DISCLAIMER: the goal of this page is to provide information to take into your doctor’s office, and is not intended to replace that relationship. You are responsible for the results or consequences of your choices based on general information presented here. Please consult with your doctor about this information. Need a good one? Go here.

****See things on this page that needs updated?  Use the Contact Me form and let me know. We are in this together, and let’s teach others!

This page outlines what patients have learned about treating sluggish adrenal function/HPA dysfunction–the latter revealed via the 24 hour cortisol saliva, then via information and experience.  Your first choice can be the T3 Circadian Method. But if you have hypopituitary and cortisol is needed, the ultimate goal is to find the amount of cortisol which is right for you—the amount that finally stabilizes fluctuating temperatures of challenged adrenals, then gets thyroid hormones from your blood to your cells (see Discovery Step Two, Step 4 on the Adrenal Info page about temp taking, or more information in Chapter 5 of the revised book), as well as allows your sluggish adrenal/HPA to rest.

Doctors we admire have stated that after you’ve held the above goals for several months or up to a year and more, and have corrected/treated other issues (aka gluten intolerance, reactivated EBV, low B12, low ferritin/iron, highly stressful situations, to name a few), you can then attempt to slowly WEAN OFF to allow your adrenals to kick back in. Some of their patients take longer than others to achieve this. Using the T3CM has helped MANY folks wean off HC faster and better.

WHAT DO I USE FOR MY ADRENALS?

When you have confirmed sluggish cortisol levels, or a mix of highs and lows as revealed by the 24 hour adrenal saliva test , it can be time to talk to your doctor about support. And often, all that is needed is Adaptogens for some (when morning is good, noon is too high, afternoon is low, for example), or over-the-counter support like Isocort or Adrenal Cortex for others. Some can benefit with the use of Licorice Root, which prevents the cortisol you do have from being broken down by the liver. All the latter can work well if you have one or two areas of low cortisol.

If there are mixed results, such as a low followed by a high, or vice versa, adaptogens have worked well for many to even those out. Adaptogens include those like Ashwagandha or Rhodiola.

But there are some adrenal saliva results which are quite low and across the board. Those patients may need to talk to their doctors about the use of HC, aka hydrocortisone.  A particular brand is Cortef. This is outlined below and would be more for folks who have hypopituitary.

Another option is in doing the T3 Circadian protocol as discovered and outlined by Paul Robinson in his book Recovering With T3.  It’s a particular way of using T3 in the early morning hours to promote the adrenals to perform well again. You can order his book from here.

IMPORTANT: many patients rush into the use of HC when Adaptogen herbs and/or OTC adrenal supports would have done the trick.

IF I NEED HC BECAUSE ADAPTOGENS OR OTC SUPPORT WASN’T ENOUGH, or YOU HAVE HYPOPITUITARY, HOW DO I DO IT?

With HC, patients used to follow a slow ramp-up of cortisol. But it became clear that it caused severe and uncomfortable adrenaline rushes in response to the low amounts of cortisol, i.e. lower doses can suppress more than they are replacing when your cortisol is too low, and thus the adrenaline response. Instead, it has become a better treatment to “start on” 20, 25 or 30 mg dosing from the start, with 25 mg starting dose the most common, and 30 mgs for more severe low cortisol as revealed by the saliva test.

Here is a good starting-dose schedule based on experience and good information. It’s important that your free T3 is not high in the range when starting this schedule. Also note that many seem to need to start at 25 or 30:

For 20 mgs (mild adrenal fatigue):  7.5 – 5 – 5 – 2.5
For 25 mgs (moderate adrenal fatigue–a common starting dose): 10 – 7.5 – 5 – 2.5
For 30 mgs (severe adrenal fatigue, Stage 5 or higher, or good for men):  10 – 10 – 5 – 5

i.e. the first of four doses is first thing in the morning, then four hours later, four hours later, and the final dose at bedtime if it doesn’t keep you awake or if your nighttime saliva cortisol result wasn’t too high.

From observation and experience, many patients seem to end up in the 30-35 mgs range when their temps are stable, and men even higher.

