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Do your adrenal glands wake you at 3 a.m.?

There is a world of difference between the opinions of conventional physicians and integrative physicians when it comes to the subject of our adrenal glands. In medical school I received excellent instruction on the anatomy and physiology (A&P) and healthy functioning of the adrenal glands. In case you skipped that lecture, they are small glands that sit atop our kidneys and are divided into two hormone-producing regions. The inner part of our adrenals (the medulla) produces epinephrine and norephinephrine, or adrenaline, our “fight or flight” hormones. These hormones kick in whenever there is a perceived threat, and gear us up for either fighting off the threat or fleeing from it. The outer cortex produces the hormone cortisol in a more gradual and consistent way, but also in response to stress, especially chronic stress. 

After A&P classes, we next studied Pathophysiology. In conventional medical “wisdom” the adrenal glands are either fully functioning or fully failed. Addison's disease is the term for complete adrenal failure, requiring life-long replacement of adrenal function. Physicians practicing in a more integrative model have realized that it's actually not all or nothing: as with many other bodily functions, the adrenals can fatigue and perform in a less than optimal manner, and that impaired level of function can be diagnosed and reversed long before it progresses to full-blown Addison's disease.

Let's look at adrenal function, particularly cortisol production, and that sleep problem I mentioned above.

Cortisol plays a key role in our physiology, I think of it as one of the two “master hormones”, affecting physical, mental, and emotional strength and well-being. Healthy levels of cortisol hormone are secreted in a carefully orchestrated 24-hour (circadian) rhythm, starting out highest in the morning and falling to mid-range throughout the afternoon, and quite low during the night. The adrenal glands start the next day's cycle just before dawn, so levels can be high enough to meet the demands of waking up and starting a new day.

Cortisol's circadian rhythm is complex, as are the relationships between cortisol and all of the body's hormones, particularly insulin and thyroid hormones. Insulin, secreted by the pancreas in response to sugars in the diet, works to take sugars out of the blood stream and store them as body fat. Cortisol, secreted in response to stress, primarily promotes fat storage as well, so chronic stress and a carbohydrate rich diet stimulate both hormones together and added fat storage. When carbohydrates have been excessive in the diet, insulin response is usually excessive, resulting in a sharp dip in blood sugar levels and more cortisol is released so the very low levels can rise back to normal. Which elicits more insulin, which …. You get the idea.

The other master hormone is thyroid, secreted by our very complex thyroid glands not in a daily pattern but rather regulated by several built-in negative feedback systems, suppressing further production when levels rise to high.  The thyroid gland releases hormone mostly in a T4 configuration, called thyroxine, which is a little like a savings account form of thyroid hormone: can be activated for use, but not immediately usable. Triiodothyronine, or T3, is the active (checking account or debit card) form that is released in smaller amounts by the thyroid and created in different body tissues when it is needed, from circulating T4. An additional feedback system is the Inactivation of T3 by cortisol (and other factors), shunting it into a form called reverse T3, which isn't useful to the body. Failure to measure reverse T3 levels is just one of the many ways an apparently normal but incomplete thyroid panel can fail to detect why you are more tired than the numbers suggest.

Almost any time that thyroid hormone levels fall below what is needed, the body perceives stress and releases extra adrenal hormones. A momentary problem might yield more adrenaline, while long sustained abnormal levels yield more cortisol. And then even more cortisol is needed, and pretty soon the body loses its ability to finely regulate that perfect circadian rhythm.

So when there is a long period of emotional or physical stress, your 24 hour cortisol producer is working a little harder. As if it feels the need to get up a few hours early to start on what will be a big task, it starts releasing cortisol more than just a few hours before dawn. In folks undergoing chronic stress, it's not unusual to see the highest levels approaching bedtime, with everyone finally wearing out and running out of steam early afternoon. These folks find it difficult to go to sleep, or wake at 2 a.m. and can't return to sleep - and then they are exhausted in the early afternoon, thinking they will really get a good night's sleep tonight. But, alas, the adrenal gland is still thinking of 24 hour patterns, and is hard to get out of last night's pattern, even when you are very tired.

Even worse, if thyroid inadequacy and cortisol dysregulation proceed too long, the adrenal gland loses its ability to even produce adequate cortisol levels. Before it devolves into full blown Addison's disease, it sometimes offers adrenaline as a substitute for cortisol, released at the same times that cortisol levels have peaked. These folks wake up at 2, 3, or 4 a.m., but they don't just slowly wake up: they wake up in a panic. And they might feel panic completely inappropriately: the phone rings, and rather than just mustering the energy to go answer it, they panic, because their adrenal medulla has stepped in on everyone's behalf and released adrenaline where it is absolutely not needed!

