HPG Axis Sex Hormones and Mental Health

Hey there, everybody, and welcome to this presentation on the hypothalamic pituitary gonadal axis, or the HPG axis and mental health. I'm your host, Dr. Donnellice Snipes. In this presentation, I'm going to give you a very, very superficial overview of the HPG axis, what it is, what it does. Hormones in the HPG axis, such as estrogen, progesterone, testosterone, and dhea, estrogen and their function and impact on neurotransmitters. Then we'll look at the impact of stress and the interaction of the HPA and HPG axes under stress. We'll then move on to looking at insulin. Now, that's not something you thought I was gonna bring up, but insulin is actually directly impacted by your gonadal hormones as well as the HPA axis. And we'll wrap up by talking about intervention strategies that counselor can use to help people modulate their HPA and HPG axes in response to mental health issues. So let's start at the beginning. Your gonadal or your sex hormones impact mood and cognition. Estrogen and testosterone are the ones we most often talk about. But then there's all those others, progesterone and dhea, and some more that we don't even have time to go into today. But all of those impact neurotransmitter levels and your mood and cognition, if you're under stress, if you are having difficulty functioning, are going to trigger that HPA axis and that HPG axis and impact gonadal hormones. So it's a reciprocal interaction. Now, I keep talking about hp. HP stands for hypothalamic pituitary. And we have three HP axes that are all involved in the stress process. We typically talk about the HPA axis or the hypothalamic pituitary adrenal axis. But there's also the hypothalamic pituitary thyroid axis and the hypothalamic pituitary gonadal axis. So to simplify it, think about the hypothalamus and the pituitary gland, like the CEO and the COO of the stress response, which is what we're talking about today. The adrenals in the HPA axis, the thyroid in the HPT axis, and the gonads in the HPG axis are sort of your vice presidents of various departments, and they all need to work together to keep the factory working. The HPG axis has been implicated in the development of psychiatric conditions like mood, anxiety, and even cognitive disorders like Alzheimer's. The HPG Axis controls reproduction, which makes sense. Estrogen, testosterone, progesterone, controlling reproduction. We got that. Development and aging, but it also impacts and is impacted by the HPA axis. It's important to recognize here that as we age, our levels of gonadal hormones change. So as we're talking about the impact of different levels of gonadal hormones, it's important to recognize that people who are in their 50s and 60s, 60s, are maybe even their 40s, because our gonadal hormone levels start to decline, you know, early in life. But they may have a different response or reaction. They may have different monoamine or neurotransmitter levels as a result of having lower gonadal hormone levels. Anyhow, affective disorders or your mood disorders show sex specific differences in prevalence and symptoms, possibly due to differences in the interaction between the HPA and HPG axes in the different biological sexes. Alterations in the HPG axis during important reproductive health events, such as pregnancy and menopause and aging, alter the sensitivity of neurotransmitter symptoms in both sexes. So in women, perimenopause is characterized predominantly by estrogen deficiency. So when people go into menopause, there is an estrogen deficiency. However, another important reproductive period is the postpartum period. In that time frame, there are deficiencies in sex hormones as well as in hypothalamus, pituitary, adrenal axis hormones. So your cortisol and your norepinephrine are actually lower during the postpartum period. So that's kind of interesting. We'll get to why this might be in a minute. In men, during the postpartum period. Yes, men's gonadal hormones and their HPG axis is affected during the postpartum period. During the postpartum period, their testosterone levels drop. They hypothesize that this is an evolutionary development in order to reduce aggression in men so they don't get quite so irritable when the baby cries and increase sympathetic responses to the baby. There's also a theory that a reduction in testosterone immediately after birth encourages the male to stay around and protect the baby instead of seeking to go out and make more of them. Obviously, we don't exactly know why it developed. We do know, however, that testosterone tends to drop during that postpartum period. Cortisol, vasopressin, and prolactin also increase in in men during that postpartum period. Now, remember, cortisol is your main stress hormone, and vasopressin is also involved in the stress response. So it's important to Recognize, stress goes up, testosterone goes down the HPA axis. Your stress response system is a critical endocrine system that orchestrates the stress response. It's the CEO. When under chronic stress, the HPA axis recalibrates. And we've talked about this in multiple other videos, how during chronic stress or in people who have complex ptsd, a lot of times we see the HPA