by Ali Miller
Progesterone and Anxiety
Progesterone deficiency can play a significant role in anxiety, racing thoughts, worry, and insomnia. When the HPA-axis is off, progesterone levels often dip because the pituitary in the brain is primarily focused on stimulating the adrenals and the thyroid, so regulating reproductive hormone balance drops. Beyond its function in fertility and menstruation, progesterone has a relationship with GABA expression, and some studies demonstrate its direct anxiety-reducing effects. If you are in a time of hormonal transition such as irregular cycles, amenorrhea (loss of your period), postpartum, perimenopause, menopause, or dealing with infertility, it is recommended to measure your progesterone levels through a salivary assessment and work with a functional medicine practitioner. Learn more in the Advanced Functional Labs on page 166.
Signs of low progesterone include:
•Anxiety
•Belly fat
•Brain fog
•Breast tenderness
•Fluid retention
•Hot flashes
•Infertility
•Insomnia
•Irregular cycles or PMS
•Low libido
•Poor circulation
•Racing thoughts
BIRTH CONTROL: A ROOT CAUSE OF ANXIETY?
It is important to remember birth control has a hormonal influence on the body and can cause your body’s hormones to be out of balance. Transdermal bioidentical hormone in the form of yam-derived progesterone cream may be an appropriate intervention to aid in hormone balance and anxiety relief. Maca, a Peruvian root with adaptogenic properties, may also be used at a dosage of 1 gram per day to support the pituitary gland in regulation of progesterone stimulation from ovaries. If your anxiety shifts dynamically with your cycle or you have an abnormal cycle, it is strongly advised to complete a functional hormone test to get more information.
Cortisol and Anxiety
Stimuli from anxiety can drive increased production of stress-responding compounds like cortisol. Over time, the system can become overworked, leading to inadequate response. An excessive response is seen as hyperadrenalism, and the inadequate or “pooped out” response is seen as hypoadrenalism, more commonly known as adrenal fatigue.
Cortisol can have a significant effect on anxiety and mood. Research shows high stress exposure in youth or chronic stress as an adult can have long-term influences on the hippocampus, a major area of the brain that regulates mood and anxiety, via the excessive release of CRH (otherwise known as CRF). This CRH and hippocampus connection is yet another vicious cycle of feedback in the body where stress response can drive more tendency toward anxiety due to physiological, stress-induced chemical release. Even when the cortisol levels are down or when the body is in a state of adrenal fatigue, the relationship between CRH and the hippocampus can cause the body to experience anxiety. The cortisol released during stressful events can lead to vascular restriction, increased blood pressure, irregular surges of energy and feelings of physical tension, and irregular blood sugar surges that increase fat storage. This HPA-axis is supposed to be down-regulated by the release of cortisol, which should reduce the release of CRH from the hypothalamus. However, this negative feedback loop often gets interrupted during high stress situations (during which the body perceives its survival to be at stake), which interferes with continued release of CRH, ACTH, and what is left of cortisol along with other adrenal stimulants. The adrenals might surge until they burn out, causing imbalance within the digestive, sexual, immune, and inflammatory systems.
Cortisol has two primary modes of operation: regulatory, which promotes the coordination of circadian events such as the sleep/wake cycle, food intake, and inflammatory processes, and reactive, which provides the ability to react to, cope with, adapt to, and recover from stressful events and triggering episodes.
CHOLESTEROL AS MEDICINE?
Cholesterol is a building block of all steroid hormones, including sexual hormones, cortisol, and vitamin D. It plays an integral role in regulating inflammation as it is in the cell wall, protecting cell contents from exposure and damage as well as supporting cellular communication. Corticosteroids, namely cortisol, are manufactured from LDL cholesterol, a rich source of dietary cholesterol and high fat to provide ample building blocks for gland recovery and optimized output. The anti-anxiety diet supports intake of saturated fat from pasture-raised animal products to support the body’s hormones and cellular integrity. As you remove processed foods and refined carbohydrates and start to focus on the dietary distribution of fat as your driving macronutrient, you will be providing your body with the best fuel to rebound adrenal gland function. If you are diagnosed with adrenal fatigue and your DHEA is suboptimal, you may consider staying on the low glycemic Phase 2 while supporting glands with strategic supplements and introducing nourishing fats.
In the Regulatory mode, cortisol peaks in the morning, allowing a natural awakening response that provides a balanced sense of energy where one would report waking well-rested. A healthy cortisol response will gently cascade throughout the day, allowing for a deep, uninterrupted sleep in the evening. If the body is not taxed or overworked by physical or emotional stress, which drives the reactive mode, the individual will maintain optimal energy, sleep, mood stability, metabolism, and immune function. Cortisol in balance also has anti-inflammatory effects as well as the ability to inhibit excessive histamine response. When cortisol levels are low, as seen in adrenal fatigue, often an individual will have increased allergies, food sensitivities, and inflammation.
