big problem with it is because they are still producing some hormones. If you feel better on BHRT (bioidentical hormone replacement therapy) then continue. Yes women who have stopped producing hormones (menopause) can feel like crap with tons of anxiety. That is because their body stopped making hormones. Quit listening to people who tell you BHRT is dangerous. Pellet therapy is the best way to go. You cannot make your body make hormones again when you go through menopause. You cannot make something out of nothing. You didn’t do anything wrong to cause this problem.

  32. Jessica says

    This article was very timely for me. I seem to be an outlier. I am currently on hormone replacement (estrogen and progesterone) because both of these hormones, along with my FSH and LH were very low. I’ve had secondary amenorrhea for almost 3 years and have been paleo (now more primal) since January 2013 because of other health issues. It is so frustrating because all my other problems have resolved and I feel amazing, but this hormone imbalance continues. I do not seem to fit into any category though that you listed above….my total cholesterol is actually very high (over 350) and cortisol levels are normal. I have always been underweight (BMI about 18), but I eat plenty and have even started gaining some weight. Recently, my blood work shows I have “evidence of insulin resistance” with low fasting insulin and high fructosamine and postprandial glucose index. My glucose and HbA1c were normal. Could the insulin issue be causing hormone disregulation even though my testosterone is normal and I show no signs of PCOS? I just hate taking the hormones especially since I am having some of the negative side effects.

    • Chris Kresser says

      If FSH, LH (and other pituitary hormones like TSH) are low or borderline low, the issue may be hypopituitarism, which is sometimes autoimmune in origin. That’s something to look into.

      Insulin resistance can definitely contribute to hormone dysregulation even in the absence of PCOS.

      • Jessica says

        Thank you for the response. My doctor did say it could be hypopituitarism, but instead of doing any other tests she just put me on hormones because she is worried about my bones. Is there any specific tests you would recommend or types of therapy you are familiar with that I could look into?

      • Maria says

        Could u please explain in detail, more about hypopituitaryism. My holistic doctor has diagnosed me with Central Hypothyroidism… Isn’t that hypopituitaryism?
        I read that 1 out of 80,000 or 1 out of 120,000 people get this. Looks like I am screwed. Please also explain what I can do to help my situation. Many thanks Chris!

Join the Conversation