The SHOCKING Connection Between Mental Health and Sex Hormones

I'd like to welcome everybody, today's presentation of the hypothalamic pituitary gonadal axis and how that impacts mental health. I'm your host, Dr. Donnelly Snipes. In this presentation, we're going to briefly learn about what the HPG axis axis is and what it does. We're going to explore the hormones in the HPG axis, including estrogen, progesterone, testosterone. We're also going to talk about dhea. It's not specifically a gonadal hormone, but it is involved in the balance of our gonadal hormones. We're going to talk about each one of their functions and their impact on neurotransmitters just a little bit. We'll explore insulin and insulin sensitivity and the HPG axis, insulin and stress and the impact of stress and the interaction of the HPA and HPG axis. So we got a lot of stuff to cover. Gonadal hormones impact mood and cognition and mood and cognition impact gonadal hormone balances. That's really what we're talking about. We're going to distill it down to the most basic basic function. And I want you to think about the hypothalamus and the pituitary. Kind of like the CEO and the COO of your company. Your body factory. And the adrenals, thyroid and gonads are the VPs of various departments and they all need to work together to keep the factory working optimally. We're really going to talk a lot about the hypothalamic, pituitary, adrenal and hypocrisy hypothalamic pituitary gonadal axis today because you really can't separate them. They are inextricably intertwined. The HPG axis has been implicated in the development of psychiatric conditions such as mood, anxiety and cognitive disorders. It controls reproduction, development and aging, but also impacts and is impacted by the HPA axis. So remember, the HPA axis is our stress response system and the HPG axis is more than. But we think about it in terms of our reproduction and development system, but they all work together. Affective disorders interestingly, show sex specific differences in their prevalence and symptoms, which we know. We know that, you know, certain disorders are much more prevalent in females than in males, possibly due to differences in the interaction between the HPA axis and the HPG axes. Remember, we all have estrogen and testosterone, but women tend to have more estrogen, less testosterone, men tend to have more testosterone, less estrogen. So they speculate that that difference may contribute to differences in modulation of the HPA and HPG axis and axes and differences in neurotransmitter balances, alterations in the HPG axis, the gonadal axis, during important reproductive health events like pregnancy, menopause, and just as a course of aging alter the sensitivity of neurotransmitter systems. It's important to recognize that as we age, and if you've. There is one commercial that comes on a lot that talks about HGH and something else. A lot of our hormones, especially our reproductive hormones and our developmental hormones, start to decline as we age, as we finish our period of growth and development. You know, our brains developed, our bodies developed, some of those hormones start to decline even as early as our mid-20s. And with our sex hormones, those also start to decline, although somewhat later, as we are no longer theoretically going to be reproducing those, the levels of testosterone and estrogen tend to reduce. And in women we know once they hit menopause, you know, there is a stark reduction in gonadal hormones when those hormone levels, when those gonadal hormones levels alter, it alters the availability of things like serotonin, dopamine and norepinephrine. Gonadal hormones affect reproductive organs. Well, we knew that. And also influence several other bodily functions by interacting with major neuroendocrine systems, including thyroid hormones. So your estrogen and testosterone interact with your thyroid. Alterations in your gonadal hormones may impact your thyroid functioning. They interact with stress hormones. You're going to learn as we talk, go through this presentation today that cortisol, our main stress hormone, suppresses estrogen and testosterone, and estrogen and testosterone tend to suppress cortisol. So they work against each other. The HPA axis is affected by similar factors as the HPG axis. It's important to recognize that whatever is going to affect the, the stress response system, the HPA axis is likely also going to affect the HPG axis. One interesting fact, and I'm just kind of plopped it in here because I thought it was important, but I didn't know where to integrate it. Alterations in maternal care, and we need to find a different word for it besides just maternal care, but alteration in care of the infant can produce significant effects on both the HPG and HPA physiology as well as behavior in the offspring at adulthood. So let's think about that. We've talked repeatedly about how when the brain is still developing, when the body is still developing, it is a lot like a clay vase that you have not put in the kiln yet. You have not fired. So it is very susceptible to damage and being altered. And, you know, well, altered. It's much more susceptible to that before it's put in the kiln than after it, after it is put in the kiln and hardened, which is when development is complete. So when a child experiences adverse childhood