ONCE I GET ON THE STARTING DOSE OF HC, WHAT NEXT?: The first step after starting on HC is to find out if that amount is giving you stable temperatures—a sign that you are on the right physiologic amount for your needs. Patients wait a minimum of five days after starting HC, then begin the process of  obtaining five-days-in-a-row minimum of a single “daily averaged temperature”. i.e. on each given day, take your temperature three hours after you wake up, three hours after that, and three hours after that. Add the three temperatures up, divide by 3. That gives you your first “daily average temperature”. Do that five days in a row. What are you looking for? That no two temps in that group of averaged temps are no more than .2-.3 apart, with a trend to being .2 apart. That will point to whether your current amount of HC is the right amount of HC for you. If you do find two temps more than .2 to .3 apart, patients have learned to raise their total HC amount by 2.5 (never going above 10 mg at any one time, by the way), wait five days, then start the temp taking process again. For most, only raising by 2.5 is crucial, since overshooting your needs can send you back to unstable temps.  To see where we learned this go to Dr. Rind’s page here and scroll partly down to the heading Recognizing Adrenal and Thyroid Correction Patterns.

WHAT IF I’M ALREADY ON DESICCATED THYROID WHEN I START USING CORTISOL: If you are already on natural desiccated thyroid when you start cortisol, patients and their doctors have discovered that they need to decrease their desiccated thyroid at the same time they are increasing cortisol to prevent uncomfortable adrenaline surges when the T3 moves into the cells. Those adrenaline surges feel like hyper with extreme anxiety, racing heart, and/or other uncomfortable symptoms. If you feel this discomfort, even after decreasing the desiccated thyroid, patients find it helpful to stop the desiccated thyroid completely for a day or two or more, then raise back up. Some may need to get completely off desiccated thyroid and move to T3. See below.

WHY I MAY NEED TO SWITCH TO T3-ONLY: It turns out that having a cortisol problem can also mean the T4 in desiccated thyroid can convert to too much RT3, which in turn prevents T3 from getting to the cells. Thus, some patients figured out that being on T3 alone (aka Cytomel or Cynomel) for awhile is the best way to lower the high RT3, allowing a full 10-12 weeks for the RT3 to clear, and to stay on T3-only longer until you discover and treat other issues like low B12, Celiac  or gluten intolerance, low ferritin and iron, etc. Other patients have had success lowering RT3 by doing a liver cleanse. To know if you have an RT3 excess: test the ratio between your free T3 and reverse T3 to ascertain an RT3 excess. See the chapter on reverse T3 as well as the online Free T3/RT3 ratio plug in.

WHY DO I HAVE MUSCLE WEAKNESS WITH MY CORTISOL SUPPLEMENTATION: The use of cortisol, even the smallest amounts, intially can cause your testosterone levels to tank. So you may need to talk to your doctor about testosterone supplementation for the first few weeks or months until they return to normal.

WHAT IS MY GOAL WITH ADRENAL SUPPORT: Patients have learned that they have to reach three goals for adrenal healing to work: one, to find the dose of cortisol which gets the thyroid hormones to the cells and helps rest the adrenals; two, the right amount of desiccated thyroid or T3 to remove hypothyroid symptoms, which in turn takes the strain off the adrenals; and three, correction/treatment of other issues (low ferritin, low B12, gluten intolerance, etc).   The optimal doses of cortisol are held for up to a year, occasionally less, many times more. Then starts the slow weaning process, allowing the adrenals to kick back in slowly, such as 2.5 mgs a week less. Stress dosing may be necessary.

LABWORK FOR HEALTHY ADRENALS  vs. DYSFUNCTIONAL ADRENALS?: Generally, individuals with healthy adrenals will have the 8 am reading in the upper part of the range, if not slightly over. The noon reading with strong adrenals will also be in the upper part of the range, but not quite as high as the morning. The afternoon result will be a bit lower, and the midnight result will be at the bottom of the range, which allows you to sleep, just as the high morning reading helps you wake up refreshed.  More on understanding lab values here. With unhealthy adrenal function, you can find your morning mid-range or lower, your noon reading high or low, your afternoon high or low, and your evening far too high, for example.  Even farther down the scale of sluggish function is finding all four times of the day low.

WHY IS THE CORRECT AMOUNT OF HC SO IMPORTANT? The right amount, according to Dr. Jeffries in his excellent book Safe uses of Cortisol, “takes the strain off of the residual adrenal tissue and provides for more functional reserve in times of stress”. The right amount helps you receive thyroid hormone in your cells instead of pool thyroid hormone in your blood. The right amount improves your immune system.  The right amount helps lower your excess Reverse T3. And so on.

HOW CAN I ABSORB MY HC OPTIMALLY: Since so many hypothyroid patients make too-little levels of stomach acid, it can help you to swallow your HC with one tablespoon Braggs Apple Cider Vinegar in water or watered-down juice.  Works beautifully. Or, use the stomach acid replacement product called Betaine.,

WHEN I DO THE 4 TIMES A DAY OR MORE DOSING, SHOULD I TAKE THE FINAL DOSE AT BEDTIME: Some patients find it helpful to take that final amount at bedtime to help them sleep, since it prevents adrenaline surges and hypoglycemia, but it’s individual. Some try 2.5 mg; others need 5 mg.