axis turn down its sensitivity. It says, I can't run this hot this long, I can't keep going at this rate. So I need to not pay attention to as much stuff. I need to be less sensitive. So it turns down its sensitivity and it takes more cortisol, more dhea, more of everything in order to get it activated. This is sort of akin to what we see in substance use when there's a development of tolerance to an exogenous substance. So it's kind of interesting. The body responds the same whether it is an overload of hormones that are naturally occurring in the body by naturally occurring processes or by something that we're doing where we're ingesting something. So that's interesting. Anyway, people with mood disorders often exhibit either hyper or hypocortisolemia, which means they either have too much cortisol, the body's still pumping out cortisol, saying, all right, how much cortisol is it going to take to get this stress response system activated? Or hypo, where they don't have enough. Now we've talked about when this HPA axis recalibrates, we go into a situation that I call the Flat and the Furious. When people are not in distress, they're not in extreme distress, they're not like freaked out, then they tend to be flat, flat or have hypocortisolemia, they have low levels of cortisol, excessively low levels of cortisol. And then when they are triggered, when something is significant enough to actually trigger that HPA axis to set off, there's a tsunami of stress hormones and gonadal hormones and everything else in response. So we see the same proportional calibration of the HPG and HPT axes as we see in the HPA axis, which is another reason why under chronic stress, people have been known to develop hypothyroid. Anyhow, gonadal steroids, particularly oxytocin and testosterone, can act in a synergistic MANNER to decrease HPA's gain and, and anxiety related behaviors. So in a functioning system, oxytocin and testosterone may actually help increase the anxiolytic response. And we'll find out in a few minutes. Increase the sensitivity of GABA A receptors. Gonadal hormones affect reproductive organs and also influence several other bodily functions by interacting with major neuroendocrine systems, including thyroid hormones, stress hormones, and the autonomic nervous system. The HPA axis, the stress response system is affected by similar factors as the HPG axis. You can't impact one without impacting all three. Interestingly, and this is another little side note here, alterations in maternal care can produce significant effects on both the HPG and HPA physiology of the infant as well as behavior in the offspring at adulthood. So stress, basically, alterations in maternal care that produce chronic stress in the infant can cause long lasting brain changes. So let's talk about some of these HPG hormones for a minute. Estrogen. What does estrogen do? Believe it or not, it increases muscle mass. It regulates fat distribution. It can be anti inflammatory. It mediates the formation of secondary sex characteristics in females. It regulates energy expenditure. It helps maintain bone density. It improves blood coagulation or clotting. It helps maintain healthy cholesterol levels. Your gonadal hormones are actually made from your gonadal steroid hormones are actually made from cholesterol. So it's important to have some cholesterol, healthy cholesterol in your diet in order to make sure that you are supporting your HPG axis. Estrogen also assists with fluid balance. And we know this when we see fluctuations in estrogen levels. We can see water retention during certain times of the monthly cycle. It also promotes lung function and sexual behavior. So that's another lung functions kind of out in left field. But they have found that adequate levels of estrogen can be protective of lung function. And there were some studies on hormone levels, gonadal hormone levels, and the impact of lung related viruses that recently came out. Estrogen also increases serotonin and serotonin receptors in the brain. Estrogen modulates higher order cognitive processes driven by dopamine, such as learning, reward processing, working memory and impulse control. Now it's important to remember that just like most anything else in our body, too much is bad, not enough is bad. So we want to go with this Goldilocks principle where it's just right. Too much estrogen can actually promote feelings of anxiety. Too little estrogen can promote feelings of depression. So we want that Goldilocks. We want it in that sweet spot for neuroprotection and modulation of cognitive processes. Testosterone. Now remember that men do have a certain amount of estrogen. And testosterone actually can be broken down into estrogen, which is kind of Interesting, but I digress. Testosterone itself in its raw form, regulates sex drive or libido fat distribution as well bone and muscle mass. It improves the insulin response. It too is anti inflammatory. It helps with strength, production of red blood cells, production of sperm, and as I said, can be converted to estrogen. It too enhances cognition and increases dopamine, serotonin and even gaba, which is your natural anti anxiety neurotransmitter. So testosterone and estrogen have very