experiences, which are often characterized by difficulties in early childhood care. You know, I'm trying to avoid the word maternal care because dads may be the one doing it, grandparents may be the one doing it, but whoever's the primary caregiver, if they are not emotionally and physically available and responsive to that child, to that infant, it creates significant stress. That ongoing chronic stress can alter the HPA axis even as young as infancy. And they've shown that the alterations in maternal care not only impact the HPA axis, which can result in emotional dysregulation and other things that we've talked about, but also it impacts the HPG axis. It impacts the levels of the primary gonadal hormones in that infant and, you know, ultimately in that adult person. So that, that's kind of interesting because that would mean that a child who experienced significant stress may have lower levels of their primary hormone estrogen or testosterone, depending on what, what gender they are when they get older, which actually may suppress the desire to reproduce, which I thought that was just kind of interesting. But it's also going to impact their mood because we know that lower levels of estrogen and testosterone, depending on the person, the gender, is going to affect the availability of dopamine, serotonin and gaba. So let's talk about estrogen. What does it do? It is not just your pregnancy hormone or whatever you want to call it. Estrogen and testosterone have very, very similar functions in the different genders. So in women it's estrogen and men it's testosterone. It's responsible for the increase in muscle mass. Who knew? I always thought that was just testosterone. But no. Estrogen in women regulates the development of muscle mass and fat distribution just like testosterone does in men. It's anti inflammatory. Again, who knew? Remember that when people have autoimmune issues, what is one of the key factors associated with autoimmune issues? Inflammation. So if estrogen in women or testosterone in men is, are low, is low, then that person is going to experience more systemic inflammation which can trigger more autoimmune symptoms. But remember, increases in systemic inflammation are also associated with increases in clinical depression. So we may see some mood symptoms just from this. Estrogen and testosterone both mediate the formation of secondary sex characteristics. Help regulate energy expenditure, maintain bone density. Now estrogen is implicated also in improving coagulation of the blood. So you want to have enough estrogen because you want your blood to clot. It also helps maintain healthy cholesterol levels, increasing good cholesterol and reducing bad cholesterol. Remember too that our gonadal hormones, our androgens, are actually made from cholesterol. So we need to have some levels of cholesterol, the good cholesterol in our body in order to support the development, the creation of estrogen and testosterone. So people who go on super, super low fat, no fat diets, you know, may be causing themselves some problems. Now the body can somewhat self regulate but you know, that is an interesting side note that there are nutritional deficiencies that will contribute to gonadal hormone deficiencies which will trigger a threat response because it starts throwing the system out of whack and trigger the HPA axis and then there's the whole cascade. Estrogen assists with fluid balance. It helps keep the fluid in our cells balanced the way it is supposed to be. Promotes lung function. Now this is another one that I just learned about preparing this presentation. But that's an interesting thing to think about when we are coming out of COVID and you know, we've had the flu for a long time and one of the major complications that elderly people who get those viruses have is pneumonia. So I'm wondering, and I don't know, I'm just wondering whether gonadal hormones, low levels of gonadal hormones may, may make some people more susceptible to lung based complications from certain viruses. Just kind of throwing that out there. I'm just hypothesizing that doesn't come from any research. Sexual behavior is also altered or implicate impacted by estrogen. Estrogen increases serotonin and serotonin receptors in the brain and modulates higher order cognitive processes that are driven by dopamine such as learning, reward processing, working memory and impulse control. It's important to recognize this and we're going to see something very similar in testosterone. And I'm just going to go through these really quick because it's pretty much a mirror image for men. What testosterone does for men is very similar to what estrogen does for women. Regulates sex drive and libido, fat distribution, bone and muscle mass improves insulin response. Now that's a little bit different. Anti inflammatory, it helps with strength and muscle mass production of red blood cells which is akin to, you know, we were talking about estrogen is needed for coagulation. Testosterone helps with Production of sperm, obviously. Estrogen, not so much. It's more involved with ovaries. Small amounts of testosterone are actually converted to estrogen in the male. And it's important for the male to have a certain amount of estrogen to help regulate certain functions. They have to have that balance. Just like women have a certain amount of