IF I AM NOT YET ON DESICCATED THYROID, HOW LONG DO I USE HC BEFORE I START DESICCATED THYROID: If you are not on natural desiccated thyroid when you start cortisol, talk to your doctor about following the schedule above. Hold several days, then do your daily averaged temps. When you find stability in those temps, it is usually safe to start on lower doses of T3-only, or in some cases, desiccated thyroid. The revised STTM book has an excellent section on using T3.

DO I NEED EXTRA CORTISOL DURING STRESSFUL SITUATIONS: Healthy adrenals would produce extra cortisol in times of physical or emotional stress. So, if you have to undergo a stressful event, or even have a sickness, patients found it wise to “stress-dose”, which is adding more cortisol to each of your daily amounts, such as 2.5 to 5 mg.. If you have a severe illness like the flu, that stress dose amount can end up being up to 20 mg each time.  Jefferies states: In events of stress, “higher dosages of cortisol are required to maintain a physiologic state that would produce hypercortisolism with it’s well-known undesirable effects in the unstressed states. The increased secretion of adrenal hormones serves to meet an increased need during stress and tends to maintain homeostasis rather than to disturb it. The increased secretion does not cause a state of hypercorticism such as develops when the titer of these hormones is increased artificially in the absence of need. Hence, a patient with adrenal insufficiency under stress may require dosages of cortisol to maintain a physiologic state that would produce hypercortisolism with its well-known undesirable effects in the unstressed state. This higher amount can be up to double what you would normally take daily.”After the illness or short term extreme stress subsides, you then start to taper down to your original doses.It’s also worthy to note that if you are having to stress dose quite often during a week’s period, you may simply not be on enough cortisol overall.

WHAT CAN I DO ABOUT THE NAUSEA I FEEL WHEN SWALLOWING MY CORTISOL?: Patients have learned that taking cortisol with food can help prevent stomach upsets. Or, some patients switch to 1% hydrocortisone cream rubbed on different spots on one’s skin. 1/4 tsp equal 10 mgs.

WHY ARE MY LEVELS OF CORTISOL SUPPORT NOT WORKING FOR ME? Just as it’s important to find the right amount of HC, it’s also important to make sure you haven’t overshot your HC needs because you failed to raise in small amounts, and also failed to rigidly do your daily average temps on each small raise.  But sometimes, even when doing it all correctly, a patient finds they are not getting good results. We have learned that low aldosterone may be an issue to explore. Additionally, some patients metabolize HC faster than others, so the solution is to space your HC doses closer together than the recommended 4 hours between doses. We have also found doctors who switch their patients from HC to Methylprednisolone with the brand name of Medrol to achieve better results, since Medrol metabolizes more slowly and is longer acting.****Another tip before raising your HC higher or switching to Medrol: try adding an HCL (hydrochloric acid) supplement to your HC dose, such as Hydrochloric Betaine. HCL represents the majority of your digestive fluids, and many hypothyroid folks can be low, making digestion less effective. Another alternative is one tablespoon Apple Cider Vinegar mixed with water–very effective.

TELL ME MORE ABOUT ALDOSTERONE: The adrenals also produce a hormone called Aldosterone, and in some adrenal patients, it can go low as well. Symptoms can include having to go to the bathroom frequently at night, and craving salty foods. Read more about aldostestrone here.

CAN I USE OTC HYDROCORTISONE 1% CREAM?  Some patients will use the over-the-counter cream after finding out with saliva testing that their cortisol results are low.  If cream is used, patients learned to change the place they put it, since HC can thin the skin. Mostly, HC cream is used until they can get to the doctor for consultation and a prescription, or for stress-dosing–the latter being an ideal use of the cream, say many patients. On a dosing syringe, the 1 ML line = 10 mg HC cream, and the 0.5 ML line = 5 mg. HC cream.  Or, 1/4 tsp equals 10 mg.