similar functions. Testosterone tends to be dominant in the male sex and estrogen tends to be more prominent compared to testosterone in the female sex. But both sexes have estrogen and testosterone. The effects of testosterone on the brain are often controlled by intracellular conversion of testosterone to estradiol. Estradiol, which is a form of estrogen. The presence of enzymes that convert testosterone to estrogen in stress regulated brain regions raises questions regarding the classical view of estrogen modulation of the HPA axis. Now, a lot of times up until recently, we've thought that estrogen does a lot of the heavy lifting in the HPA axis, but they're now starting to see, well, if testosterone can be converted to various, broken down into various forms, including estrogen. Maybe testosterone levels are at the core. Maybe we weren't going back far enough in trying to figure out what was regulating the HPA axis. Testosterone in males may work through the estrogen receptors since it can be converted to 3 beta diol and thereby act through estrogen receptor beta to reduce the gain in the HPA axis. So when testosterone is broken down into 3 beta diol, which is a metabolite of the androgens, it can act on the estrogen receptor beta, which is kind of interesting. We've talked about estrogen, we've talked about testosterone. Now let's talk about progesterone. Progesterone receptors are found in the hypothalamus as well as the hippocampus cortex and the amygdala. Now remember, the amygdala is the fear processing area of our brain. Progesterone influences the central nervous system in both sexes through interaction with multiple multiple neurotransmitter receptors, including glutamate, GABA A and your nicotinic receptors. So progesterone actually acts on some of those nicotinic receptors, which can help you understand to a certain extent some of the mood effects of nicotine on the body. But it is interesting to know. Note how dispersed the progesterone receptors are and the fact that they are in the amygdala and progesterone is the precursor of cortisol. Who knew? Well, you do now. So people have to have progesterone in order to make adequate levels of cortisol. Your main stress hormone, progesterone is increased in response to stress because guess what, it needs to be broken down to make cortisol to be released when the HPA axis or your stress response system is activated. Low progesterone can cause low cortisol or hypocortisolism, which is another reason we need to look at this. Hypocortisolism has a lot of symptoms of depression. Now, people with depression can have hypocortisolism and other things going on, but people with hypocortisolism may develop depressive symptoms. And when that. When those hormone systems are brought back into balance, their mood symptoms may rapidly dissipate. Progesterone has an anxiolytic properties thought to modulate the stress response. So, yes, progesterone is broken down to make cortisol, but it also impacts the GABA receptors and may help modulate the stress response. So it may be involved kind of in both sides of the response. Under chronic stress, reduced levels of cortisol and progesterone leaves estrogen to dominate. So when we're under chronic stress, remember that HPA axis is turned way down, so our stress response system is turned way down. So cortisol is not being recruited nearly as often or in significant amounts. Therefore, progesterone is not being recruited nearly as often. So you have lower levels of cortisol and progesterone. So estrogen just can just kind of run wild, which can lead to mood swings, increased anxiety, weight gain, hair loss, sleep disruption, and memory and cognitive disruption. DHEA is another hormone that we're going to talk about, and it is a steroid hormone produced in the adrenal glands. It assists in the creation of androgen, like testosterone and estrogen, sex steroids, both in the gonads and in various other tissues. DHEA is stimulatory. When people take dhea, it tends to increase their libido. You know, it increases the production of some of those androgens. And it also tends to have an anxiety producing effect on a lot of people. And this can be related to the fact that it may stimulate the production of cortisol. DHE elevation by itself produces stimulatory effects and can exaggerate glucocorticoid resistance. If people are taking DHEA or have too much dhea, just like cortisol stimulates the stress Response. DHEA can also stimulate the system and cause it to further turn down and its sensitivity, if you will, so it becomes even more resistant. Glucocorticoid resistance leads to increased secretion. When somebody is resistant to glucocorticoids, when they've turned down that system sensitivity, then it takes more cortisol, more DHEA in order to get that system to activate. So we see, that's when we start to see the tsunami build. There is a reciprocal relationship between the HPG and the HPA axes. Both testosterone and estrogen modulate the response of the HPA axis or the stress response system. But when activation is chronic, it has an inhibitory effect upon estrogen and testosterone secretion, until which point glucocorticoid resistance develops. These things work in concert