testosterone, it is imperative. Testosterone has been shown to enhance cognition and increase levels of dopamine, serotonin, and gaba, just like estrogen. Testosterone and estrogen are decreased by adrenaline or epinephrine, by stress. Our stress hormones suppress. Stress suppresses. Think about it that way. Stress suppresses estrogen and testosterone. Progesterone is another hormone that we have, and it increases in response to stress. And cortisol, remember that estrogen and testosterone decrease. Progesterone actually goes up. Progesterone is the precursor to cortisol. So when there's stress, progesterone is released so it can be converted to cortisol. So you're going to have higher levels of both progesterone and cortisol in people who are stressed under chronic stress and reduced levels of cortisol. Remember, at a certain point, the body starts having difficulty responding to stress appropriately. It starts becoming resistant to stress. Just saying, you know, I can't. I can't do it. So under chronic stress, there are reduced levels of cortisol and progesterone. As a result, estrogen becomes dominant. Why do we care? Well, estrogen dominance is a phrase that is used by some people that characterizes certain mood characteristics that especially women may experience when estrogen becomes dominant. Mood swings, increased anxiety, weight gain, hair loss, sleep disruption, memory and cognitive disorder disruption. So it's important, if we have a client who presents with these symptoms that we want to examine, you know, what may be going on. Remember that the inadequacy or imbalance of our monoamines, our neurotransmitters, is a symptom in most cases of. Of some sort of underlying pathology. Something is causing the serotonin system or the dopamine system or the norepinephrine system to not function like it's supposed to. So we don't want to stop there and just say, well, let's just throw some SSRIs at it. We need to explore why is the person's serotonin or dopamine low or too high or whatever the case may be. Low progesterone is associated with low cortisol. Remember, because cortisol is made from progesterone, pregnolone. So it's important to recognize that alterations in sex hormone levels may affect stress response. Progesterone has anxiolytic properties that are thought to modulate the stress response, which I think is kind of interesting considering progesterone is actually the hormone that is a precursor to cortisol, that progesterone itself can actually reduce anxiety. The reason I put that in there, just for your own edification, especially if you are working with female clients who are on synthetic birth control, it's important to recognize that there are various different things that are different balances of hormones that women take in order to prevent pregnancy. And some are like, you know, progesterone heavy, others are, you know, I don't know what all the alterations are, but if someone started developing mood symptoms that are causing them significant dysfunction, and it can be traced back to starting to take birth control pills, or it can be traced back to anything that may have altered their hormone balance, whether it's a hysterectomy, even a partial hysterectomy, or simply aging. We do want to be aware of that. In terms of being tied to breast cancer, I really didn't look at any of the research related to breast cancer. But yes, it is true that a lot of our, a lot of the breast cancer is hormone dependent. There are actually several different types of cancers that are hormone dependent. So when one hormone we'll take estrogen, because that's the one that's usually blamed. When estrogen becomes dominant to the extreme, it can theoretically make somebody more at risk for different types of cancers. That's why, for example, when people have high levels of obesity, they tend to have high levels of estrogen, and that makes them more at risk for, for the development of breast cancer. DHEA is the other hormone we're going to talk about, and it's actually made in the adrenals, but it is involved in regulating those gonadal hormones. So you can't really have this discussion without talking about dhea. Unfortunately, DHEA is sold over the counter and a lot of people think it is the next magic anti aging pill that they can take. Unfortunately, just like everything else, what we're taking over the counter, number one, is not standardized for the most part. But number two, the amount that you're taking is likely so much higher than what your body needs, it may be causing, you know, adverse reactions as a result. So I never recommend to people that they go out and even consider taking over the counter DHEA or things like that. Actually, if they start talking about that, I strongly Caution them to talk with their doctor first to make sure that it's not going to increase their anxiety or other symptoms. Anyhow, DHEA assists in the synthesis of your androgen and estrogen sex hormones, both in the gonads and in other tissues. So without dhea, you can't synthesize the your sex hormones. Dhea, like your sex hormones, reduces with age, which is why a lot of people think, oh, well, if I just supplement with dhea, then everything will be wonderful and I'll feel great again. Not necessarily. DHEA is inversely related to cortisol. So as stress goes up, and I think most people know this just from personal