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When we think of a Type A person, we generally think about high achievers, go-getters, motivated movers, and possibly more. In a society that is constantly on the go and demanding achievements and status, it can be easy to get caught up in the current of our societal structures – especially as a Type A male.
We are inundated with suggestions that males are unable to keep up with the demands of being a “man”: ads on social media, television, radio, etc suggest that most males need testosterone support to keep up with the capacity for sexual, professional, and personal health. What happens when you load testosterone onto someone whose cortisol and stress response are overwhelmed? Our stress hormones have a significant effect on sex hormones, including Testosterone and the overall sense of well-being in our well-intentioned males of today. The Type A man usually shows higher levels of cortisol and reports the impact of stress including sleep issues, feelings of overwhelm, fatigue, and concerns about sexual health.
Male Cortisol Physiology
As we’ve discussed in previous blog posts on the subject, cortisol is produced in the adrenal glands (adrenal cortex), and cortisol is released in response to stress. Stress signals the brain at the hypothalamus, and this begins the brain signaling to the adrenal glands via the HPA (hypothalamic-pituitary-adrenal) Axis. This means the stress response begins in the brain, and stress is triggered by real and/or perceived stressors including psychological stress. Cortisol is not made and stored, so it must be produced on demand as the brain is signaled to make cortisol. When the body is working through stress, that stress response becomes the priority. This means that all other physiology is now secondary. Stress is meant to be protective and keep us alive! When the body is gearing up to fight a saber tooth tiger, it deprioritizes immune response, sexual drive and function, and digestion. It also floods the body with glucose to be ready and available for muscles and the brain. In an acute situation, this will create an optimal environment for fighting stress but when allowed to be continued, if the stress response turns chronic, we begin to see a maladaptive response to stress.
Signs of Maladaptive Stress Response
- Blood sugar dysregulation (diabetes)
- Metabolic dysfunction
- High blood pressure and cardiovascular risk
- Immune dysregulation (getting sick easier, or more difficult to get over being sick)
- Gastrointestinal dysfunction including malabsorption, variable bowel function
Cortisol and Testosterone
In males, we know that there is an inverse relationship between cortisol and testosterone. The more cortisol that is produced and released, the less testosterone is available. In males, it is not uncommon to link testosterone to libido and sex drive. This is quite limiting given that testosterone also influences mental health including a sense of well-being, cardiovascular and blood vessel health, muscle and joint health and lubrication, muscle mass, and metabolic regulation.
Cortisol, Testosterone, and Sleep
Cortisol has an intimate relationship with our circadian rhythm, as does testosterone. Cortisol is our daytime hormone and melatonin is our nighttime hormone. We rely on appropriate fluctuations in cortisol as it follows the sun, with cortisol peaking generally around 9 a.m., then dropping at night to allow for appropriate sleep and sleep phase activation. This is relevant to our discussion as testosterone is produced in its highest amount in males during sleep. The deep sleep phase is where we have the most volume of testosterone produced. The deep sleep phase usually happens the longer you are asleep, which usually correlates to the early hours of the night. When sleep is interrupted, it is difficult to achieve deep sleep. This is an important distinction in understanding that poor sleep, disturbed sleep, interrupted sleep, etc. can all contribute to a hindrance of testosterone production.
Cortisol, Testosterone, and Estrogen
When stress is high and cortisol is elevated, we can see an increase in inflammation. This inflammation is usually at a low level in the beginning but may become more pronounced as stress continues. Testosterone is converted to estrogen through the aromatase enzyme. In situations of high stress and inflammation, it is not uncommon to see an upregulation of the aromatization of testosterone to estrogen. This may lead to lower levels of testosterone with increased levels of estrogen. Higher estrogens in males may show up as low mood, increased belly fat, reduced libido, and poor sexual response including decreased climax and erection response.
When we combine high cortisol, higher estrogen levels, and lower testosterone levels, we now see a circle of weight gain and loss of testosterone that can strongly impact not only quality of life on a daily basis, but also increases overall risks for disease in general.