In the Reactive mode, cortisol does not have a predictable cascade or optimal flow. The peaks of cortisol are in response to emotional or physical stressors at a time of stimulation, driving anxiety reactivity during the event or at a delay with intermittent peaks, such as the middle of the night, driving insomnia. Emotional or mental stress can be from an argument, worrying about a parent or a child, financial woes, professional struggles, or generalized anxiety disorder. Physical stressors can come from recovering from an accident or injury, carrying a child, and even exercise, especially HIIT (high intensity interval) exercise, which can be perceived by the adrenals as “running from a cheetah,” so the body goes into cortisol surge through fight-or-flight response. In this fight-or-flight response, the blood pressure rises, the breath becomes shallow, blood sugar spills out from the liver into the bloodstream, and digestive processes shut down. In fact, as you may recall from Chapter 3, in fight-or-flight the body only makes a quarter of the necessary digestive compounds, leading to bloating, indigestion, weight gain, inflammation, and increased susceptibility to food sensitivities!
“Stressed and Wired” or “Stressed and Tired”?
Many of us thrive on adrenaline in fight-or-flight mode based on lifestyle, external demands, or the way we react to stressors. Although welcomed at moments of need, unmanaged excessive demand of adrenaline can drive imbalanced expression, which results in anxiety, panic attack, worry, racing thoughts, and difficulty resetting after times of stress demand. This can be seen as an example of “stressed and wired,” an over-reactive HPA-axis.
“Stressed and tired” occurs later on, once the adrenals have become fatigued. In this under-reactive HPA-axis, the adrenals don’t have surges of cortisol or catecholamines to release. It is very possible to express both an overactive HPA-axis and underactive HPA-axis, and bounce back and forth from “stressed and wired” to “stressed and tired,” but generally, people go hyper or overreactive first and then follow with hypo or underreactive when the gland gets fatigued from overuse.
HPA-AXIS UNDER STRESS AND ANXIETY
In an anxiety-induced individual, the glands in the HPA-axis are in overdrive. Certain functions are reduced, including production of oxytocin, and others are increased, such as production of the stress hormone cortisol.
HPA-Axis Impact on Your Immune System
The immune system is often impacted when the body’s regulatory function is skewed for an extended period.
When the adrenals are in overdrive, the immune system is over-stressed, the adrenals are hyper-reactive, and the body goes into auto-attack mode. One might be more prone to autoimmune flare-ups, including rheumatoid arthritis, Crohn’s, ulcerative colitis, lupus, multiple sclerosis, and other autoimmune diseases. Conversely, when the adrenals are fatigued and hypo-reactive, the body produces less cortisol, DHEA, and catecholamine. The immune system is insufficient at this time and may allow pathogens, yeast, cancers, and other invaders to proliferate, without having the ability to upregulate the anti-inflammatory and immunological army. Additionally, in this fatigue state, the body is more prone to histamine reactions and inflammation, because cortisol has a natural anti-histamine, anti-inflammatory impact. Stress from both mental and physical stimuli will greatly determine how your immune system responds to the many threats it encounters and ultimately impact your body’s resilience.
Cortisol Levels
Excess Cortisol (Stressed and Wired)
•Apple body or excess abdominal fat
•Immune resistance, less susceptibility to cold/virus, and potential autoimmune reactivity (hyper-immune response)
•Insomnia
•Irritability, tension
•Anxiety
Insufficient Cortisol or Adrenal Fatigue (Stressed and Tired)
•Low energy
•Increased histamine response (more susceptible to seasonal or food allergies/sensitivities) and bloating
•Brain fog and difficulty concentrating
•Flat affect/depression
•Anxiety
Are you over- or under-reactive in your HPA-axis? Use the Adrenal Fatigue and HPA-Axis Imbalance Quiz to assess your body’s state of reactivity and need.
Adrenal Fatigue and HPA-Axis Imbalance Quiz
Respond to the following questions with Never, Sometimes, or Often. Give yourself a score of 2 for each Often response, 1 for Sometimes, and 0 for Never. This quiz will be used as a tool to determine if adrenal fatigue and HPA-axis imbalance are your root causes of anxiety, requiring additional support such as advanced testing or nutritional supplementation.
The recommendations on the following pages correspond to formulas carried in my clinic. In the Appendix’s Supplement Support for the 6 Foundational Rs section, you will find information on dosage, active ingredients, and mechanism of action so you can determine if these formulas are a good fit, or find comparable ones that have similar composition.
1. Do you feel chronically fatigued, even after a good night’s sleep?
Never
Sometimes
Often
2. Do you experience insomnia or sleep issues?
Never
Sometimes
Often
3. Are you apathetic or indifferent, even in areas of your passion or interests, and/or do you feel wildly impassioned and uncontrollably motivated with difficulty winding down?