one another to maintain balance and to maintain the integrity of the system. Excess stress leads to hypothyroid and glucocorticoid resistance, which are both symptoms of HPA axis dysregulation. So, so when somebody is under too much stress for too long and they start to have that HPA axis recalibration, if you will, then it impacts the thyroid levels. Thyroid levels often go down. And because the person has been so stressed for so long and there's been so much cortisol in the system for so long, they've developed glucocorticoid resistance. The tissues almost are unresponsive. It doesn't get the same response to cortisol as it did, you know, when cortisol was only mildly there and when the system was not constantly activated. Glucocorticoid resistant subjects have higher free floating cortisol. Well, it makes sense. It takes more cortisol to trigger the receptors so they can have more in their system and it's really not doing anything. So they can have more cortisol floating around, they can feel more stressed, but they just aren't getting the stress response, they're not getting the energy. Stress induced elevations of cortisol and reductions in the neuroprotective hormones dhea, estrogen and testosterone can enhance oxidative stress. Now we've talked about oxidative stress in other videos. That, that is the, those are sort of the byproducts. That's the garbage, if you will, that is produced when the system functions. But when the system is functioning at a high rate because it's under stress, you know, it's ramping up production, then it's going to produce more garbage. The body is not able to get rid of that Garbage at that enhanced rate. So oxidative stress is when the garbage starts building up, the free radicals start building up in the body and causing stress on the body. Oxidative stress plays a central role in the development of many different disorders, including polycystic ovarian syndrome. So we've got stress again, that actually is implicated, directly implicated in the development of a gonadal based dysfunction, polycystic ovarian syndrome, diabetes, neurocognitive and neuropsychiatric disorders, including anxiety disorders and depression. So oxidative stress is a bugger. Oxidative stress cannot exist if the system is functioning well, if the HPA axis is calibrated and the HPG axis is calibrated. Now again, remember, the HPG axis alters as we age. So as we get older, as we get out of that reproductive cycle, our sex hormones, our gonadal hormones tend to decrease. And it's important to recognize that because that will have a direct influence on the HPA axis. I am not necessarily advocating for hormone replacement therapy or anything, but it is important to recognize that you cannot have a change in the HPG axis without similarly influencing the HPA axis and the HPA or the thyroid axis. Studies investigating the interaction between HPA and HPG axes have found consistent suppression of the HPA axis by androgens, which are your male sex hormones and the HPA system, hyperactivation in depression like behavior. Okay, so let's break that down for a second. There's when male sex hormones are high, when your androgens are high, like testosterone is high, HPA axis can be suppressed. When people are depressed, then you have the HPA axis hyperactive, which means testosterone may go up. So it's kind of interesting. A pathway of testosterone metabolite that might explain this is that instead of testosterone being metabolized into 3 beta diol, it might be metabolized into 3 alpha diol, which is an upregulator of GABA A receptors, which produces sedative and anxiolytic effects. So it's possible that in a normally functioning system, when the HPA axis is activated, there can be a feedback loop in which testosterone is actually converted to a metabolite that will promote relaxation and down regulating of that HPA axis at the appropriate time. Chronic stress in adulthood mediates HPG activity in women. Stress activates a sympathetic neural pathway originating in the hypothalamus, which releases norepinephrine, which is one of our stress hormones. Energy hormones focus hormones into the ovary, which produces non cyclic anovulatory ovary that develops cysts. So it produces basically a non functioning ovary that's not ovulating. So it develops those cysts. So it's interesting to note it note that chronic stress contributes to norepinephrine alterations and secretion into the ovary. And the ovary says, you know what, it's not a good time to ovulate right now because there's too much stress out there, so we ain't going to do it. And that throws the whole system into chaos. Glucocorticoid resistance was found in more than 50% of patients with PCOS. And that's important to recognize because that indicates that's one of the ways they found the connection between chronic stress. Chronic stress produces glucocorticoid resistance. Glucocorticoid resistance is associated with pcos. And then they started looking at, you know, why is that? Why do we see this, this occurrence? People with PCOS exhibit symptoms of depression, facial hair, hair loss and oily skin. A lot of people with PCOS also have because of depression and the implicate interaction with the HPT or thyroid