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 (Important note: STTM is an information-only site based on what many patients have reported in their treatment or the wisdom they gained. Please work with your doctor. This is not meant to replace that relationship or guidance, and you agree to that by reading this website. See the Disclaimer.)

Do one of more of the following fit you??

    1. Having strange reactions of hyper-like symptoms when trying to raise natural desiccated thyroid or T3 (heart palps, fast heartrate, shakiness, anxiety, or etc)
    2. Not doing as well on desiccated thyroid or T3 as you hoped, even when your doctor had you raise to 2 grains or higher of NDT, or 50 mcg or higher of T3? 
    3. A high free T3 with continuing hypothyroid symptoms
    4. Feeling anxiety more than you think you should
    5. Finding yourself more defensive than normal, or a need to argue, or feeling paranoid?
    6. Having internal or external shakiness?
    7. Insomnia…or waking up an hour or two after you fall asleep for the night
    8. Waking up consistently at 3-4 am, i.e 3-4 hours before you would wake up for the morning
    9. Not getting up feeling refreshed; feeling sluggish or tired; feeling tired again 1-2 hours later.

Here’s a potential reason why:

If you …

  • were hypothyroid for several years before being diagnosed (either because no one understood, or your doctor kept using the lousy TSH and saying it was normal)
  • have been on T4-only medications like Synthroid, Levoxyl, Eltroxin, Oroxine, Tirosent, etc (which end up poorly treating hypothyroidism for all too many)…
  • have experienced chronic/ongoing emotional or biological stress of any kind…
  • have chronic inflammation, lyme, or mold exposure, or any chronic illness.

…your stress-busting adrenals may have been working hard to keep you going. They first do this by providing you with rising cortisol (and adrenaline), aka high cortisol levels as revealed by a saliva cortisol test. Even a poor diet and excess exposure to heavy metals, toxins, mold, lyme and more could have further stressed your adrenals.1

But the body can only keep up with high cortisol for so long. So then what happens? The second part of the process:
cortisol will start to fall in places. The last chapter of the STTM II book by Lena D. Edwards, MD explains this brilliantly and is highly recommended. You can even have a problem in the HPA axis, which is the messaging between your hypothalamus, pituitary gland and adrenals, and can result in the adrenals failing to respond well.2 This can mean adrenal function inhibition.

Then comes low cortisol

The third part of the process involves patients who report finding themselves with poor levels of cortisol as revealed by both symptoms and saliva testing.  Results will show moderately low cortisol, or seriously low cortisol. This low cortisol is not the same as the disease called Addison’s in most. Instead, it’s simply a situation where, though your adrenals may still work, they are either ut-of-sync or inhibited. Aldosterone can fall in some, too, patients have reported.

Why is the right amount of cortisol so important?

Cortisol, a corticosteroid hormone, has a variety of important functions, from the metabolism of carbohydrates, proteins, and fats, to affecting the blood sugar levels in your blood, to helping reduce inflammation, to helping you deal with stress. The latter is especially huge.

But cortisol also plays an important role for you as a thyroid patient! Namely, cortisol raises your cellular level of glucose3 which seems to work with cell receptors, ATP and mitochrondria to receive T3 from the blood to the cells. So without the right amount of cortisol, you remain hypothyroid.

Signs and symptoms of a cortisol problem

Dysfunctional adrenal output can result in T3 going high in the blood rather than reaching the cells, called pooling. Some
patients may not realize it’s happening. Others will either still feel quite hypo, or can have symptoms like anxiety or nervousness, light-headedness, shakiness, dizziness, racing heart, sudden weakness, nausea, feeling hot, or any symptom which seems like an over-reaction to desiccated thyroid or T3, but are in reality the result of low cortisol, or a mix of high and low in the early stages of sluggish adrenal function. Low cortisol can also keep you
hypothyroid with hypo symptoms.

  • Click here to read actual recorded patient symptoms of poorly functioning adrenals.

Thus, it can be important for you and your doctor to rule out insufficient adrenal function. Most patients will notice the strange reactions early on, while a minority may not until they get as high as 3 grains or more.

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DISCOVERY STEP ONE:
Here are exploratory questions similar to the beginning of this page, and if you answer yes to two or more of these, you may have struggling adrenal function (the revised STTM book has more questions in Chapter 5):

1) Do you have a hard time falling asleep at night?

2) Do you wake up frequently during the night?

3) Do you have a hard time waking up in the morning early, or feeling refreshed?

4) Do bright lights bother you more than they should?

5) Do you startle easily due to noise?

6) When standing from sitting or from lying down, do you feel lightheaded or dizzy?

7) Do you take things too seriously, and are easily defensive?

8 ) Do you feel you don’t cope well with certain people or events in your life?