experience, as stress goes up, your DHEA will go down, which means your testosterone and your estrogen, you know, testosterone or estrogen will go down, which means your libido is going to go down. You know, it's not when you're stressed, your body's going, hey, it's not the time to reproduce right now. So it totally makes sense. It totally makes sense that the body is going to put the brakes on some of those other things, you know, building muscle mass and maintaining bone density and all of those other secondary things. When it thinks that it needs to fight or flee, when it thinks that there's a threat to survival. DHEA elevation by itself, which is why I was talking about the supplements, can exaggerate glucocorticoid dysfunction. So DHEA by itself can actually cause the body to become more resistant to the effects of cortisol. There exists a reciprocal relationship between the HPG and the HPA axes. And so both testosterone and estrogen modulate the response of the HPA axis. So testosterone and estrogen, remember I said, typically try to tamp down or suppress the HPA axis, that they actually tend to want us to not be stressed. But when activation is chronic, it has an inhibitory effect on estrogen and testosterone. So those hormones go down and the HPA axis actually flares up and becomes more extreme, which may lead to glucocorticoid resistance. Remember, that happens when the stress has been chronic enough and the tissues have been bombarded or annoyed enough by the cortisol that they're just not responsive to it anymore. They've developed a tolerance. If you want to think about it that way, chronic stress in adulthood mediates the hypothalamic pituitary gonadal axis. And when we talk about stress, I know not everybody's been with. Been with me before. When we talk about stress, we're not only talking about emotional Stress or cognitive stress. We're also talking about physiological stress. I know a couple of you work in dual diagnosis facilities, substance ingestion, substance use, as well as substance withdrawal. Both of them in their own right are perceived by the body as stressors. Both of them, intoxication and withdrawal will trigger HPA axis and subsequently HPG axis activation because it is a, I mean you're ingesting a toxin, but then when the person starts to withdraw, the body has to try to adjust to it. And that is often also perceived as a stressor on the body. So we're talking about chronic physiological or psychological stress impacts the HPG axis in women. For example, stress activates a sympathetic neural pathway originating in the hypothalamus. Remember I said the hypothalamus and the pituitary are like your CEO and your CEO of your factory. So the hypothalamus is up there and it is involved in the stress response. HPA axis and the gonadal system, HPGA axis. When there's stress, the hypothalamus causes the release of norepinephrine into the ovaries, which produce a non cyclic, an ovulatory ovary. So a non functioning ovary that becomes cystic, it starts to develop cysts and pcos. Polycystic ovarian syndrome is actually not uncommon in people with depression. Symptoms of pcos, and I think we'll talk about this a little bit later, but symptoms of PCOS in your clients or family members, even thinning of head hair. So you may start to develop like male pout, male pattern baldness, thinning of the hair, especially on top of the head, development of unwanted hair, especially on the face, the chin, the chest and the buttocks. Oily skin, development of acne, development of significant weight gain. It really impacts the energy system, if you will, when this happens. So those are some symptoms. Now think about clients that you've worked with before who've presented with depression, who have had these symptoms. I know that I've seen dozens of clients who present with depression not recognizing that they might also have an underlying hormonal imbalance and that may be contributing to their mood. In some people with pcos, it is biological in nature. You know, whatever's causing the internal stress and causing the cystic ovaries may be biological. But we've got to remember that stress and activation of the HPA and HPG axes will also contribute over activation of those will also contribute to the development of pcos. They've started to really identify a strong connection between that in the literature. So the point being, just like depression is a indication that neurotransmitters are out of balance, but that's a symptom of a breakdown in the, in the system somewhere. PCOS is an indication of norepinephrine in the ovaries, cystic development in the ovaries, which is an indication of some other pathology that may be causing that, including, including chronic stress and stress that may be continuing to be carried as a result of adverse childhood experiences that caused a functional alteration in the HPA and HPG axes in the child that, you know, obviously is continuing and perpetuating into adulthood. So all this stuff is really interesting how stress, you know, cognitive or physical stress can impact so many different systems and, you know, especially if it happens in prior to the age of 24, before development is solidified, how it can have permanent cause, permanent alterations. Not to say that we can't work around them, but it is interesting to just kind of really think about that. Inability of