axis. They also have weight gain. If you have a patient and the most notable symptom of PCOS is severely thinning hair and facial hair in someone who is biologically female and not undergoing hormone therapy. And if you see that it's important, it is vital to refer them to an endocrinologist who can help them examine what they may be able to do to deal with that. Because PCOS is debilitating on many fronts. And yes, as clinicians, we can help them learn how to regulate their stress response as much as possible. But they may also need medical intervention in order to get the system back calibrated and head on their way to feeling better. And that also means they may not have adequate symptom remission from their depressive symptoms unless they also see an endocrinologist. Hormones are among the major physiological regulators for brain development. Therefore, any dysfunction of the endocrine system is implicated in the onset or progression of neurocognitive issues. Neurocognitive disorder development. This is your dementia. Your Alzheimer's involves progressive dysregulation of both the HPA and HPG axes. That's really interesting to note that they've followed people who have had progressive dementia or Parkinson's disease, or Alzheimer's disease, other neurocognitive issues, and they found that as the disease progresses, there's also progressive alterations or dysregulation of the HP axes. HPA axis dysfunction contributes to cognitive decline through reciprocal dysregulation of the HPG axis, causing reductions in neuroprotective gonadal hormones like testosterone and estrogen. Additionally, gonadotropins, which are regulated by the HPG axis, have also been associated with cognitive decline. People with cognitive dysfunction often have a high concentration of glucocorticoids, cortisol, resulting in the extensive loss of neurons. We've talked about this in videos on the impact of trauma on the brain. But when cortisol is high, when glutamate is high, when the HPA axis is really in full fledged activation, it can have neurotoxic effects, especially if it is maintained for too long. Excessive stress kills prunes back neurons. We know this. It results in structural changes in the brain and loss of weight or brain matter. In certain regions, men and women with Alzheimer's disease, anxiety, depression and other neurocognitive issues have lower levels of testosterone and estrogen and than those without neurocognitive or mental health issues. They found so frequently the correlation between neurocognitive and mood issues and disruption in or imbalance in gonadal hormones that it should be a matter of course. When we see someone for counseling, we need to ask them, when was your last physical? When was your last set of blood work done? Because no amount of talk therapy is going to fully alter gonadal hormone levels, for example. And there are a lot of things besides just stress that can cause alterations in thyroid hormones and gonadal hormones. So it's not hard for people to get a physical and get their annual blood work done. Chronic activation of the HPA axis, the threat response system, contributes to alterations in the HPG axis, including reductions in testosterone and estrogen. Now, interestingly here, insulin resistance and diabetes are highly correlated with with reductions in testosterone and estrogen. Who knew? Well, let's think about it a little bit. When the HPA axis is activated, it releases cortisol and glutamate and it triggers the liver to release blood glucose. You need energy for the fight or flight response. So if your body is constantly under a state of stress and constantly releasing glucose for the fight or flight response, then guess what? Just like the body becomes tolerant to alcohol or tolerant to cortisol, it's going to become tolerant or resistant to insulin. So we see the same sort of process at work here. People under chronic stress and tend to develop more insulin resistance and some can go on to develop diabetes. We also recognize that because testosterone and estrogen have stress Mediating effects. And because there is the interaction between the HPA and HPG axis, that testosterone and estrogen may have initially caused the stress response or may have gotten thrown out of whack as a result of the stress response. But we need to recognize that they are also likely out of balance in people with diabetes and insulin resistance, and that can be contributing to mood issues as well as cognitive dysfunction. The presence of functional insulin receptors in the hippocampus and cerebral cortex is necessary for cognitive functioning and regulates glutaminergic and GABAergic transmission. In order for glutamate, our stress hormone, and GABA, our relaxation hormone, 2 to function, it requires the presence of functioning non resistant insulin receptors in certain parts of the brain. So if the insulin receptors have become resistant, then glutamate and GABA have difficulty doing their job. Any imbalance in insulin thus may lead to neuronal dysfunction, resulting in memory impairment. Insulin also affects the HPG axis and insulin changes in diabetes and obesity can impact the HPG axis. Dysregulated insulin signaling, impaired glucose uptake, and insulin