Cortisol, Testosterone, and metabolic challenges
In the scenario of increased cortisol and loss of testosterone, we can also see loss of muscle mass. Lowered muscle mass creates an environment for increased body fat as well as impaired glucose management. Low levels of testosterone may precede increased insulin, HgbA1c, and blood glucose levels. We see that increased body fat is likely associated with low testosterone levels. We know that fat tissue acts as its own endocrine organ, therefore it may have end results that impact endocrine and metabolic function. With visceral fat accumulation, we can also see an increase in inflammatory cytokines. These inflammatory cytokines wreak havoc on endothelial and blood vessel cells linking visceral weight gain to metabolic dysfunction as well as blood vessel and cardiovascular dysfunction and risk.
Evaluating Stress-Related Symptoms in Males
In summary, we can link our high achievers and go-getters with increased levels of cortisol and stress. Understanding the physiology behind our cortisol/testosterone relationship can strongly impact treatment as well as quality of life including all-cause mortality reduction in males.
It is important to evaluate levels appropriately to understand how best to support and treat our patients. DUTCH testing allows for a comprehensive evaluation of cortisol production, how much cortisol is produced on a daily basis, and how that cortisol is used throughout the day. DUTCH testing is also a valuable tool in evaluating androgen levels, as well as estrogen levels.
Understanding the presenting symptoms and confirming hormone levels allows appropriate treatment. In reviewing treatment, we know some key factors include: 
- Stress management – reducing the negative effect of cortisol
- Appropriate sleep patterns – this includes the ability to fall asleep, as well as falling into the appropriate sleep phase for optimal hormone production and metabolism
- Exercise/purposeful body movement – generally for a Type A personality, doing activities that modulate stress are preferred, such as yoga or something more meditative. It is not generally helpful to include additional stressors to the body such as intense HIIT, Orange Theory, or other activities that can draw more cortisol on top of an already stimulated stress response
- Nutrition – anti-inflammatory in nature with whole foods that are real foods! The less processed, the better
- Herbs and supplements – things that can generally support stress response include Vitamin C, B/B complex, and Fish Oil
- Supportive relationships and a strong support network – our relationships significantly affect our mental health. Feeling alone can exacerbate feelings of stress, anxiety, tension, and overwhelm
Testosterone Therapy is Only Part of the Equation
An important consideration and question would be: Does Hormone Replacement Therapy (HRT) (testosterone therapy -TTh) help to reduce these issues? We have seen that herbs may help to improve testosterone receptor function as well as HPA balance. TTh has to be a discussion between the patient and provider as each individual should be evaluated according to their own age, overall health risk, and predictive health risks depending on personal and family history. There are studies that show TTh can reduce risk and improve quality of life. But we need to be aware that TTh is not the only answer – TTh can only work well when other factors – such as stress and cortisol – are also well balanced. So the foundational approach to this should always include a review of stress and cortisol. As cortisol is involved, we will want to review the importance of HPA function as well.
Tips for HPA Support and Managing Stress
Our HPA relies on appropriate circadian rhythm, as well as overall stress management, time management, and blood sugar management. So beginning support for our HPA response includes:
1. Routine – we need to have routine in our schedule, which should include- Routine bed time and sleep time (consistent hours of sleep)
- Routine blood sugar – expected eating times through the day, not erratic
- Routine physical activity (some complementary overlaps for Testosterone and cortisol!)
2. Stress management
- Time management
- Finding a way to release stress – this could be individualized as appropriate
- Ashwagandha, Rhodiola, holy basil, cordyceps
- B Vitamins
- Amino acids that support healthy resilience in stress including taurine, l-theanine
Foundational support is important for overall treatment and outcomes. Remember that TTh won’t work without a strong foundation. We can wave off stress fairly easily, especially as a Type A person, but we need to understand the positive AND negative impacts this can have on overall health. Not just for today, but also for our future.
