When we think about our approach to any particular patient, there are almost an unlimited number of procedures and tests we can “do” to them. What I hope to do here is to help set a template or at least a way to think about how you want to plan what tests you might think about doing – at least with an initial functional assessment of a patient – or if you want to or need to limit the number of tests you are doing for any number of reasons.
For me, the “money shot”, that is, the place where you get most bang for your buck is taking a closer look at the HPA-T Axis (surprise!). This is where I get to understand a little better the inner workings of my patient – or what makes them tick. Why they act, react, and feel the way they do. The balance of neurotransmitters, hormones, and peptides in the body is central to sleep, energy, mood, emotion, drive, motivation, and a myriad of other fundamental processes.
That is why in the initial workup of the vast majority of patients I include these 5 important tests:
- Comprehensive thyroid panel
- Sex hormone panel (including progesterone, testosterone (free and total), estradiol, estrone, estriol, and SHBG)
- Adrenal panel (4 point salivary cortisol and 2 point DHEA-s)
- Neurotransmitter profile (serotonin, GABA, epinephrine, norepinephrine, dopamine, and glutamate)
- Micronutrient panel
Add to that, depending on the patient, a comprehensive diagnostic stool analysis (CDSA) and/or other functional gut testing such as an intestinal permeability test. These are my “go to” tests from a functional medicine perspective.
Certainly, there are many others like detox panels, heavy metal testing, genetic testing, etc. you can do depending on the patient’s circumstances and history. Most patients already have gone through “standard testing” with their family doctor and can bring those with them. That is, lab tests like the CBC, fasting blood sugar, Hgb A1c, SMAC, etc.
As I have stated above, the five or so tests outlined is “where the action is” for me.
If I can bring the patient back into a more balanced state and address any deficiencies, they will invariably feel better. Which at the end of the day, is pretty much why we do what we do!
Let’s see if we can dissect why I feel this is the case as we “peel the layers of the onion” away to reveal some of the core imbalances that can cause symptoms in our patients. We can start with thyroid.
Many patients come to us with TSH in hand and tell us, “My doctor said my thyroid was fine.” And yet, the patient in front of you is cold (especially extremities), tired, sometimes depressed, constipated, with dry and thinning hair and dry skin, to name a few of the symptoms that go along with sub-clinical hypothyroidism. It is beyond the scope of this blog to go into all the possible reasons for the condition, but we hear that story ALL THE TIME. Which is precisely why we need to be doing a comprehensive thyroid panel so we can ferret out the reasons and help bring our patients back into better thyroid balance. And nothing moves in the body without thyroid! It is truly fundamental in terms of helping everything else. The medical literature tells us that not only can thyroid (particularly T3) help treat depression, but anti-depressants don’t function very well without adequate thyroid hormone. That’s just for starters; there are many, many conditions where having optimal thyroid function is important.
There is a tremendous overlap and inter-connectedness between thyroid function and neurotransmitter release and function. For instance, without adequate thyroid, serotonin levels wane. And it is serotonin that causes TSH to rise. So the systems are intricately and intimately related. It is also the reason why we need to be testing neurotransmitters when we are looking at thyroid and vice versa. How many patients that we see on a daily basis are perhaps sub-clinically hypothyroid because they have inadequate serotonin stores? This is just one example of the interactions and inter-relationships between neurotransmitters and hormonal systems. There are plenty of other examples that could fill several volumes or at least several hours of lectures and webinars.
This is why it is important to get the whole picture on our patients. These systems do not live in separation from one another. They are all related and play off one another. In functional medicine we talk about the “web of interactions”. That is, when you put stress on one area or cause an imbalance in that area, it causes an effect on another system or can affect an entire cascade of events. By being able to see what is happening in the thyroid system and then how neurotransmitter levels, for instance, affect that system, you begin to get a window into the neuroendocrine system that heretofore we have not had.
The same thing is true with sex hormone assessment. We know thyroid hormone is incredibly important in the metabolism and balance of sex hormones. In the same way, we know neurotransmitter levels and function are intimately involved with sex hormones. That is, we know from the medical literature the information on using SSRI’s and SNRI’s as a non-hormonal treatment for menopausal symptoms in women. Those drugs don’t affect the hormonal system, they affect the neurohormonal system. In the same way, we can have an effect on a woman’s hormonal state by adjusting and rebalancing her neurotransmitter levels. Again, there are many, many other examples that are outside the scope and depth of this blog, but neurotransmitter balance does have a significant impact on a person’s hormonal state. For instance, in younger women when their ovaries start to become senescent around age 35-40, we see oftentimes a decrease in their ability to obtain solid and restful sleep. This has been shown to be a result of an overall decrease in the levels and function of progesterone. By lowering the overall level of progesterone, there is a corresponding decrease in the GABA tone of the system through a decrease in the progesterone metabolite allopregnanolone. Allopregnanolone is one of the most potent GABA-A agonists that we are aware of. So as we pull away the progesterone, GABA function wanes and our patients end up with sleep disruptions. So replacing and balancing progesterone and supporting the GABA system through the use of GABA agonists and precursors can help bring balance and health back to the patient – without having to resort to habit-forming medications that can actually cause the brain (and patient) to go into a sleep mode. Those drugs really prevent them from entering into stage 4 sleep – that restorative sleep that we all remember from our childhood – that decreases as we age. . Adding drugs can disrupt those natural rhythms and may actually harm us in the long run.
