Hormone Treatments in Chronic and Intractable Pain
Once chronic or intractable pain is reasonably well controlled, patient and physician alike want some curative or permanent amelioration, in addition to symptom relief. To date, some physical therapy techniques and possibly some nutritional supplements provide a degree of permanent amelioration of pain, but these measures often fall short of wanted results.
Although early in what is clearly an emerging practice, some hormone treatments appear — albeit based primarily as anecdotal reports — to greatly enhance symtomatic pain control and possibly bestow some curative and ameliorative properties. Basic science research on some hormones distinctly points out sound reasons why some hormones should enhance pain treatment. Summarized here is a compilation of hormone treatments and their rationale for current usage by pain physicians to compliment their standard symptomatic treatments.
Definition Of Hormone
For purposes here, a hormone is defined as a compound which is produced in a body organ and secreted into the blood stream to perform some physiologic function(s). Some hormones, such as gamma amino butyric acid (GABA) and pregnenolone are produced within neurons and secreted into the blood as well as function within neurons as neurotransmitters.1-4
Why Are Hormone Treatments Needed?
Undertreated severe, chronic, and intractable pain depletes many hormones.5-8 With good pain control, some low serum hormone concentrations may return to normal.9 Some adrenal stress hormones, such as cortisol and adrenalin, may elevate in uncontrolled pain as evidenced by tachycardia and hypertension. Prolonged hypercortisolemia produced in severe, intractable pain may produce manifestations of Cushing’s disease including osteoporosis, dental erosion, obesity, fatigue, and muscle wasting. Adrenal insufficiency, with symptoms of Addison’s disease including cachexia, hypotension, electrolyte depletion and muscle wasting, may occur as the adrenal gland exhausts. While severe, chronic pain produces some hormone deficiencies, opioid administration may also suppress pituitary excretion and worsen some hormone deficiencies, particularly testosterone and possibly thyroid.10,11 Hormone treatments are basically given to replace those that are depleted or suppressed by severe, chronic, or intractable pain and/or the underlying disease. It may also be that intermittent supraphysiologic serum levels of some hormones such as pregnenolone, adrenal androgens, GABA, human growth hormone, and chorionic gonadotropin may promote healing of nerve and other soft tissues to permanently reduce pain12-15 (see Table 1).
Precursor of adrenal and sex hormones
GABA & NMDA receptor binding
|Gamma Amino Butyric Acid (GABA)||Inhibitory Neurotransmitter
Release growth hormone
|Dihydroepiandrostone (DHEA)||Testosterone production|
|Human Growth Hormone (HGH)||Tissue construction|
|Chorionic Gonadotropin (HCG)||Tissue construction
Releases thyroid and testosterone
Table 1. Table of hormones currently used in pain patients
Testing For Hormone Deficiencies
Serum testing is available, reliable, and accurate for pregnenolone, androstenedione, DHEA, testosterone, cortisol, and thyroid. However, serologic tests for GABA, growth hormone (HGH), and chorionic gonadotropin (HCG) are best considered research at this time. GABA and HCG have such baseline low levels that deficiency assessment is impractical, and HGH is secreted in pulsatile fashion, making a single blood analysis unreliable.
Serum testing is best done in the early morning when most hormone serum levels are at their peak.5,9 All clinical laboratories have connections to reference laboratories who perform most of the hormone tests which are used in pain treatment. Almost all insurance and health plans cover the cost of hormone testing. Testing for certain hormone deficiencies is particularly recommended for the severe, intractable pain patient who is going to require long term pharmacologic treatment with opioids and neuropathic agents. Re-testing can be done at any interval such as quarterly or yearly once hormone treatment is initiated or a hormone abnormality is detected.
Hormone treatments are generally started at a low, daily dosage and titrated upward over time to either normalize a low serum concentration or achieve a therapeutic response. Table 2 lists the author’s recommended starting dosages. Human growth hormone, chorionic gonadotropin, and testosterone products have recommended, labeled dosages. Total daily thyroid replacement is about 3 to 4 grains and cortisone is about 20 mg. Lesser dosages than total replacement usually suffice in pain patients who initially demonstrate serum deficiencies.
|Pregnenolone||50 to 100mg a day|
|Gamma amino butyric acid (GABA)||1500 to 3000mg a day|
|Androstenedione||25 to 50mg a day|
|Dehydroepiandrosterone (DHEA)||25 to 50mg a day|
|Thyroid||1 to 3 grains a day|
|Cortisone||10 to 15mg a day|
|Human Growth Hormone (HGH)||5mg a day|
|Chorionic Gonadotropin (HCG)||1000 USP units (1cc), 1 to 3 times a week|
|Testosterone||Males— 5 grams of 1% gel each day, Females— 2.5 grams of 1% gel every other day|
|* Dose is titrated upward, over time, to achieve a clinical response.|
Table 2. Recommended starting dosages.