DISCOVERY STEP TWO:
The following are self-tests to try if you suspect your adrenals are struggling:

TEST ONE:

Take and compare two blood pressure readings—one while lying down and one while standing. Rest for five minutes in recumbent position (lying down, tho some do sitting) before taking the reading. Stand up and immediately take the blood pressure again. If the blood pressure is lower after standing, suspect reduced
adrenal gland function, and more specifically, an aldosterone issue–another adrenal hormone. The degree to which the blood pressure drops while standing is often proportionate to the degree of hypoadrenalism. (Normal adrenal function will elevate your BP on the standing reading in order to push blood to the brain.) It can be wise to do this test both in the morning and in the evening, since you can appear normal one time, and not another. (More about blood pressure plus how to take it correctly here, plus this.

TEST TWO:

This is called the Pupil test and primarily tests your levels of aldosterone, another adrenal hormone. You need to be in a darkened room with a mirror. From the side (not the front), shine a bright light like a flashlight or penlight towards your pupils and hold it for about a minute. Carefully observe the pupil. With healthy adrenals (and specifically, healthy levels of aldosterone), your pupils will constrict, and will stay small the entire time you shine the light from the side. In adrenal fatigue, the pupil will get small, but within 30 seconds, it will soon enlarge again or obviously flutter in it’s attempt to stay constricted. Why does this occur? Because adrenal insufficiency can also result in low aldosterone, which causes a lack of proper amounts of sodium and an abundance of potassium. This imbalance causes the sphincter muscles of your eye to be weak and to dilate in response to light. Click here to see a video of fluctuating pupils, and thanks to Lydia for providing this.

TEST THREE:

Let someone shine a bright light your way. Even the above pupil test could have revealed this. Do you find
yourself overly sensitive and uncomfortable with the bright light? That could be a sign of adrenal fatigue as reported in literature. And this can also be true if you have searing headaches along with the sensitivity.

TEST FOUR:

You can determine your thyroid and adrenal status by following Dr. Rind with a temperature graph–doing your Daily Average Temps with a LIQUID THERMOMETER. You simply take your temp 3 times a day, starting three hours after you wake up, and every three hours after that, to equal three temps. (If you have eaten or exercised right before it’s time to take your temp, wait 20 more minutes.) Then average them for that day. Do this for AT LEAST 5 days. If your
averaged temp is fluctuating from day to day more than .2Fyou need adrenal support. Again, your daily average temps should lean towards the .2F or less from each other when on enough cortisol for your needs. Summary from Dr. Rind: If your temps are fluctuating but overall low, you need more adrenal support and thyroid. If your temps are fluctuating but averaging 98.6F, you just need adrenal support. If it is steady but low, you need more thyroid and adrenals are likely fine. (We note that mercury thermometers are the most accurate.)

For those already on cortisol, the above temperature test (comparing at LEAST 5 days of averages) is ideal to know if you are on enough cortisol for you needs–a physiologic dose. In other words, if any daily averaged temps (not individual temps_ are more than .2F from another day’s, you are not on enough cortisol, patients have learned (most of those daily averages should be .2F or less from each other). Overshooting your cortisol supplementation can also cause this instability.

***Women: if you are still menstruating, it’s best to do your Daily Average Temps started at the end of your period i.e. away from your mid-cycle or ovulation.

DISCOVERY STEP THREE:

EVEN MORE CONCLUSIVE, and the test which patients agree is critical if any of the above are suspicious: a 24 hour adrenal saliva test, NOT a blood test. Note that the 4-point saliva test is very adequate. Save your money instead of getting the 6-point.

Saliva testing is stated to measure your cellular levels at four key times in a 24 hour period–revealing whether you have high cortisol (which can have similar to symptoms to low cortisol), or a mix of highs and lows (which can be problematic in raising NDT and cause too much RT3), or a majority of lows, which is extremely problematic when raising thyroid meds, causing hyper-like symptoms and excess RT3.

Unfortunately, doctors tend to recommend a one-time blood test, or an ACTH Stimulation test, or a 24-hour urine test, but patients have reporting saliva to give them better information.(4)

Blood is measuring both your bound and unbound cortisol–not always helpful, report patients, nor does it tell what goes on at different times. It can look high when you are actually low! The ACTH Stimulatory will tell you how much stimulation your adrenals are getting, but not how much cortisol they are producing. Granted, the ACTH Stim test can be valuable if there is suspicion of a pituitary dysfunction, Addison’s or Cushings.(5) Let your doc help you with that! But we have noted that most patients with sluggish adrenal function have healthy ACTH stimulation. A urine test simply gives you an average of a 24 hour period, and that masks being high one time, and low another,
which are important clues to sluggish adrenals. (More detail on this in STTM book)

IMPORTANT NOTE: Patients have discovered there are many supplements they need to be off of for up to two weeks to get a clear picture what is going on. But study the page carefully.

**ORDER YOUR OWN 4-point SALIVA TEST

The treatment patients have used successfully

The Adrenal Wisdom page explains what patients have learned for treatment of their adrenal issues, whether high cortisol, a mix of highs and lows, or mostly low cortisol.