the HPA axis and the HPG axis to regulate circulating levels of cortisol, your glucocorticoid hormones, has been implicated in the development of neurocognitive disorders as well, including things like Alzheimer's disease and dementia. Studies investigating the interaction between the HPA and HPG axes found a consistent suppression of the HPA axis by the androgens. So as I mentioned earlier, testosterone and also estrogen traction try to suppress the HPA axis. They try to be calming, they're anti inflammatory. Ultimately they seem to be really helpful workers in our body factory and they try to keep that HPA axis from overreacting. Hormones are among the major physiological regulators for brain development. So if the hormones are out of whack as a result of early childhood stress, that may impact the development of the brain itself, not just the gonads or the hormones, but we're impacting the development of potentially the hypothalamus, the adrenals and the pituitary gland and all that stuff. So any dysfunction of the endocrine system may be implicated in the onset or progression of neurocognitive issues. This is a really interesting avenue they're looking at now for early identification of people who are at risk for developing dementia and or Alzheimer's, Parkinson's disease, by evaluating the health of their endocrine system and the balance of their hormones. Neurocognitive disorder development involves a progressive dysregulation of both the HPA and HPG axes. So an endocrinologist may actually Be one of the first people who can help identify physiological issues that are going on with the person which may indicate the development or early onset, you know, early, early warning signs of some of those neurodevelopmental or neurocognitive issues. The earlier we find out, the earlier we can intervene, the longer the person is able to often live with mild to moderate symptoms. The HPA axis contributes to the cognitive decline through mild hypercortisolemia. So when the HPA axis is chronically elevated and in some people they never develop hypocortisolism, they stay with mild hypercortisolemia. So they've got too much cortisol in their system most of the time, which contributes to dysregulation of the HPG axis. Cortisol is going to suppress those gonadal hormones. And remember, those gonadal hormones are the ones that are responsible for higher order cognitive functioning through dopamine and norepinephrine and serotonin. Additionally, gonadotropins, which are regulated by the HPG axis, have also been associated with cognitive decline. That's another one of those I was just kind of throwing in there. It's important to recognize that there are other hormones in the HPG axis and high levels of them may be associated with cognitive decline. If you've got a client who is evidencing cognitive decline, having them get a full blood workup is going to be really important to make sure that we are addressing whatever the underlying issues are that may be contributing to serotonin, dopamine or norepinephrine insufficiency. People with cognitive dysfunction often have a high concentration of glucocorticoids, cortisol, resulting in the extensive loss of neurons. Remember, when that HPA axis is activated, and especially if it's hyperactivated, because testosterone or estrogen aren't there to kind of help regulate it so it doesn't overreact. When, when glutamate levels and cortisol levels get high, then we start to see neuronal death. So it's. Our sex hormones are actually very neuroprotective. And if we start losing them, you know, as we start losing or seeing decreased levels of our sex hormones, we lose that neuroprotective factor. Men and women with Alzheimer's disease, anxiety, depression and other neurocognitive or mental health issues have been found to have lower levels of, depending on the gender, testosterone or estrogen than those without neurocognitive or mental health issues, Excess stress. So let's talk about how the HPA axis, which is our stress response system and the HPG axis, our gonadal system, really interact. Excess stress can lead to high levels of cortisol, which can cause lead to hypothyroid. Cortisol prevents T4 from being converted to being from being converted to T3 and glucocorticoid resistance. So your thyroid hormones can't be made like they're supposed to, and the tissues start to become resistant to cortisol because it's just always there and that it starts ignoring it. Basically both of these are symptoms of HPA axis dysregulation. When this happens because the gonadal hormones interact with the thyroid hormones and the gonadal hormones and cortisol interact with one another, when those things start to become get out of balance, it will also cause a disruption. And in the HPG axis, in the levels of your gonadal hormones. Glucocorticoid resistance was found in more than 50% of patients with polycystic ovarian syndrome. So what that's telling us is patients with pcos tend to have a dysfunctional HPA axis which is causing or contributing to to dysfunction in the HPG axis. We're going to talk about what to do about that in a couple of slides. We're almost there. Higher glucocorticoid resistant subjects. So the more resistant their tissues were to cortisol, the more tired of, you know, paying attention to the cortisol the tissues were, the higher the levels of free floating cortisol and