resistance are some of the prime factors in the onset or progression of many neurocognitive issues. Oh, okay. So we talked earlier about the fact that there's a correlation between gonadal hormone imbalances and the onset of neurocognitive issues. Now, we're also recognizing that there is an impact of insulin problems on the development of neurocognitive issues. And we know that gonadal hormones impact insulin effectiveness. So you see how it is not linear. There's a matrix here. When one part of the system goes fluid, it impacts the entire system. In males, testosterone increases with acute bouts of exercise, with evidence of lower testosterone in endurance athletes. They hypothesized this might be due to the restricted energy availability, which negatively affects hormone levels. So when there's not enough insulin or when insulin receptors are not working well, then we may see reduced gonadal hormone levels in females. Decreased energy availability over an extended period inhibits the HPG axis, leading to menstrual irregularities and lower bone density. We see this a lot in really thin athletes and people who are who have anorexia, where the reduction in energy intake, the energy deficit they're constantly at, causes their HPG axis to say there must be a famine, therefore not a time to reproduce. So we start having seeing menstrual irregularities, lower bone density, lower lowering of the HPG hormones. And another little interesting side point. It didn't fit nicely anywhere in here, but it was I thought it was interesting since so many people are do take opioids at a certain point. Opioid use of greater than three months can also dysregulate the HPG axis, resulting in hypogonadismadism. Now, most people are not going to be on opioids for greater than three months. But for those people with chronic pain, those people being maintained on methadone or suboxone, this is important because being maintained on those medications is going to likely reduce gonadal hormones, which is going to impact the neurotransmitter levels and that will impact their mood and their cognition. So what do we do? As counselors, social workers, pastors, we aren't in a position to be prescribing. However, anything we can do to help regulate the HP axes, plural will be helpful to regulate mood symptoms. And if we help regulate the HPA axis, the stress response system or the threat response system, it's going to have positive effects on the HPG and HPT axes. So as counselors, we do have a role. We can educate people about sleep hygiene and help them improve their sleep. Sleep deficiencies Sleep disruptions are significantly implicated in hyperactivation of the HPA axis, which is going to activate the HPG axis. Nutritional improvement is important to help clear out oxidative stress. So eating those colorful foods, fruits and veggies and making sure to get enough good cholesterol is important in modulating the system as well as water. Water helps wash out, flush out the toxins, helps get some of those free radicals out of the system. Stimulant reduction is also important whether it is caffeine or nicotine. Any stimulant that you're taking is triggering that HPA axis and impacting the HPG axis and impacting your gonadal hormone levels. Likewise, pain management important. When we are in pain, it triggers our stress response. Being in pain can be stressful. So managing pain to reduce our stress response, especially for people with chronic pain who just who can't get rid of it, altering the reaction Altering the stress response to pain can be really important to prevent glucocorticoid resistance, HPA axis dysregulation and sequential HPG axis dysregulation hormone balance. And I mentioned this a minute ago, we are not going to do this because we're not prescribers, we're not endocrinologists. But it is important that we educate people about the importance of, of getting their annual blood test, at the very least in order to make sure that their thyroid and gonadal hormones are in the quote, appropriate range and that they have a frank conversation with their doctor. And ideally they'll monitor on their own. You know, each time they get their blood tests, they monitor how their mood is doing. So then the next year, if they go back and they get their blood test and their levels are lower, and guess what, their mood is lower and their energy is, is lower, they can say, hey doc, there seems to be a correlation here. We also want to help people not only avoid distress, but promote feelings of physical relaxation. Regulating that nervous system can be very important, prompting the release of gaba and those relaxation neurochemicals. Yoga and Tai chi can be very helpful active methods of doing this. Meditation is exceptionally helpful. But even square breathing can be helpful. And what I mean by square breathing is breathing in for four, holding for four, exhaling for four and then holding for four. So it's a, a 16 count ultimately for your breath. But when you slow your breathing like that, it triggers what they call the rest and digest response. So you're sort of manually overriding and forcing the down regulation of that stress response. Affective. Ideally, we want to reduce unnecessary dysphoric