Dr. Lindner, Guest
Thyroid Nation

Adequate levels of cortisol are essential to health and quality of life

This fact is becoming increasingly clear to doctors who are trying to help people by natural scientific methods. In fact, cortisol is the foundation of the entire endocrine system. It is essential for our adaptation to the demands of life, yet all other major hormones counteract it. If a person does not make sufficient cortisol, their quality of life is low. They also cannot tolerate or benefit from the optimization of their thyroid, estrogen, DHEAS or even testosterone levels. By trying to help patients with fatigue and pain with natural methods and by performing saliva testing for cortisol levels, Dr. Lindner has learned that partial cortisol deficiency is common, especially among women. Women have lower cortisol levels/effects and responses than men do.

Cortisol deficiency accounts for women’s much higher incidences of fatigue, anxiety, depression, fibromyalgia, and autoimmune diseases.

Indeed many studies have demonstrated a hypoactive hypothalamic-pituitary-adrenal system in persons with these problems. Studies also show that the SSRI anti-depressants (Prozac, Paxil, Lexapro, etc.) act upon the brain to increase ACTH production and cortisol levels. This is one reason why they alleviate so many different kinds of symptoms, and also why it is so hard to stop taking them (cortisol withdrawal). Indeed, many drugs of abuse have been shown to raise cortisol levels including amphetamines, marijuana, cocaine, ecstasy, nicotine, and even caffeine! This fact is, no doubt, one reason that these drugs are so addictive–especially to persons with low cortisol levels–and why stopping these drugs is so difficult.

The symptoms of partial cortisol deficiency

The symptoms are just milder versions of those found in severe adrenal insufficiency.  They include:

• Fatigue
• Aches and pains
• Brain fog
• Allergies
• Frequent infections
• Low blood pressure
• Low stress tolerance
• Anxiety
• Irritability
• Hypoglycemia
• Frequent nausea
• PMS/PMDD
• Autoimmune diseases
• Excessive sweating
• Teeth grinding
• Restless legs
• Hot flashes
• Insomnia

Sufferers feel like they often have the flu. One of cortisol’s functions is to maintain the blood sugar level throughout the day. Hypoglycemia causes irritability, confusion, headaches, hot flashes, sweating, and palpitations and can trigger seizures. Hypoglycemia can also awaken a person from sleep at night with anxiety and sweating. Cortisol deficiency is often unmasked when a person takes thyroid hormone. The higher thyroid levels increase both the metabolism of cortisol and the need for cortisol.

If a person feels worse taking thyroid doses that they need, they have an underlying cortisol deficiency.

Higher estradiol and progesterone levels in the latter half of the menstrual cycle also block cortisol’s effects in women; so cortisol deficiency is often the cause of severe PMS/PMDD and of intolerance of estradiol and progesterone replacement in menopause. The nausea and vomiting of early pregnancy and post-partum depression have both been associated with cortisol deficiency and have improved with cortisol supplementation. For those who need it, cortisol supplementation improves mood, energy, mental functioning, sleep quality and the ability to handle physical and emotional stress. It helps with allergies and autoimmune diseases. We all need optimal levels of this foundational hormone.

Most common form of cortisol deficiency is partial central adrenal insufficiency

This is due to inadequate ACTH production. It is not diagnosable by current conventional practices. Most doctors think that all cortisol deficiency is Addison’s Disease. However, the problem usually does not lie in failure of the adrenal glands. The brain-hypothalamic-pituitary system is simply not secreting enough ACTH throughout the day to stimulate sufficient cortisol production by the adrenals. The usual screening test for cortisol deficiency, a serum AM cortisol test , is insensitive for a number of reasons. It’s reported with a reference range of 5 to 20mcg/dL, yet experts know that a result under 14mcg/dL is suspicious. Even physicians suspect cortisol deficiency, they believe that they can rule it in or out with an ACTH stimulation test. This is a false idea. It is superphysiological test that proves only that the adrenal glands can make normal AM amounts of cortisol under maximal stimulation. The ACTH stim. test is abnormal only in cases of nearly complete pituitary or adrenal gland failure. It is normal in the much more common partial central cortisol deficiency. This has been repeatedly documented. To diagnose cortisol deficiency, the physician must consider symptoms first and the free cortisol levels second. A serum cortisol test shows the total cortisol in the blood, but this level is affected by the amount of cortisol-binding globulin. Serum free cortisol levels are available at some laboratories, but one’s cortisol level prior to being stuck with a needle after driving to a lab is not likely to represent one’s usual level. The best test of free cortisol levels in the blood throughout the day is a diurnal salivary cortisol profile. These samples are collected at home during a normal day. The accuracy of saliva cortisol testing is well established. Unfortunately, most doctors do not do saliva testing, and the statistical ranges that most labs report have low lower limits of “0”, obviously incompatible with health. So as it is, physicians have no way of seeing the low free cortisol levels in their patients with fatigue, depression, hypoglycemia, and chronic pain. Based on research done by ZRT Laboratories to create diagnostic saliva cortisol reference ranges, published studies, and his own experience, Dr. Lindner uses these ranges for LabCorp/Quest LC/MS saliva tests:

Morning: 0.25 – 0.60  mcg/dL   (30 mins after awakening)   Labcorp range   0.025 – 0.60
Noon:      0.08  -0.20  mcg/dL   (right before lunch)             Labcorp range <0.01 – 0.33
Evening: 0.04 – 0.13  mcg/dL   (right before dinner)            Labcorp range <0.01 – 0.20
Night:      0.02 – 0.07  mcg/dL   (right before bedtime)         Labcorp range <0.01 – 0.09

ZRT’s own ranges, and those of other labs that use immunoassays are about 50% higher. See Testing for more information about testing for adrenal insufficiency. Notice that LabCorp’s lower ref. range for the AM saliva cortisol is almost zero, far below the level of 1.8 or 2.0 mcg/dL advocated by some experts. It is, in fact, incompatible with life–yet this is what happens with ranges when one performs a 2 standard-deviations-from-the-mean analysis on a population data set that is not a perfect bell-shaped curve.

Even if physicians suspect cortisol deficiency, they are afraid to prescribe cortisol

Doctors have no experience with cortisol replacement, but have a lot of experience with the damaging effects of pharmacologic doses of powerful non-natural “steroids” (e.g. prednisone, dexamethasone). They inappropriately generalize this negative experience to cortisol supplementation. They believe that any dose of cortisol taken long-term will cause negative effects like Cushing’s syndrome. They are not completely wrong, because they do not understand the importance of DHEA. Oral glucocorticoid therapy, whether hydrocortisone (HC) or an artificial steroid, suppresses ACTH and therefore DHEA production, thus creating a severe deficiency of a major anabolic hormone. DHEA is the body’s natural cortisol antagonist and prevents many of the negative effects of cortisol. DHEA has anabolic effects through conversion to estradiol and testosterone within tissues throughout the body. DHEA is practically unknown to conventional medicine, even though it is the most abundant steroid hormone in the human body (20 times more abundant than cortisol, 8000 times more than estradiol or testosterone!). There are thousands of studies detailing its contributions to health and the consequences of deficiency. For instance, studies show that women on 10mg of prednisone daily start gaining bone mass when given DHEA. Again, it’s another example of the use and misuse of pharmaceutical hormone substitutes causing doctors to overlook the benefits and safety of balanced hormone restoration. Dr. Lindner prefers sublingual DHEA as it delivers more of the active hormone into the circulation. People taking cortisol or any artificial steroid must restore their average DHEA levels to those of a young person of the same sex: around 200mcg/dL in women, 300mgc/dL in men. This usually takes 10 to 25mg of sublingual DHEA for women, 25 to 50mg for men. If DHEA is swallowed, the dose needs to be 25 to 50% higher.

Physiological cortisol supplementation accompanied by DHEA, by definition, does not produce any negative effects

Since HC produces much more fluid retention than the artificial steroids, over-dosing is much easier to detect. A person will
notice fluid retention, weight gain, facial puffiness, higher blood pressure and increased blood sugar. The doctor and patient
simply have to look out for these signs and reduce the dose if they appear. HC is short-acting compared to the artificial steroids– this also helps avoid overdosing. Dr. Jefferies popularized the ideas that people should take only 20 to 30mg of HC daily.
Conventional medicine gives 20 to 35mg/day to Addison’s disease patients. People with central cortisol insufficiency often also need full replacement doses also since every dose they take further suppresses their already weak ACTH production. Higher cortisol doses are needed in persons who are replacing their DHEA, as they must, and in those who are taking thyroid hormone as both of these counteract cortisol strongly. Many people need 40-60mg/day. Cort. supplementation, optimized to the lowest dose that provides full clinical benefit, and combined with DHEA replacement, is just good medical practice. It is more effective and far safer for inflammatory conditions than the alien “steroids” and non-steroidal anti-inflammatory medicines doctors prescribe every day (e.g. prednisone, methotrexate, Motrin®, Enbrel®, Humira®, Mobic®, etc.).

(Hopefully we will have Plenadren here someday–it should greatly simplify cortisol replacement with a once-daily tablet that provides both a quick-release of cortisol and a slow-release over 24 hrs. As it is, oral HC replacement therapy is a kind of pulse therapy. With the immediate-release HC tablets, cortisol levels peak at 1 hr at superphysiological levels, then drop rapidly to pre-dose levels in several hours–how long depends upon the dose and the time of day. Generally, it is best to take the largest dose upon awakening, about half that dose at lunchtime, and, only if needed, half of the lunch dose at dinner time and at bedtime. Daytime-only (morning-afternoon) dosing is preferable if it works as the person’s own ACTH-cortisol production then must kick in overnight; so there is suppression of endogenous production.)

