The Hormone Hierarchy: An Introduction to the New Series on Hormones

Dr. Aaron Hartman

January 4, 2022


This new blog series will discuss hormones and hormonal health as we step through many different hormones and discuss them individually. But first, in this post, I’d like to discuss the top-down functional medicine approach to addressing hormonal imbalances.

The Hormonal Hierarchy

First, what do we mean when we talk about hormones? For many people, estrogen, progesterone, and testosterone come to mind first when they think about hormones. However, there are multiple levels of hormones, and the way we address those in functional medicine is referred to as a hormonal hierarchy.
The hormonal hierarchy allows us to address the most important, preceding factors first – those that affect other hormones beneath it in the hierarchy. For example, often people jump to working on estrogen, testosterone, and progesterone without understanding the appropriate hierarchy and how to address factors that are further upstream.

Let’s unpack some of the hormones within the hormonal hierarchy. First and foremost, cholesterol is the precursor of the major classes of hormones. Yes, you’re reading this correctly – all of your sex hormones are ultimately made from cholesterol. So if your cholesterol is not balanced appropriately, that will affect everything else downstream.
At the highest hormone level, we have pregnenolone, which forms the hormones DHEA (dehydroepiandrosterone), progesterone, and estrogen. DHEA, in turn, plays a role in creating cortisol, testosterone, and estrogen. DHEA is further discussed in our next post in this series.
The most important hormones in this hormonal hierarchy are insulin, cortisol, and thyroid hormone. Not only are these main hormones absolutely essential for life (you actually cannot live without them), but all other hormones depend on these three.
While sex hormones (estrogen, progesterone, and testosterone, as well as others) are important for sexual development and healthy, vibrant living, they are not essential for life itself. For example, young children and the elderly have almost unmeasurable levels of sex hormones. Insulin, cortisol, and thyroid hormone are the critical factors to focus on first.
Once the thyroid, adrenals, and sugar levels have been balanced, we then 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 called the enterohepatic circulation. This is the process in which the liver filters the blood and either kicks out waste metabolites of hormones so that they can be removed 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.
After addressing gut health first, so that your body’s detoxification is flowing, only then should we address the sex hormones: estrogen, progesterone, testosterone.

Continuing This Series

In the rest of this series, I’ll walk through each one of these levels in the hormone hierarchy: the sex hormones, cortisol, insulin, and thyroid as we finish up. I’ll discuss symptoms, issues that accompany imbalances, and help you understand better how to maximize your hormonal health. The end goal of this series is to support you in living a vibrant, healthy life, in this phase of life and the next.
Take care and be well.
Since 2010, Richmond Integrative and Functional Medicine has been helping people to restore their health and hope with an integrative approach to conventional and alternative medicine that’s entirely science-backed. We at RIFM believe everyone is made for health. We offer a comprehensive, in-person patient membership program to ensure you get access to the care you need to thrive.


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