emotions. Now anxiety, anger, depression, all of the feelings that we feel have a purpose. They're designed to kind of tap us on the shoulder and go, hey, there might be a problem here, There might be something you need to be, need to address. It doesn't mean there is a problem, it means there might be. And then our body responds by giving us the energy. In the case of anxiety and anger to, to get up and figure out, is there something I need to address and if so, what do I do with it? Holding on to anger, nurturing it, stewing in guilt and resentment. All that does is bathe your brain in stress hormones, cause neuron loss, prune back neurons, alter your sex hormones. So there's, you know, libido tends to be lower, there tends to be more mood issues, and even things like bone density tend to go down. So there's a lot of physiological reasons that people may not want to stew on negative emotions and may want to start developing tools to figure out, all right, how do I manage these feelings? As I mentioned under physical, promoting feelings of relaxation are important. Mindfulness and meditation can be super helpful. Now I mentioned meditation earlier and square breathing, mindfulness is useful, especially non judgmental awareness of the present. That means I'm not going to get upset with myself, I'm not going to feel guilty, I'm not going to should myself about something I am just going to be mindfully aware of the present moment and figure out, okay, this is how I feel right now. It is what it is. If I don't want to continue feeling this way, how do I improve the next moment? But mindfulness makes us more aware of distress when it's down here at a 2 or a 3 instead of ignoring it until we can't possibly ignore it anymore because it is a 8 or a 9. And laughter, they've actually found that laughter reduces stress, releases endorphins, increases oxygenation. Find something to laugh at or laugh with if it's a comedian, if it's funny, animal videos, whatever it is that helps you laugh. A good few minutes of laughing every day has been shown to also increase immunity and balance out all kinds of hormones. Cognitively, we can help people learn distress tolerance skills. And I usually use the mnemonic tags thoughts that are distress tolerant where the person is saying okay, this sucks and I can get through it instead of telling themselves that they cannot tolerate the distress and it's going to absolutely consume them. So thoughts that are encouraging and distress tolerant activities that can help the person tolerate the distress and maybe even distract from from what's going on for a minute. I'm not saying avoid it completely and forever. I'm saying turn your attention away from it for a few minutes until you can downregulate your stress response and get into your wise mind. That can be going on a walk, that can be doing push ups, that can be reading a book or listening to music, whatever it is. G stands for guided imagery. Guided imagery can help people go to a safer place or a happier place, or even visualize themselves successfully handling whatever the issue is, but that can help down regulate that stress response. And S is sensory sights, smells and sounds that can either trigger the relaxation response, like pictures that make you happy or comedians that make you laugh or aromatherapy, chamomile, lavender, something that triggers a relaxation response. Or sometimes I've talked to people who have said no actually for sensory I like something that is jolting. You know, I'd rather have a smell like rotten eggs that, you know, shocks me for a second and that helps me get into a different mindset. So whatever works for you. But tags thoughts that are distress tolerant activities. Guided imagery and sensations help people increase awareness of their cognitive distortions and their biases like all or none thinking, mind reading, exaggeration, personalization, and I do have videos on those as well increase their positive attitude and appraisals. Hardiness and dialectics are two ways to do this. Hardiness is characterized by the three Cs commitment, control, and challenge. You start out by identifying all the people, things and experiences in your life that are important to which you're committed. Control focusing on the things in your life that you can control, and viewing things that hardships as challenges instead of as barriers. When you become more aware of all of the things that you're committed to, it's easier to see that, okay, well, this one thing right here is going really crappy. And I have these other things in my life that are important and that are adding meaning and richness and helping me, you know, feel happy. Dialectics means embracing the good with the bad. And I usually use the example of we have animals, we live on a farm, and keeping our house dust and dander free is darn near impossible. Cleaning our house is kind of like brushing your teeth and eating Oreos at the same time. Is it frustrating sometimes? Yeah, occasionally. But I wouldn't trade my animals for the world. So I embrace the good with the bad. Yeah, they can be smelly and they have a lot of dust and dander and they bring immense amounts of happiness to my life. We can also help