Never
Sometimes
Often
4. Do you suffer from seasonal allergies or rely on antihistamines (natural or over the counter)?
Never
Sometimes
Often
5. Do you have poor circulation, cold extremities, or difficulty regulating body temperature?
Never
Sometimes
Often
6. Do you crave salt or experience constant thirst?
Never
Sometimes
Often
7. Does your mind feel thin or overworked, and/or do you experience racing thoughts?
Never
Sometimes
Often
8. Is it difficult to complete tasks and multitask, and/or do you often finding yourself distracted?
Never
Sometimes
Often
9. Do you experience pain throughout your body?
Never
Sometimes
Often
10. Do you get heart palpitations or tightness in your chest?
Never
Sometimes
Often
11. Do you feel impulsive, irritable, and reactive or snappy?
Never
Sometimes
Often
12. Do you rely on exercise as the one time you feel good or energized?
Never
Sometimes
Often
13. Do you have a low libido/sex drive?
Never
Sometimes
Often
14. Do you experience dizziness and have issues with low or high blood pressure?
Never
Sometimes
Often
Total Score: ______________________________
Less than 10
It looks like your adrenals are functioning optimally and your stress axis is in check! You may benefit from the use of adaptogenic herbs during times of stress and fatigue to support your body’s resilience. Consider using AdaptogenBoost to optimize your HPA-axis during times of stress demand.
Less than 15
It looks like your adrenals could use some TLC and your stress axis may be in overdrive. To preserve your adrenal function, use adaptogenic herbs daily in the form of a capsule or warm herbal decoction with tea to support your body’s stress response. Consider using AdaptogenBoost to optimize your HPA-axis and aid in stress-induced fatigue on a daily basis. Increase salt intake if venturing into the Phase 1 ketogenic diet, as your adrenals will need some support in electrolyte stability with reduced carbohydrates during transition. Limit caffeine to one coffee or espresso daily. Matcha is recommended as an alternate or can be consumed additionally to provide L-theanine to modulate caffeine effects. Beyond adaptogens to support adrenal rebound, a quality bioavailable B-complex with active B6, such as Naturally Nourished B-Complex, is recommended to aid in neurotransmitter production. Consider GABA in chewable form, such as GABA Calm, to serve as a tool at times of need, acute anxiety, tightness, or “white-knuckle effect” from stress.
Greater than 15
It looks like you are suffering from adrenal fatigue and your stress axis is imbalanced. Due to the state of adrenal fatigue, it is recommended to wait at least four weeks into the foundational anti-anxiety diet with adrenal supplemental support prior to venturing into Phase 1 ketosis with carbohydrate restriction. If considering ketosis after the first month of this program, be sure to increase salt intake, as your adrenals will need some support in electrolyte stability with reduced carbohydrates during transition. In addition to following the supplement recommendations for those with a score of less than 10 and less than 15, it is recommended to completely eliminate coffee and espresso, with matcha as the only form of caffeine. Due to the elevated scoring and serious potential of adrenal fatigue, consider additional supplemental support, such as Calm and Clear, which can be brought initially while waiting on additional testing for strategic adrenal and neurotransmitter support. Adaptogen Boost, Calm and Clear, and GABA can be taken preliminarily without advanced testing to modulate anxiety and stress effects; however, some more intensive formulas, such as glandulars in Adrenal Support, should be used only if needed per advanced testing to confirm low levels of both DHEA and cortisol.
Slowing the Anxiety Drive
Beyond cortisol and DHEA, the adrenals play a role in neurotransmitter expression. Chapter 7 will delve deeper into how neurotransmitters work; however, when focusing on rebounding the adrenals, I want to dig into catecholamines, the neurotransmitters made in the medulla of the adrenals.
Catecholamines are stress-responding neurotransmitters, including epinephrine, norepinephrine, and dopamine, that are stimulated by cortisol and ACTH release. These excitatory neurotransmitters in excess drive anxiety and over time, often following prolonged stress response, dopamine becomes depleted, driving issues with motor skills, with extreme cases being seen in Parkinson’s disease. As norepinephrine declines, an individual may experience memory issues, brain fog, and reduced cognitive function; however, in excess,
norepinephrine can drive heart palpitations, sweats, racing thoughts, panic, and anxiety response. Similar effects are seen with epinephrine.
With neurotransmitters, both excess and deficiency can have significant effects on mental and physiological imbalance. The influence of catecholamines can be countered by higher levels of inhibitory neurotransmitters GABA and serotonin, which can serve as landing gear to mellow out stress response.
Supplements for Adrenal Fatigue and Stress Resilience
The adrenal glands take much of the hit of stress on your body and can become insufficient if overworked. The glands generally start in overdrive mode, which can attribute more of the “stressed and wired” influence on the body seen with insomnia, panic, palpitations, and excessive stress response. Both burnout and excessive output can create cortisol and HPA-axis imbalance. Some supplement formulas may be appropriate for both approaches, and the food recommendations that follow are the foundation to support both rebound and recovery in the adrenal gland.
Adaptogens to Support Stress Demands
Adaptogens are a group of traditional herbs that help us to be more resilient to stress, improving our ability to handle stress demands without getting overwhelmed or fatigued. These herbs are very tonifying to the body and optimize mitochondrial and thyroid activity. Rather than targeting one pathway, adaptogens are multifocal, hitting many physiological influences in the body. They support immune function, focus, sustained energy, and the ability to take on stress-stimulating activity without going into overdrive or burnout. By definition, in order for an herb to be classified as an adaptogen, it must be non-toxic to the recipient and must yield support for homeostasis via the HPA-axis glands, driving balance throughout the body and regulating cortisol.