While HC dosing must ultimately be guided by symptoms, seeking the lowest doses that eliminate symptoms, saliva testing is accurate when a person is swallowing HC tablets and can be used to  help adjust the HC doses. (Saliva tests are not accurate if person is taking the HC sublingually or transdermally.) One can use ZRT’s ranges or Dr. Lindner’s Labcorp/Quest ranges. Saliva cortisol levels just prior to the next oral dose should be low-normal or a bit low for that time of day–since the level was much higher for a couple hours after the previous dose. For instance, if a saliva cortisol level prior to the noon or dinner doses is high-normal or high for that time of day, then one should try reducing the previous dose. Conversely, the cortisol dose may be too low if a peak saliva cortisol level at 1 to 2 hrs after a dose is just “normal”–since it will be much lower at 3 or 4 hrs when the next dose is due. If someone is taking HC, the awakening saliva cortisol, before the dose, will show how much cortisol they are making on their own–since the bedtime dose will be long gone. If the AM saliva cortisol, before taking HC, is very low, it does mean that there is marked suppression of their own ACTH/cortisol production. That is OK if that HC regimen is what is necessary for that person–they will just  have to be more careful to stress dose and not to miss doses. Since most cortisol insufficiency is central, in such persons oral HC doses can easily suppress the already weak ACTH production. People vary a lot in the amount of HC and the number of doses that they need. Each person has to find out just what doses they need, at what times, to eliminate their cortisol-deficiency symptoms–and the goal is always the lowest dose that still works.

Mild insufficiency, even if recognized, often does not require cortisol supplementation

A person can greatly reduce their demand for cortisol by taking steps to eliminate stress in their life, by getting a good night’s sleep, by assuring that they have time for enjoyable activities, by moderate daily exercise, by getting proper nutrition and taking supplements, by eliminating any foods from their diet to which they are allergic (gluten, dairy, soy, eggs, etc.), by identifying and by identifying and treating any ongoing infections in their body (root canal, H. Pylori, intestinal dysbiosis, etc.). The best physicians to help with these kinds of problems are those trained in Functional Medicine.

Deciding to supplement with cortisol is a serious matter, as cortisol is the body’s major stress-response hormone

A person who requires cortisol supplementation to function and feel well didn’t make enough cortisol prior to therapy, and will make less cortisol in response to stress when they are taking cortisol–due to the suppression of their own already-weak ACTH production. Therefore most people on long-term cortisol replacement need to take additional cortisol when ill and prior to stressful activities. The person must essentially take over their own cortisol regulation–increasing the dose whenever they realize that they are under more stress, are more physically active, or are ill. They should wear some easily-noticed medical alert jewelry stating that they have “Adrenal Insufficiency”. There are many options today, including USB drives that contain all relevant medical history. See this site for examples.  The medical alert jewelry will prompt medical care providers to look for a medical card, so patients should also carry a medical card containing the diagnoses, personal identifying information, doctor’s names and contact numbers, and medications. One can create a medical card online. Patients can obtain an emergency treatment card with specific recommendation for doctors here.

About the Author

Dr. Lindner graduated Magna Cum Laude in 1984 from Jefferson Medical College in Philadelphia. Being more interested in philosophy and neuropsychology than medicine, he entered a psychiatric residency. However, he soon realized that psychiatry was committed to a pharmaceutical “diagnose and drug” scheme based upon false genetic and neurotransmitter theories. He resigned after a rotating internship, deciding to do “real medicine” instead. He was assigned to be a general medical officer and flight surgeon in the US Air Force. After service in Izmir, Turkey and Lowry AFB in Denver, he left the Air Force in 1989 and took a position in Riyadh, Saudi Arabia as the chief physician for the employees and families of Boeing and McDonnell-Douglas corporations in that country. It was not until he returned to the US in 2004 that he discovered there was an alternative to pharmaceutical medicine. He was introduced to bioidentical hormone replacement by Dr. Sandra Lane–a chiropractic physician who had taken a course with Dr. Neal Rouzier. He is writing papers and books on the need to re-create the practice of endocrinology. He thought initially that he would just replace hormones typically lost with age–the male and female sex hormones. However, he soon began to see many women seeking “hormone replacement” who had severe fatigue, pain, insomnia, and other symptoms  that did not respond to sex hormone replacement. Seeking a natural explanation for their symptoms, he found that they often suffered from undiagnosed or undertreated iron, Vitamin D, thyroid and/or cortisol insufficiencies. He now believes that most cases of chronic fatigue, fibromyalgia, and depression and other general symptoms are caused, at least in part, by deficiencies of these known hormones and nutrients. Please follow him at his website.

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