Your Hormones in Harmony | Part 1

The Hormone Hierarchy

Prioritizing Hormone Interventions to Harmonize Your Health

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Dr. Aaron Hartman

January 30, 2024


Two years ago, I published a series on hormonal health. Since then, I’ve had the opportunity to further reflect on the beautiful harmony of our bodies’ hormones. I’ve talked with patients and clarified my approach. In this series, I am going to move systematically through the “Hormone Hierarchy,” providing practical guidance for correcting and maintaining your body’s harmony of chemical signals.

But I’m getting ahead of myself. What is, after all the Hormone Hierarchy?

The Hormone Hierarchy

Which hormones are the most important for your health?

For many people, estrogen, progesterone, and testosterone come to mind first. However, there are other hormones further upstream that will affect your estrogen or progesterone. If we don’t balance those first, then working on your estrogen or testosterone levels will be counterproductive. The way we address those in functional medicine is referred to as the hormone hierarchy.

The hormone hierarchy allows us to address the preceding factors first — those that affect other hormones beneath them in the hierarchy.

To understand how we arrive at this hierarchy, let’s dip (very briefly) into biochemistry. Hormones are any chemical signals that your body uses to stimulate cells or tissues to act. These chemical signals aren’t all made of the same kind of stuff. There are three basic types of hormones:

  • Lipid-derived
  • Amino acid-derived
  • Peptide-derived

All of your sex hormones (estrogen, progesterone, and testosterone) and cortisol are lipid-derived. They’re actually made from cholesterol. Yep; you heard me right — cholesterol.

So if your cholesterol is not balanced appropriately, that will affect everything else downstream.

At the top of the chemical hierarchy, we have pregnenolone, which forms the hormones dehydroepiandrosterone (DHEA), estrogen, and progesterone. DHEA, in turn, plays a role in creating cortisol, testosterone, and estrogen.

But the chemical composition isn’t the whole story. DHEA forms both your sex hormones and cortisol. But your cortisol levels have a greater impact on your overall health than your DHEA levels. The specific ways these chemicals act on our bodies have cascading effects. The Hormone Hierarchy represents that priority of effect.

Primary & Secondary Hormones

The primary hormones in this hierarchy are insulin, cortisol, and thyroid. These hormones are absolutely essential for life (you actually cannot live without them). All other hormones depend on these three.

It’s worth noting that some functional doctors will rank hormones into four separate tiers (e.g. 1 Insulin, 2 Cortisol, 3 Thyroid, 4 Sex Hormones). I’m including a diagram with 3 tiers but in many ways, I only think about the hiearchy in terms of primary and secondary. The “most important” primary hormone will often depend on your personal context.

What is critical to understand, however, is that you cannot adequately address the secondary hormones until you have addressed your primary hormones. While sex hormones are important for sexual development and healthy, vibrant living, they are not essential for life itself. Insulin, cortisol, and thyroid hormone are the critical factors to focus on first.

Before moving on, I want to highlight the Gut-Hormone Connection.

After your sugar levels, adrenals, and thyroid have been balanced, we next need to work on the main system that detoxifies all these hormones: the gut.

Gut Function in Hormonal Health

Many people do not realize that sex hormones are detoxified in the liver and gut system (remember that chemically, they are derived from cholesterol). In this process of detoxification, called enterohepatic circulation, the liver filters your blood. Your liver either kicks out the waste metabolites of hormones so that they can be removed via the gut, or makes them into water-soluble metabolites to be removed by your kidneys. If your gut is not functioning properly and you are constipated, have diarrhea, are not digesting properly, or are inflamed, that will affect your body’s ability to detoxify hormones.

Here is a brief (1 min) excerpt from my course, “Connected Health Gut,” where I discuss the Gut-Hormone Connection.

Only after first addressing gut health — so that your body’s detoxification is flowing — should we address the sex hormones: estrogen, progesterone, testosterone.

From another perspective, then, we might revise our diagram with the following:

The specific diagram we use, of course, is less important than that you get the concept. If your primary hormones are unbalanced, we need to address those first. Then, we need to address your gut health. Then and only then, can we effectively address your sex hormones.

Continuing This Series

In the rest of this series, I’ll first walk through the primary hormones (cortisol, insulin, and thyroid) then the secondary hormones (estrogen, progesterone, and testosterone). I’ll discuss symptoms and issues that accompany imbalances, and help you understand better how to maximize your hormonal health.

As always, remember that you were made for health. Your endocrine system (the fancy term for your hormonal system) is designed to create a beautiful harmony of signals in your body. When you know what to look for and what to prioritize, you can support your body and live a vibrant healthy life.

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