At the 22nd Annual A4M Las Vegas Conference in mid December 2014 Dr. Thierry Hertoghe, an endocrinologist from Belgium gave a lecture on “Burnout: A multiple hormone deficiency syndrome”, in short: hormone changes with burnout. I have heard him speak on several congresses before. He is always very thorough and extremely knowledgeable. I decided to use this topic as a separate blog.
He said that burnout is common in teachers, soldiers, emergency room physicians (who have to deal with life and death situations) and firefighters. In essence they burn out their hormones. In burnout several hormones are affected, with the cortisol axis being the main one (low cortisol readings and flattening of the diurnal hormone curve), but at the same time other hormone glands are affected as well. As a result endocrine glands age prematurely and symptoms of fatigue, exhaustion, gastrointestinal problems, anxiety, depression and aggressiveness develop.
When hormone levels are measured, there is a lack of cortisol, thyroid deficiency, growth hormone deficiency, testosterone/estrogen and progesterone deficiency and oxytocin deficiency. Holocaust survivors were found to have lower 24 hour cortisol levels. With burnout already the morning output of the adrenal glands is reduced. The health care provider must check prolactin levels, because if prolactin is not high, cortisol will work; however, if prolactin levels are high, cortisol will be ineffective and high prolactin levels have to be addressed first. There is a questionnaire that has been originally developed for teachers (teacher’s burnout scale) to monitor whether burnout is imminent. Soldiers who return from combative situations will also benefit from being assessed with the teacher’s burnout scale; they often suffer from burnout or from PTSD. In suspected cases hormone laboratory tests give concrete answers about hormone deficiencies.
In men growth hormone, melatonin, thyroid, testosterone, cortisol, DHEA and aldosterone have to be replaced to bring the hormone balance back to normal. Instead of aldosterone (a adrenal gland hormone) fludrocortisone is used. In women missing hormones are replaced by bioidentical progesterone and estradiol, but small doses of testosterone are also required.
Dr. Hertoghe discussed cortisol deficiency and its replacement at some length, as this is the main stress hormone that is deficient with burnout. Different treatment protocols for cortisol replacement are used as dosing varies for different degrees of burnout. Other hormones must also be replaced as necessary, possibly for a prolonged period of time, if not life long. Supportive counseling sessions have been shown to elevate cortisol levels and several studies were discussed. A counsellor or psychiatrist will help to tone down increased brain activity and help regain the internal balance. Balanced hormones are necessary on a cellular level to regulate the metabolism of every cell in the body.
Hormone balance and symptoms of various deficiencies
Cortisol is placed on one side of the scales and is balanced by androgens (DHEA), estrogens in women and testosterone in men, growth hormone and melatonin on the other side of the scales. When fainting is part of the burnout, it is because of extremely low aldosterone from the adrenal glands. The best treatment for this is fludrocortisone, which will bring the blood pressure up and remove the hazardous symptom of fainting. Symptoms of “slow thinking, slow moving” and tiredness are often from hypothyroidism. The best treatment for this is T3/T4 (Armour thyroid) treatment. Many physicians still use either T3 or T4, which is not physiological. Symptoms of “poor resistance to noise” are due to DHEA deficiency. In addition there often can be moderately poor resistance to stress and joint aches (arthralgias).
When permanent fatigue is present it is time to measure sex hormone levels. If deficiencies are found in a woman, bioidentical estrogen (Bi-Est) is given transdermally from day 5 to 25 of the cycle, and progesterone transdermally from day 15 to 25 of her cycle. Depending on how severe the hormone deficiency is hormone replacement doses in women range from 2.5 to 5.0 mg for bioidentical estrogen and from 100 mg to 150-200mg for bioidentical progesterone per day.
In this age of exaggerated sports activities a new entity of burnout, the sports fatigue has emerged. A low free testosterone/cortisol ratio is a reliable marker for overtraining. When this ratio shows a decrease of 30% or more, it shows that there is a temporarily incomplete recovery from intensive training. In the lab often an increase in the sex hormone-binding globulin (SHBG) can be measured, which leads to a lack of free testosterone. In a study of Chinese over-trained soldiers there was a complete recovery from this sports fatigue with multi-vitamins and a liposomal testosterone gel.
Restless, non-restorative sleep can be a symptom of melatonin deficiency and happens more often in people above the age of 50 as there is a natural hormone decline with age in the older generation. Treatment consists of replacement, which is easily achieved either with sublingual tablets (mild: 0.05mg, moderate: 0.15 to 0.5 mg, severe: 0.5 to 1mg). Oral melatonin doses are more problematical as there are average absorbers and poor absorbers. For mild, moderate to severe symptoms of insomnia the dosages are for average absorbers 0.2mg, 1 mg, 2mg and for poor absorbers 0.3mg, 1.5mg and 10mg. One should use the lowest effective dose of melatonin as it opposes cortisol and when melatonin is overused, adrenal gland weakness can be the result.
An overpowering feeling of exhaustion can be due to growth hormone (GH) deficiency. This is diagnosed by taking insulin-like growth factor-1 (IGF-1) levels. When these are low, daily subcutaneous injection of low-dose human growth hormone is given. Depending on how severe growth hormone deficiency is, different GH doses are administered. The patient self-injects with an insulin injector. Mild GH deficiency requires 0.05 mg (1 click) per day, moderate deficiency 0.1 mg (2 clicks) per day and severe deficiency 0.15 mg (3 clicks) per day.
Dr. Hertoghe pointed out with the help of a publication where runners had developed overtraining syndrome that adrenaline deficiency can be part of burnout. Laboratory tests on these runners showed that overnight catecholamine (metabolized adrenaline) excretion was only 50% of healthy runners. Often this is associated with thyroid deficiencies (in males and females) or with estrogen deficiency in women. Treatment consists in rectifying the thyroid and sex hormone deficiencies (estradiol and progesterone treatment in women).
Treatment of burnout
Dr. Hertoghe suggested a 5-step treatment protocol.
- Improve the diet
This involves the removal of sugar and starch as both lower the levels of essential hormones. He specified that sweets, chocolate drinks, soft drinks, milk, bread, pasta, commercial mueslis and high temperature cooked meats need to disappear from the diet plan.
The consumption of animal protein is desirable, but the food should be cooked at low temperatures. Fresh vegetable and fruit consumption should be increased. I like to add that these foods are best consumed as organic foods. These foods will increase your natural hormones and produce energy in your cells (ATP, NADPH).
- Improve your sleep
This requires a dark bedroom at night and day light exposure in the morning. Avoid TV’s, electrical alarm clocks, i-phones, computers at the bedside (EMF can disturb your sleep). If your environment is noisy, you may require ear plugs to shut out the noise. In case of hormone deficiency, it may be necessary to replace missing melatonin, growth hormone, see hormones above (especially progesterone in women), and oxytocin.
- Treat adrenal deficiency, if present
The missing hormones here to be replaced are cortisol, DHEA and often aldosterone, which is replaced with fludrocortisone.
- Treat other associated hormone deficiencies
The other hormones, which are often overlooked, are growth hormone, thyroid hormones, estradiol/progesterone in women and testosterone in men.
- Treat nutritional deficiencies
The most common missing minerals and vitamins are iron, magnesium, folic acid, vitamin B12, vitamin E and others. Replacement of these along with the missing hormones is essential for normal cell function.
In an attempt to add to our physical fitness we may overlook our limits and run into a burnout situation without noticing it. Your medical care provider should think about multiple hormone and nutritional deficiencies that can be treated, although treatment can be multifaceted. If in doubt ask for a referral to an anti-aging physician.