testosterone. So basically what that's saying is the body keeps amping up how much cortisol it's pumping out to try to get a response. If you think in terms of drug addiction, you know, let's just take it back to something that we maybe may be more familiar with, opioids or alcohol. People start taking it and initially when they take it, they only need a certain amount in order to get the high that they are looking for. But as their system becomes resistant or tolerant to that drug, they need more in order to get the same high. The same thing is what's going on with our stress response system with cortisol in our HPA axis. As the body becomes tolerant to the cortisol, it starts to secrete more cortisol to try to get you to get up off your butt and do something to respond. So you have higher levels of cortisol floating around in the bloodstream, but just not getting paid attention to stress induced elevations of cortisol and reductions Corresponding reductions in neuroprotective hormones, dhea, estrogen and testosterone lead to enhanced oxidative stress. So we know that high levels of cortisol are related to increased oxidative stress. Combine that with. Not only are we increasing the level of the poison, if you want, just go with me on that one, but we're also reducing the protective factors. We're reducing the buffers that keep the cortisol from. And the glutamate from becoming too toxic to the. To the neurons. So that's another interesting interaction that we see. As stress goes up, our neuroprotective hormones go down, which leads to increased oxidative stress and increased neuronal death. Oxidative stress, you know, that's when you have all those free radicals that are caused from, you know, just regular activity in the body. But when there is too much, which you. You can think, when you're stressed, you're probably ramping up production of your free radicals, so you get an abundance of free radicals. When there are too many free radicals and they can't be cleared out and balanced effectively, it causes oxidative stress. Oxidative stress is now recognized as a central contributor to the development of many different disorders, including pcos and neuropsychiatric disorders, including anxiety and depression. There's another little aspect of this that we haven't talked about a lot, but. But that's insulin. And insulin is its own. Is kind of its own animal. But it's important to learn and to recognize that our gonadal hormones actually impact our insulin sensitivity. People with diabetes tend to have. They tend to be more insulin resistant, and they tend to have lower levels of testosterone or estrogen. So that's another important thing to recognize that people with diabetes may have some mood issues that might be caused or at least in part by insufficient levels of certain gonadal hormones. In males, testosterone increases with bouts of acute exercise. So, you know, lifting weights, doing something for 45 minutes or an hour. But testosterone actually lowers in endurance athletes. They think that this may be possibly due to restricted energy availability, which negatively affects hormone levels. Makes sense from a survival perspective. If there's not enough fuel, there's not enough energy to fuel the body, then the body says, hey, there's a famine out there, but now's not the best time to reproduce, and I need to direct my energy elsewhere, not to the HPG axis. In females, especially in females who are strong restrictors, there is significant evidence that decreased energy availability over an extended period inhibits HPG axis, so it reduces Their estrogen, leading to menstrual irregularities and lower bone density, among other things. Dysregulated insulin signaling, impaired glucose uptake and insulin resistance are some of the prime factors in the onset or progression of many neurocognitive issues. So it's important to recognize that testosterone and estrogen are going to reduce in the face of stress, and insulin resistance may become an issue. Chronic activation of the HPA axis, the threat response system, contributes to alterations in the HPG axis, including reductions in estrogen and testosterone. I think you got that by now. Insulin resistance and diabetes are highly correlated with reductions in testosterone and estrogen. So it's interesting to note that it could be that the diabetes is causing stress on the body, which keeps that HPA axis highly activated. Highly, well, highly activated, and that reduces the testosterone and the estrogen. We're not really sure what, what causes what in this whole scenario, but we do know, or they do know, that chronic HPA axis activation can contribute to problems in insulin regulation. Because remember, when the HPA axis kicks off, you have the secretion of adrenaline, cortisol, glutamate, and the body dumps a ton of blood sugar in order to prepare you to fight or flee. So when the HPA axis is activated, it impacts insulin receptors. The presence of functional insulin receptors in the hippocampus and the cerebral cortex is necessary for cognitive functions and to regulate glutaminergic and GABAergic transmission. So insulin, interestingly enough, is involved in the regulation of glutamate, which is our main excitatory neurotransmitter, that is secreted when that HPA axis kicks off. And gaba, which is made from glutamate, that is secreted when the HPA axis is