And again, it is important to really see a comprehensive sex hormone panel – at least initially when you are trying to figure out the treatment path you are going to take with the patient. This also allows you to see the relative values of estrogens on board and see where there may need to be some rebalancing or increased metabolism, etc. Knowing this can help you better understand how and where to supplement, add exercise, and adjust other lifestyle factors such as diet. Harkening back to thyroid, it goes without saying how very important adequate levels and functioning are to the metabolism of estrogens.
Neurotransmitter testing truly has added a piece to the patient puzzle that was missing for me for many years of my early practice. Being able to sit with a patient – particularly one with symptoms of depression, anxiety, other mood issues, fatigue, or poor sleep and show them the results of their neurotransmitter test and how that might be impacting how they feel opened up a whole world of possibilities for support and treatment of my patients. I began to see how hard the body works in order to keep itself in balance or homeostasis with regard to our neurotransmitters. I began to see how strong the interactions and inter-relationships were between the various neurotransmitters. And I saw how I could, with targeted nutritional therapies (TNT), not only move the numbers that were deficient and re-balance those that were running high, but actually then sit back down with the patient and have them tell me how much better they were feeling. And, perhaps most importantly, sitting next to a patient and going over their report with them, I was able to really validate my patients and substantiate how they were feeling. Many patients have turned to me, some with tears in their eyes, and said, “Now I understand why I feel the way I feel! Why hasn’t anyone ever offered this kind of testing to me before?” We have already begun to establish above how important understanding the relationships between neurotransmitters and hormones can be. Having this information really does begin to “flesh out” a much deeper and more thorough understanding of the current state of your patient’s health and helps you much better direct their care.
Remember too, that the initial HPA test is a starting place – along with the other tests and treatments you are working with your patient on — as you begin to assess the patient’s baseline. But this is not the end – by a long shot! You have to keep moving with your patient on the plan you are working on together. Allow retesting of the HPA profile(s) to be your guideposts – your signs guiding you on the path to help your patient get to where they want to go.
You wouldn’t do a TSH and find it to be high, start the patient on thyroid medication and never test them again, right? You want to bring the patient’s thyroid into balance – get them back to homeostasis with regard to their thyroid numbers and symptoms. The same thing holds true for neurotransmitter testing,that is, bringing the patient’s neurotransmitters and hormones back into balance. You can’t assess the patient just one time and then guess where they need to go from then on. You and your patient might get moving down a wrong path and end up where neither of you wanted to go.
Doing an adrenal profile on the patient adds another facet and dimension to your understanding of why your patient is feeling the way they are feeling and helps validate those feelings. Fatigue is such a common symptom that we see. Often times in conventional practice, while there is much to consider in terms of causes and etiologies, once the “bad” stuff has been ruled out, there is often little to do about it – other than offering anti-depressants which usually don’t help, in my experience – particularly if the patient isn’t depressed! Again, I am offering my own clinical experience here, but my years in practice have told me that about 85% of fatigue has it root cause in poor functioning adrenals or a poor functioning thyroid. From an adrenal standpoint at least, this is usually due to the patient getting signals from their body for many years, but not paying any attention to them, or getting those signals and trying to mask them by adding caffeine (which basically is a sucker punch to the adrenal glands) in order to get “more energy” or self-medicating with things like alcohol or marijuana when they are “wired and can’t sleep”. Understanding how the adrenals work, how well they are working in the patient sitting in front of you, and knowing how they interact with the neurotransmitters and other hormones you are assessing begins to give the practitioner a richer and fuller understanding of where the patient stands neurohormonally. As such, this can help that medical provider devise a workable and successful plan with the patient. For instance, when you understand that high levels of cortisol can negatively affect serotonin levels at least 4 different ways, you can deduce why many patients that are “stressed-out” eventually succumb to depression or anxiety. Knowing a patient is running around with high cortisols can also explain why many patients begin to experience “brain fog” and loss of mental acuity and memory during stressful situations. We know that high levels of cortisol actually can cause hippocampal atrophy. The hippocampus is where much of our memory is stored. This is usually a reversible situation with proper care and treatment. However, in children who are still in their formative years, chronic stress or PTSD situations can cause permanent deficits in brain growth and mental development.
The test I usually consider strongly when particularly seeing a new patient is the micronutrient assessment. There are a number of these out there, but I typically use Spectracell. This test is important because it gives you an overall sense about how well the patient is nourished. In addition, there are many vitamin and mineral cofactors that are necessary for proper thyroid function, hormone production and function, and certainly that is true for neurotransmitter production, function, and metabolism. It can give you a fairly good idea about things like magnesium status as well. This is a particularly difficult test to get a meaningful reading on from the plasma. If you see a low serum or plasma magnesium, rest assured, the patient’s magnesium status is definitely needing some support. I’ve found it helpful too when looking at several vitamin families at once. This is particularly true with regard to fat-soluble vitamins. Today we are beginning to look at more things like vitamin D status – even in conventional medicine – we tend to isolate and place these markers into silos. This is to be resisted. When thinking about fat-soluble vitamins, we must think of them together. That is, we have to look at vitamins, A, E, D, and K. They do work in concert and we should try to keep them in balance and fully functional. And, although we rarely see full-blown or severe vitamins deficiencies in Western medicine, we see sub-optimal vitamin/mineral levels all the time. That is just one example of why looking at micronutrients is important.
So these would be my “go to” tests that really help me establish the patient’s neuroendocrine status – particularly with a new patient. That is not to say that testing gut function, heavy metal testing, detoxification assessments, and the like are not important. They most certainly are important and doing those tests or not doing them must be put into the context of the patient’s whole story. You very well may want/need to start looking at gut function or dysbiosis or intestinal permeability first if that is where you and your patient feel looking would yield the most benefit. All of these decisions must be made between the physician and his/her patient.