people improve problem solving. That's pretty self explanatory. Environmentally encourage people to reduce their stress by addressing their environment. They need to feel safe and empowered in their environment. They need to see things in their environment that make them smile, that make them feel happy or relaxed, even if they can't do it in their whole house, where they have a little oasis, a corner, a room that is theirs, that is clean, that is, you know, smells how they want it to smell, what have you sounds. And this can be increasing positive sounds or reducing sounds because they just need some quiet. Reducing sounds when they sleep is also important. They found that people who live near wind farms, where the wind turbines are going all the time, and people who live in big cities where there's constantly, you know, car traffic, noise and stuff, have much higher levels of mood disorders than people who live way out in the country. So making sure that there are times where the person feels relaxed, where they're not being bombarded with horns honking or trains going by or this or that, and making sure that at night they have quiet and smells, smells are strongest memory trigger. Encouraging people to add smells into their environment. It doesn't have to be aromatherapy, just smells into their environment that make them feel happy or trigger happy memories. Aromatherapy can be used. Bergamot, lavender, rose and rose geranium have all been found to Increase feelings of contentment, if you will. Some say happiness, but it's not like super excitability. However, some of them may increase estrogen levels. So if you've already got high estrogen levels, you may smell these essential oils and think, oh no, that's not for me. That's your body saying I've got enough of that already, thank you very much. It's also important to help people reflect on their finances and housing, our base level of needs. We need food, shelter and a place to raise young as, as the, as the saying goes. And it's important to recognize that if we are not feeling safe in our housing or we don't know whether we're going to have a roof over our head or having a hard time getting enough money to afford food, that is going to add stress. So this is something. It's more of a case management issue, but it's still something we need to help people make sure they're meeting. Because if they don't get adequate sleep and because they don't have adequate housing, if they don't get adequate nutrition, then they're not going to be able to balance their make the neurotransmitters they need to balance their mood and they're going to hyperactivate their stress response system and throw their gonadal hypothalamic pituitary gonadal response system out of whack as well, which will have all kinds of cascade effects. Finally, relationally help them improve their supportive relationships, enhance their interpersonal skills like communication skills and boundary setting so again they feel safe and they don't feel threatened or intimidated when they're around other people and help them develop self esteem. Gonadal hormones play a key role in the regulation of the HPA axis by influencing the response and sensitivity to releasing factors, neurotransmitters and hormones. Gonadal steroids help orchestrate the activity or the gain of the HPA axis and help fine tune the levels of stress hormones in general circulation to increase survival and reproductive success. The HPA and HPG axes work together to fine tune each other, thereby integrating environmental, psychological, reproductive and genetic factors. So if the HPA axis is super activated, then the HPG axis is going to say not the time to reproduce probably. Gonadal hormones decrease as we age in response to stress and even due to some medications or diabetes. Just because your gonadal hormones were fine three years ago doesn't necessarily mean they're in balance now. The HPA and HPG axes both impact the stress response, chronic Stress causes dysfunction in the HPA and HPG axes. Gonadal hormones alter levels and the sensitivity of the receptors for dopamine, serotonin, gaba. So if we're altering, you know, we have stress that alters the HPG axis, which alters your gonadal hormones, which is going to alter the sensitivity of your neurotransmitter receptors. We need to understand that it's all intertwined in that matrix. People need to be educated about the impact of stress and cortisol on the HPA axis, the HPG axis, and as a result, their mood and their energy level. Stress impacts everything. The impact of hormonal imbalances on stress tolerance, mood, and cognition is another thing a lot of people may sort of take for granted. But it's important to recognize. And people with premenstrual dysphoric disorder, for example, are acutely aware of how hormone fluctuations impact their ability to tolerate stress and think clearly and their mood. We also just in general, want to help people develop strategies to maximize their health and wellness. Because if the body is functioning well, then all of the systems are going to be better calibrated. When the body is sick in one way or another, that is a stressor, and that stressor is going to throw everything out of whack.