downregulating. It's our natural valium, if you want to think about it that way. Any imbalance in insulin leads to neuronal dysfunction, resulting in memory impairment. Insulin affects the HPG axis, and insulin changes in diabetes and obesity can also affect the HPG axis. So a lot of these things, we can't just separate it and go, oh, it's this over here or it's that over here. We have to recognize that any change in the body is going to affect the rest of the body. Any change in one department in the factory is going to impact the efficiency and the functioning of the whole factory. Another issue that affects the HPG axis that I think is important to note is people who are on opioids for a period of greater than three months also tend to have DYSREGULATED dysregulated HPG axes and suppressed levels of testosterone or estrogen. Now, you may be thinking to yourself, well, who would be on opioids for over three months? People with chronic pain. There are some people with chronic pain who are on methadone or buprenorphine or just straight up opioids, even if they are not. People who are addicted to opioids and are using them recreationally. Some people, you know, I worked with veterans for a long period when I was in Florida, and many of them were prescribed long courses of opioids to manage their chronic pain. So it is possible that there are people out there that are by prescription, as prescribed by a doctor, on a long course of opioids. Okay, that's fine. If that is helping them function and live their highest quality of life, alrighty. But we do need to recognize that being on those opioids is likely suppressing their sex hormones, which means that it's also likely impacting their mood, impacting their energy, and suppressing the neuroprotective factors that the sex hormones provide. So it may be important for them to get their gonadal hormones evaluated to make sure that they have adequate levels in order to maintain effective cognition and mood and energy and all that other stuff. So let's talk about interventions real quick. Physically, we want to reduce stress. We want to reduce physiological stress. Sleep is very, very important. The body resets itself. A lot of the functions that the gonadal hormones are involved in take place when we sleep. That's when the resting and rebalancing and all that happens. And we know that sleep deprivation triggers or activates the HPA axis and will impact accordingly the HPG axis. So good quality sleep, important nutrition improvement is essential to make sure the body has the building blocks that it needs to make, you know, like the cholesterol to make the hormones to make the neurotransmitters to support functioning, but also to make sure that the body has just plain the energy it needs. So it's not perceiving a famine out there which would cause a reduction in gonadal hormones. Stimulant reduction is another one that we want to look at just because that does stimulants increase cortisol? Cortisol suppresses gonadal hormones. Pain increases cortisol. When we're in pain, it increases cortisol. We want to help people figure out ways to manage their pain. You know, living pain free is pro all the time is probably not realistic. But how can they manage their Pain when it does happen, when they have flare ups, what strategies can they use up to and including medicine that can help them manage their pain? To reduce their HPA axis activation, to reduce their distress caused by the pain hormone imbalances, you know, easy to measure with blood, blood tests. So important, so important that we encourage clients to get these things evaluated to see where they're at. Because if we are, if the, well, we aren't doing it, we aren't prescribers, but if the psychiatrist is giving them anti antidepressants to increase their serotonin. All right, well that's kind of spitballing it. What if the problem is actually, you know, complete suppression of their estrogen or low testosterone that is making serotonin less available? You know that there are a lot of reasons why is there serotonin low and is it even serotonin? Could it be dopamine or norepinephrine? We want to also help people promote feelings of physical relaxation. Yoga and Tai chi have both been found to increase levels of dopamine and serotonin. When we increase relaxation hormones, when we increase our happy hormones, it is naturally going to help down regulate the HPA axis. So things kind of get back into sink if you will. Affectively helping people reduce dysphoric emotions, recognizing that pain, as Hayes says in acceptance and commitment therapy, pain is inevitable in life. However, we can live a rich and meaningful life and experience pain. We just need to have the tools to do it. And dialectical behavior therapy tools, distress tolerance, emotion regulation, problem solving and acceptance and commitment therapy tools can be really helpful here as well as, you know, obviously processing issues, stuff that people may still be dealing with, that is projecting into the present. You know, they may still have resentment or anger or trauma from the past that is impacting their present. So if we can help them recognize what is causing their dysphoric emotions and give them the tools to deal with it, well then great. We want to help promote feelings of physical and emotional relaxation with mindfulness and meditation