Chapter 6 in the revised STTM book gives an excellent detailed explanation of what patients have learned in the use of HC/hydrocortisone/Cortef (and it can also refer to the use of Adrenal Cortex). But the use of HC should be your LAST choice, say patients, and/or only based on extremely low cortisol levels. Minor to moderately low cortisol might benefit from adrenal cortex (ACE) supplements, but you still need to follow the guidelines as shown in Chapter 6, say informed thyroid patients. Or some use the CT3M successfully,
especially if they only have low morning cortisol. Work with a good doctor on all this! None of this is meant to replace that relationship or guidance.

**Do note that if you have chronic inflammation, that can potentially cause a sluggish HPA axis, hampering even the T3CM/CT3M. Test both ferritin and CRP to see your inflammation state.

You can also participate in discussion on either of these adrenal treatment methods by joining Facebook patient groups, listed here.

WHAT ABOUT HIGH CORTISOL??

Cortisol going high three or more times in a 4-point saliva test is actually the first stage of a “progression” that can eventually lead to having low cortisol. i.e. the rising high cortisol represents the early and persistent stress on one’s body, or can represent ANY ongoing stress at any time. If this stage is caught by a patient via saliva testing, it becomes a matter of lowering all those highs. This page is an example of what patients use to lower their high cortisol.

IS IT POSSIBLE I HAVE CUSHINGS DISEASE EXPLAINING MY HIGH CORTISOL?

The vast majority of hypo patients have observed over the years that their high cortisol had nothing to do with Cushings. Cushings is usually defined as having an ACTH-producing tumor on the pituitary gland (or less often, elsewhere in the body) or a dysfunction in the adrenals themselves.

But if you have any reason to suspect having true Cushings Disease, most doctors define three kinds of tests to get a clue. Many doctors admit pitfalls with any of these in diagnosing since other issues can cause high cortisol, but it’s a start:

1) DEX SUPPRESSION TEST–this is the most common test and measures how your cortisol levels change in response to an injection of dexamethasone, a strong cortisol-like medication.
2) 24-HOUR URINE TEST — if high, could imply Cushings, but even thyroid patients with high cortisol could show high urine levels, so it may not be definitive by itself. Some doctors admit this, as well…
3) 11 pm to MIDNIGHT SALIVA TEST – researchers feel this gives a high sensitivity for the diagnosis6, BUT.…we
know from observation that many hypothyroid patients can still have HIGH late evening cortisol not from having Cushings.

An MRI can be another diagnostic too to discern if one’s high cortisol comes from an ACTH-releasing pituitary tumor.

Another small body of thyroid patients could have created what is called “Cushings Syndrome7. This could happen with someone who is determined to be on HC/Cortef in too high amounts (not doing ones Daily Average Temps to find their right physiologic amount, as taught by Dr. Rind), or being on HC/Cortef even though their saliva results didn’t show the need for it (the reason patients and informed doctors see the need to do saliva cortisol testing). Please work
closely with your doctor on this.

The above is simply information, not a diagnosis. Work with your doctor. 

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P.S. For “some”, sluggish adrenal function causes extra estrogen production. And sadly, the higher your estrogen, the more bound both your thyroid hormones and cortisol will be.  Explains Dr. Hotze here (in relation to childbirth and postpartum, but applies to what I explained above):

High levels of estrogen causes an increase in levels of cortisol-binding globulin which – you guessed it – binds cortisol in the blood. The amount of free cortisol available to enter the cell membranes and activate receptors inside the cell is now greatly diminished. In addition, estrogen dominance interferes with the release of cortisol from the adrenal cortex. Another key fact is that cortisol is made from progesterone. When progesterone levels dramatically decline after pregnancy, so does cortisol production. Whether it is an inhibited output of cortisol from the adrenal cortex, an overall decrease in cortisol production or whether cortisol is bound in the bloodstream, all follow with the same result: adrenal fatigue.

  • Some people have low cortisol/adrenal insufficiency due to other issues like Addison’s, hypopituitary or a hypothalamus problem. Read about them here.
  • Click here to read the most FREQUENTLY ASKED QUESTIONS about adrenal support.
  • Why exercising after the baby is born is not a good idea if you have low cortisol.
  • A comprehensive article explaining the adrenal glands.
  • Go here to read the Internt’l Hormone Society’s CONSENSUS on CORTISOL REPLACEMENT, and sign the petition

Please let me know if any of links suddenly fail to work. Websites do change occasionally.

(1) http://dujs.dartmouth.edu/fall-2010/the-physiology-of-stress-cortisol-and-the-hypothalamic-pituitary-adrenal-axis

(2) http://qjmed.oxfordjournals.org/content/93/6/323

(3) http://www.jbc.org/content/239/5/1299.full.pdf

(4) http://www.sciencedirect.com/science/article/pii/0009898181903533

(5) http://patient.info/doctor/pituitary-function-tests

6) https://csrf.net/understanding-cushings/diagnostic-testing/

7) https://csrf.net/doctors-articles/med-induced-cushings/medication-induced-cushings/