WHAT DO I NEED TO REMEMBER: In folks with healthy, non-sluggish adrenals, their adrenals give them the amount of cortisol they need automatically. So for those with sluggish adrenals, your goal with adrenal support is to give back to your body what your adrenal dysfunction with low cortisol can’t give. And sometimes it’s a guessing game, but you will come to know your body and how it feels. Additionally, the purpose of adrenal support is to help your adrenals to hopefully rest and recover.  Generally, once you have been on an ideal amount of adrenal support for several months and more,  have found your optimal dose of desiccated thyroid or T3 (which takes the stress off the adrenals), and have identified and treated other conditions, you will want to consider a very slow decrease of your adrenal support (2.5 mg every three weeks, for example) to allow your own adrenals to kick back in. During this time, it’s wise to be on Vit. C., since the highest concentration of ascorbic acid in the body occurs in the adrenal cortex. Giving your body Vit. C helps the adrenals to function better, and supports them. This is ALSO true with sea salt. Dr. Brownstein recommends 1/4 to 1/2 tsp in good water per day…Dr. Wilson advocates that numerous times throughout the day. Again, just be sure to drink at least an 8-10 ounce glass of good water (no fluoride or chlorine, if possible, since we get too much of both) for each 1/4 to 1/2 tsp you take. One patient likes taking 1/4 – 1/2 tsp. in about half a cup of water, and then follows that with a big glass of water.

WHAT IF UPON TAPERING DOWN MY CORTISOL, I GET UNCOMFORTABLE: If, upon a slight decrease, you find symptoms returning, it’s a sign you need to hold your optimal adrenal support a bit longer. So you can go back up to your former cortisol dose, hold, and try a decrease later on. Hopefully, the Daily Average Temp taking was done to know that a dose was the right dose. Thyroid patients on cortisol have learned that the wean has to in small amounts, and very slow.

• The following comes from Peatfield’s book Your Thyroid and How to Keep It Healthy:
  

  Page 122, Your Thyroid and How to Keep it Healthy: Once the hydrocortisone is started, the full support dose is now built up to effective levels over two or three weeks….spread out through the waking day. The reason (to spread the doses out throughout the waking day) is that it is not stored by the body and gets rapidly used; two or three hours will see it pretty well used up completely. Since a smooth level of support is desirable, the dose needs to be spread out. The final dose is usually 20 mgs daily, that is half a tablet four times a day; but careful adjustment relating to the response may take the dose to 25 or 30 mgs daily, exceptionally even 40 mgs. These higher doses are related more to absorption in the stomach than to deficiency, but low adrenal reserve reaching Addisonian levels may make such doses necessary. And on page 123: The length of time necessary to provide adrenal support is really very variable. My normal practice has usually been to obtain the best result with thyroid and adrenal support, and after six or eight weeks {of having optimal thyroid support with optimal cortisol support], start to tail off the cortisone supplement. If there is no adverse results, it may then be stopped–taking, say four weeks in the process. Sometimes, the patient starts to lose ground; and you then have the choice of replacing it with a glandular concentrate for a longer period or restarting the cortisone, and in another eight weeks or so another attempt to tail it off is made. Sometimes, the adrenals have been so badly hit that the adrenal support may be required for months, and if the adrenal glands never fully recover, for a more indefinite time. Again, I emphasize that if adrenal support is required, it must be given for as long as it takes; there is no risk to this since one is simply restoring the situation to normal, in the same way, and for the same reason, that thyroid support may have to be given indefinitely.

To see this chapter from Peatfield’s book in it’s entirety, go here.

FINAL REMINDER: As mentioned by Peatfield and as observed in patient experience, remember that those on adrenal support have TWO goals. First, to find the amount of cortisol that gets the thyroid hormones from the blood to the cells and stops your fluctuating temps, and second, to be on an optimal amount of desiccated thyroid along with a good heartrate and blood pressure. If you don’t achieve both, adrenal rest and healing can be delayed.

WHAT IF MY CORTISOL IS HIGH AT NIGHT: Generally, those with high nighttime cortisol are going to have low morning or noon cortisol. So being on the scheduled cortisol above is going to eventually correct the high nighttime cortisol. In the meantime, try supplementing with 300-800 mg. Phosphatidylserine aka PS. Take it before bedtime. You may need to be on the higher end of the range above to lower it. To read even more about PS, click below: http://qualitycounts.com/fpps.html Another patient has been able to lower her nighttime cortisol by taking Melotonin before bedtime. It may take several weeks before you notice the difference.

Want to order your own labwork?? STTM has created the right ones just for you to discuss with your doctor. Go here: http://www.stopthethyroidmadness.com/recommended-labwork

****SEE things on this page that needs updated? Use the Contact Me form and let me know. We are in this together, and let’s teach others!

• Click here to read the most FREQUENTLY ASKED QUESTIONS about adrenal support.
• Go here to understand the 7 stages of adrenal fatigue. You will see that some stages mean you have levels all over the place before they all come down. Note: When I have done an unofficial poll, as high as 75% of those who participated had confirmed adrenal insufficiency. It’s common.
• Can you take DHEA with adrenal fatigue? Some studies say it will lower cortisol; others say it doesn’t. And some adrenal patients will tell you they do fine with it. See Dr. John Lowe’s comments about this here.