Table of Contents:
Salivary Cortisol: Testing
One hormone that is not optimally tested in the blood is cortisol. For many reasons, saliva is better than blood. For one, saliva testing was the first way ever developed to test for cortisol.89 Saliva is a better indicator of intra-cellular levels.90 What goes on inside the cells tends to be more important than what goes on in the serum, or liquid, part of our blood. Finally, the very worst time to check the level of the “stress hormone” cortisol is right after stabbing the person with a sharp object. And a blood draw is stabbing a person with a sharp object. Immediately, this alters cortisol levels.
FIGURE 6.8 Salivary control.
Spitting tends to be a lot less stressful for most people. Plus, cortisol levels need to be checked at 8 AM, noon, 5 PM, and 10 PM.91 Saliva cortisol testing kits are available from several companies (Figure 6.8).
Salivary Cortisol: Interpretation
Cortisol, the “stress hormone,” should be highest in the morning and go down as the day progresses, hitting its low point at bedtime.91 We fall fast asleep easily. Nothing keeps us awake. We get wonderful restorative sleep. Nothing wakes us up. No pain, no bladder, no noise. Nothing. The “sleep of the dead.” We then wake up feeling great. Totally energized and refreshed. We then jump out of bed and do it all over again. As you might imagine from this description, many of the chronic pain patients seen will have cortisol issues and may even have the completely opposite rhythm: low all day long and then cannot shut down at night. “Tired and wired” is one way this may present.
Cortisol is designed to go up and down many times a day with any kind of stress. To the body, stress is stress. It doesn’t matter if it is emotional, physical, spiritual, or biochemical stress. It is all the same stress to the body. If you stub your toe and hop around in pain, this is physical stress. Driving in a bad snowstorm is emotional stress. But if a person experiences too much or too great a stress or for too long, cortisol can go all the way up and stay in the “on position.” They are stuck in the “fight or flight” mode. The “life or death” mode. The “there is a bear chasing me trying to kill me” mode.
Now when the body is stuck with cortisol running high at all times tested, this is called stage 1 adrenal fatigue.92 (I believe it is important for every physician to know that these terms and concepts have been described in the scientific literature for many decades. This reference here, in the British Medical Journal, is from 1950.) The hormone DHEA, like cortisol, will need to stay in an ideal level, or even increase temporarily, in order to allow the person to continue “running from the bear” even though they do not feel very well. If a bear is chasing you, you want to be able to keep running even if you don’t feel so well. Stop running and you are dead, or so your body thinks. But because the person is running 24 hours a day, 7 days a week, day after day, month after month, they are feeling worse and worse over time.
This cortisol crash also seems to be a last-ditch effort by the body to protect itself and mainly the brain which is “on fire” and deteriorating rapidly. The most problematic area is the hippocampus, but also, the hypothalamus, prefrontal cortex, and amygdala.93 The long-term high cortisol levels downregulate the immune system, creating an immunosuppressed state thus allowing the infections to get into the body and establish themselves.
When one out of the four cortisol test results is lower than the ideal and the others are still high, this is called stage 2 adrenal fatigue.92 When two or more are low, this is stage 3.92 When a person has crashed all four times in the day this is the worst. This is when a “time bomb” starts ticking for things like a heart attack, stroke, cancer, and diabetes91-94
Some newer terms that may more accurately reflect what is truly occurring are starting to take the place of the older, more traditional terminology: hypercortisolism when levels are high, hypo- cortisolism when low, and mixed cortisolism when some levels are low and some high.
Salivary Cortisol: Treatment
No matter what stage of adrenal dysfunction a person is in, they need calm. The free apps “Insight Timer” and “Calm” may be good options for many patients. The biochemical stressors that we have been discussing in this chapter must also be addressed.
But the most important item to use is a supplement product called an “adrenal adaptogen.”95 This is a combination of several different herbs and some vitamins that create calm in the adrenal gland.
As an “adaptogen,” it is not directional. It is balancing. If a person has a cortisol level that is high, it will help to bring it down. If a level is too low, it will come up. If a person has a combination of high and low, all cortisol levels will tend to move towards the ideal.
Eventually, when cortisol curves have normalized, the adrenal adaptogens can be stopped as well.