The use of salivary cortisol in evaluating the status of our adrenal system can be very helpful when treating fatigue, insomnia, anxiety, depression or post-traumatic stress syndrome.
Adrenal Function and Cortisol
The conventional interpretation of cortisol found in the blood is often restricted to the diagnosis of hypocortisolism or hypercortisolism. The most common examples of these disorders are Addison's disease (low cortisol) and Cushing's syndrome (high cortisol). Naturopathic medicine, in some cases, has embodied the approach of simplifying the non-conventional approach to the definition of "adrenal fatigue," which is quite often inadequate. Adrenal function is complicated and involves numerous levels of functioning in the body.
The hypothalamus (in the brain) controls reactions to stress and regulates various body processes such as mood. This system is deeply connected to the very make-up of our physical and emotional well-being. One approach to treating individuals with low cortisol is to provide them with adrenal supplements or glandular products. When cortisol is elevated, especially at night, using anti-stress techniques or herbal products to reduce the hormone can help.
Cortisol Regulation
Cortisol is at the highest level upon awakening and gradually declines throughout the day. There does seem to be a day-to-day variation in the pattern; however, the early morning peak with a gradual decline is "typical." Numerous factors can have an effect on daily cortisol patterns. Aging, quality of sleep, and time of awakening will affect this pattern. For example, in normal individuals, earlier than usual awakening is associated with increased morning peak levels of cortisol, while late awakening exhibits decreased levels. This variation is important when performing and interpreting salivary cortisol tests. In addition, conditions such as depression, anxiety, chronic fatigue syndrome (CFS), fibromyalgia, cancer and metabolic syndrome all show blunted or inconsistent cortisol patterns.
Changes with Aging
As we grow older, a general shift to increased evening levels of cortisol has been noted in the normal, healthy elderly population. In relation to cortisol, studies suggest that frailty, depression and dementia can affect the "typical" diurnal pattern in elderly persons. One study found that elderly persons with memory deficit and/or depression demonstrate a flat or blunted diurnal pattern of cortisol.
Depression/Anxiety
A common symptom of depression is early morning awakening. Many of my patients, prior to treatment for depression, report a "cortisol-like" surge upon awakening. In addition, if salivary cortisol is measured on early awakening it may increase this peak surge level. This surge will most likely correct itself following treatment. It may take the patient some time to adjust to this normalization. Individuals showing major depression with associated anxiety or post-traumatic stress disorder (PSTD) may demonstrate a pattern of evening cortisol hypersecretion.
Relaxation Techniques
There is ample evidence that lifestyle changes can have a huge impact on cortisol dysfunction. In a study published in Applied Psychophysiology & Biofeedback, it was reported that the use of progressive relaxation resulted in lower salivary cortisol levels and an increase in salivary immunoglobulin A (sIgA). Reduced levels of sIgA have been linked to increased upper respiratory infections in endurance runners. These relaxation techniques have also been shown to reduce conditions of high blood pressure, depression and anxiety.
Studies have been conducted on the effects on cortisol by using Mindfulness-Based Stress Reduction (MBSR). A one year follow-up involving patients trained in MBSR with breast and prostate cancer showed reduction in proinflammatory cytokines, reduced cortisol levels and reduction in self-reported stress levels.
Natural Interventions
Supplementation for cortisol dysfunction should be centered on trying to correct or adjust the underlying problem. Supplementation with hydrocortisone or DHEA may have a place; however, the use of these products may not be getting to the root of the patient's condition.
The use of amino acids such as L-glycine and L-tryptophan has been a foundation in my therapy in treating depression and anxiety, as well as insomnia. In addition, using a good B-complex supplement and a product called Cortisol Manager can also be very helpful.
- L-glycine is a strong neurotransmitter inhibitor, acting on the locus ceruleus, giving the patient a sense of well-being and calmness without sedative effects. High doses of 3-4 grams three times per day may be needed to get such an effect. I almost always use L-glycine in cases of anxiety or substance abuse-related anxiety and/or withdrawal.
- L-tryptophan, in combination with melatonin, can be very effective for insomnia associated with depression and/or anxiety. A starting dose of 1-3 grams of L-tryptophan with 3-5 mg of sustained-release melatonin seems to be a standard dose for my patients. L-tryptophan, of course, is a precursor to serotonin and melatonin. An increased intake of L-tryptophan results in increased brain levels of serotonin. Serotonin is found primarily in blood platelets and in the gastrointestinal tract. Other practitioners find similar results with 5-hydroxytryptophan (5-HTP).
- B-complex is an important adjunct therapy when treating with neurotransmitters, as thse vitamins are involved in numerous physiological processes. Taking 1-2 capsules each morning can benefit people suffering from any cortisol dysfunction.
- Cortisol Manager is a great supplement to balance cortisol levels, especially when people have trouble getting to sleep at night. I have people take 1-2 capsules about an hour before bedtime.
- When cortisol levels are low throughout the day, which is found in conditions such as chronic fatigue syndrome, I use a product called Cortrex by Thorne Research. The daily dose depends on each individual's needs.
Timothy Schwaiger, NMD