Diagnosis and Management

Suspecting an adrenal problem is the first step in diagnosis. Common presenting problems, in addition to sleep disturbances, are fatigue, blood sugar imbalance (including hypoglycemia, pre-diabetes, and type 2 diabetes), frequent illness, excessive levels of inflammation, change in normal moods, osteopenia or osteoporosis, worsening of allergies.

Diagnosis requires a combination of blood tests (for thyroid levels, including reverse T3 as mentioned above) and a saliva test called the Adrenal Stress Index. Four saliva samples collected over a 24-hour period reveal what your adrenal glands' circadian rhythm is, and relates it to other hormones as well. The conventional medical test is one or two blood samples which do not reveal the circadian rhythm.

A search for causes might include a recent personal and medical history and physical examination, investigation of nutritional status, possible food allergies and digestive health, and an evaluation of the environmental toxin load to which you are exposed, all of which can create stress and lead to adrenal problems.

Management of the problem depends of course, on the cause, the nature and severity of your problem: are your adrenals mildly stressed, completely dysregulated, or heading towards burnout?

For mildly stressed adrenal glands, and for prevention of problems if you're currently totally healthy, a healthy lifestyle includes the following considerations:

  1. Nutrient dense foods, with abundant animal protein, organ meats, healthy fats, fresh fruits and vegetables.
  2. Avoidance of toxic foods, certainly vegetable oils and margarines, fast food, GMO containing foods, and excessive caffeine, alcohol, and sugars. Other exclusions depend on your own food sensitivities
  3. Supplement with vitamin D as needed and Fermented Cod Liver Oil for essential fatty acids. If you have some early morning wakening, but without other worrisome symptoms, consider taking Integrative Therapeutics Cortisol Manager which combines phosphatidyl serine (good adrenal food) with herbs well recognized for their adrenal calming effects. Take 1-2 tablets at bedtime for managing pre-dawn cortisol surges.
  4. Get some real sunlight! Spending time outside at dawn and late afternoon can help regulate the pineal gland, and for some folks helps with sleep disruptions.
  5. Exercise, but not enough to stress yourself! If you work hard at anything physically, give yourself a day or two to recover before you tackle another big task or physical challenge.
  6. Sleep at least 7 hours a night, more if you've been sleep-deprived before that. No screen time 2 hours before bed, no electronics in the bedroom, and keep that bedroom as dark as you can, and cool enough so your face is cool, however many covers your body needs. Read our article on getting a good night's sleep for more tips.
  7. Include some pleasure and play in your life.

For more advanced problems, all the same rules apply, though they might get a bit more stringent! A wider supplement protocol is usually required, tailored individually depending on the results of the personal evaluation. So at the end of it, the bad news is that your adrenals can truly suffer and your standard lab tests will not reveal what's going on. The good news is that there is a lot you can do to reverse early problems and that almost any integrative or functional medicine physician will be able to help you resolve more serious problems!

From DrDeborah's Desk

Andrea had been a patient of mine for some time when she came in complaining of severe exhaustion. She had been on thyroid replacement for quite some time, and her levels seemed adequate. When we met - close to twenty years ago - I was only “conventionally” educated about the adrenal glands and frankly didn't consider that they could be a problem. However, when she saw the endocrinologist he realized they were the problem and ordered conventional testing. Not only were her adrenals barely producing cortisol, they failed to do so in response to an ACTH challenge, the gold standard of adrenal failure. Her glands were depleted and he did not expect them to function ever again in her lifetime and started her on cortisol replacement. He said she had definitive Addison's Disease and that it would be permanent.

If I saw her now, the part of the story written above would have unfolded differently, but it had a happy ending, even that long ago.

She was not happy with life-long cortisol replacement (“Thyroid hormone is enough!”) and asked if we couldn't do something to get her adrenals going again, despite the grim prognosis from the specialist. We reviewed her recent life, which had included quite a dramatic series of initiations, voyages to the Amazon, some challenges and some heroic rescues. Although she was exhausted she had quite wild and even euphoric dreams. She described her senses as “on fire”, and revealed that sounds were too loud, lights too bright. With many other confirmatory symptoms, I prescribed the homeopathic remedy made from Ayahuasca from the plant family Geraniales.

When she went back to her endocrinologist, off the prescribed medication and measuring normal on all her adrenal tests, he said she indeed no longer had Addison's Disease.

She: “Have you ever seen Addison's Disease go away before?”

He: “No, it doesn't do that.”

She: “But mine did.”

He: “Yes it does appear to have resolved.”

She: “Do you want to know what I did?”

He: “Not really, but I do want you to keep doing it, whatever it is.”

At the time I wondered why he wasn't curious, but a few years later when I realized I had to devote all my after hours study to either conventional or integrative medicine, I was glad I had a solid background in conventional medicine, knew my keeping current would be limited, and appreciated his honesty and support!