and laughter. Laughter is so important. You all know I harp on this all the time, but. But laughter actually increases serotonin, increases dopamine, decreases cortisol, decreases glutamate. It's a great thing and it improves your immune system to boot. Cognitively helping people develop distress tolerance skills can be important at reducing stress and increase awareness of their cognitive distortions and their biases as well as increasing their positive attitude and positive appraisals. Challenging people when they have a negative appraisal of something to also Develop a positive appraisal and evaluate the facts supporting each one and then see which one they want to hold on to improve their problem solving skills. Like we talked about, environmentally, safety is so important. You know, it's hard to feel relaxed, it's hard to feel happy, it's hard to want to reproduce when you are stressed because you don't feel safe. And helping people identify sights, sounds and smells that can help them feel safer, but also sights, sounds and smells that may be triggering a sense of unsafeness. And figuring out how to deal with that, whether it's eliminating the trigger or you know, what do you do with it in order to mitigate the impact of that trigger in your life. Aromatherapy, bergamot, lavender, rose and rose geranium have all been found to increase serotonin and dopamine, which will help reduce cortisol, which will help. When the cortisol is reduced, the gonadal hormones may rebound a little bit. Weighted blankets or vests have also been found to increase oxytocin and your positive neurochemicals, improve supportive relationships, enhance interpersonal skills and develop self esteem. Gonadal hormones decrease as we age. Whether we like it or not, it happens. They also decrease in response to stress and even due to some medications like opioids or things like diabetes. So there are a lot of things that can alter the levels of gonadal hormones. The HPA and HPG axis both impact the stress response and chronic stress can lead to dysfunction in both the HPA and HPG axes. That's where we come in. We can't help people regulate their estrogen biologically. That's what the doctors have to do, the endocrinologists, the family practice, physicians. But we know that like, well, we don't know likely by the time people come in for counseling or for treatment from a behavioral health professional that they are experiencing some level of chronic stress that is exacerbating the problems in the HPA and HPG axis. So we are that complementary half. You know, remember the cognitive behavioral triad. You have your, your feelings, your thoughts and your behaviors. You know, work. We can help people with those things which are all going to impact their physiology and their physi physiology, the health of their body is going to impact those things. Gonadal hormones increase levels of certain neurotransmitters or the sensitivity of the receptors of dopamine, serotonin and gaba. These directly correlate to alterations in mood and cognition. Dopamine is so involved in attention and concentration and desire to persevere and keep on. And motivation and serotonin obviously helps as well. So it's really important in terms of mood and cognition to assess levels of what may be contributing to the deficiency of these particular neurotransmitters. People, our clients, our family, our friends, our community. I'm not just talking. You know me. I think it's really important that we get out there and increase people's health literacy because an ounce of prevention worth a pound of cure. People need to be educated about the impact of stress and cortisol on the HPA axis and the HPG axis and how those things impact their mood and energy. You can talk to them about the HPA axis until the cows come home, but if you don't connect the dots and help them understand how it impacts their mood, their energy, even their weight and their libido and their ability to conceive, it may not hit. They need to understand why they care. We need to connect the dots so they understand why it's important to know about these things. They need to be educated about the impact of hormonal imbalances on stress tolerance, mood and cognition and develop strategies to maximize their health and wellness. In response to Pat's question, no, I don't think most doctors actually look at these, whether they're family practice docs or whatever, which is exceedingly frustrating to me. A lot of times if somebody comes in and presents with depression, the first thing they do is write a script and send them to a counselor instead of doing blood work to test for thyroid and go nadal hormones and vitamin D levels and iron deficiency and other things that could be contributing to the mood symptoms. Now, recognizing most of the time, there's probably a combination of everything. By the time somebody actually is willing to go to the doctor for a problem, they probably have also developed some learned helplessness, some, you know, dysfunctional cognitions and stuff that could benefit from counseling. But counseling is probably not going to be the be all end all. In response to Danielle's question about cancer, if you want to stick around, I will try to look that up. If you are ready to go and take your quiz, just log into allce.com, click on the class, go in, take your quiz, and be done with it.