Saliva Cortisol Testing and Adrenal Fatigue

Saliva Cortisol and the Adrenal Stress Index Panel

Normally cortisol is 10 times higher in the morning than at night. How much stress you are under, and what you eat can also cause it to fluctuate during the day. Therefore, a single blood tests can not tell you much. You need to have multiple sample to make sure you don’t miss something. Saliva cortisol has several advantages over blood. First, it is a more true representation of how much cortisol each cell is actually getting. Secondly, saliva cortisol can be collected just about anytime and anywhere. This allows for multiple collections during the day. Saliva cortisol can also be collected when you are most under stress. That’s often when people need their cortisol tests.

The adrenal stress index panel is a test used by my go to lab for saliva hormones, Diagnostechs. The panel measures cortisol and other markers useful for assessing adrenal fatigue. More on the ASI panel at the bottom of this page.

The following sample cases show the advantage of saliva cortisol collection over blood tests.

Low cortisol through the entire day

In this case saliva cortisol is sub-optimal during the whole day. This is someone who is tired all the time and needs adrenal support. Support for other systems is probably needed as well. This could be working on diet, infections, detoxification, emotional stress. What the exact support needed is depends on the rest of the intake. 

ASI adrenal test. low cortisol at all times

Elevated morning cortisol

This person can have several symptoms. One may be high blood sugar. Cortisol raises blood sugar, so if it’s spiking during the night then someone may have high blood sugar while they sleep. Sometimes people eat well and have normal blood sugar during the day, but when their doctor tests them, they are become diabetic. Cortisol may be one reason why.

Anxiety and fatigue may also be present with this pattern.

Cortisol is very high in the morning. The rest of the day it comes back down to normal.

Inverted cortisol pattern

This person will be tired during the day and have a hard time waking up. Later on at night they may get a “second wind” finally have energy to do things and stay up late. Insomnia is possible with this pattern. I have often had people collect saliva cortisol late at night (or even if they wake up in the middle of the night) to see if there is a cortisol issue causing insomnia.

Inverted cortisol pattern on test. it is below normal in the morning and higher at night.

Getting cortisol tested

The lab I have always used for cortisol tests is diagnostechs. I like them because they are affordable and have lab panels which make sense and are clinically relevant.

Typically, cortisol is tested as part of the ASI test (Adrenal Stress Index). This panel includes the following markers:

  • 4 cortisol samples
  • DHEA: another adrenal hormone which helps to interpret cortisol levles and degree of adrenal fatigue)
  • 2 insulin samples: high cortisol can raise blood sugar and insuline
  • 17-OH progesterone: A progesterone made by the adrenal glands. This aids in overall interpretation.
  • Gluten IgA: a good screen test for gluten allergy and sensitivity. Can contribute to adrenal fatigue.
  • Secretory IgA: marker of immune system function. Greatly effect by stress and cortisol.

Small panels are also available is all of the above is not needed.

Naturopathic Treatment of Adrenal Fatigue

What Is Adrenal Fatigue?

The adrenals are small glands about the size of an almond that sit on top of each kidney. They produce the stress hormone cortisol. Cortisol is our body’s major stress hormone. It greatly affects how we feel and how much energy we have. Adrenal fatigue is the concept that long-term stress lowers the adrenals gland’s ability to make cortisol. Low cortisol then causes people to feel tired.

Image of adrenal glands

The General Adaptation Syndrome

In 1956 Hans Selye’s book “The Stress of Life” was first published. He based this on animal research of cortisol and adrenal function in animals. Experiments where done such as putting rats under stress, then testing then for changes in cortisol and size of the adrenal glands. He found that stress caused profound changes to the adrenal glands in three stages. He called this the general adaptation syndrome.

The stress of life book

Phase 1: Alarm

This is the fight-or-flight response. It’s designed to help us survive immediate danger. Cortisol surges to move more blood and oxygen to the lungs and muscle. Other systems not needed at the moment slow down.

Functions stimulated

  • Increased blood pressure
  • Strengthens heart contractions
  • increases blood sugar
  • Excites mood and focuses mental clarity.

Functions supressed

  • Decreased digestion
  • Decreased detoxification
  • Lowers immune system function
  • Protein catabolism. The body breaks down its own proteins for fast, emergency energy.

Phase 2: Resistance

If the acute stress does not go away, then cortisol can remain elevated. This lead to illness of high stress such as hypertension, and cardiovascular disease.

Phase 3: Exhaustion

If the adrenals glands can’t keep up and cortisol production drops. Too much cortisol is bad, but so is too little. We need to have enough cortisol for the following processes:
  • Maintain blood sugar
  • Maintain blood pressure
  • Regulate inflammation
  • Proper fluid and electrolyte regulation

Symptoms of adrenal fatigue include:

  • Low blood sugar (may cause hypoglycemia)
  • Inflammation (arthritis, aches, pains, worsens inflammatory conditions>
  • Insomnia (especially people who wake 2 – 3AM)
  • Decreased immune function – may often get sick with colds/flu/viral infections and takes longer to recover
  • Low blood pressure – may feel faint when standing up quickly
  • Cravings for salty food
  • Depressed mood
  • Frequent urination

Saliva Cortisol Tests

Cortisol is normally about 10 times higher in the morning than at night. It varies much during the day. Stress of eating sugar raises it. Reducing stress lowers it. A single blood test is typically not going to be very helpful.

When saliva cortisol tests came out, practitioners finally had a tool to measure cortisol through the whole day. Too high or low cortisol could now much more easily be found. Some people also have deregulated rhythms, such as cortisol low in the morning and high at night. At times knowing the pattern of adrenal function can help treatment.

For more on cortisol tests go to the functional medicine page.

What Is Stress?

Selye  defined stress as “the body’s nonspecific response to any additional demand.” Any is the key word. It doesn’t matter if the stress is long hours at work, a poor diet, or physical illness. The body has only one stress response. It tells the adrenals to make more cortisol.

The society we live in puts great stress on people. This can be from working too many hours, emotional stress, or eating a bad diet. Lifestyle changes help. This includes meditation, exercise, calming music or anything else which relaxes the nervous system.

We can’t easily escape from our stress. But supplements for adrenal fatigue can help us handle it better.

  • Herbal adaptogens
  • Calming herbs
  • B vitamins
  • Pregnenolone and DHEA
  • Glandulars

For more information, go to the page on adrenal supplements.

Adrenal Fatigue versus Chronic Fatigue Syndrome

Adrenal fatigue referrers to a state of diminished cortisol brought on by any prolonged stress.

Chronic Fatigue Syndrome is a condition of debilitating fatigue. It is typically associated with a weakened immune system. Someone with CFS may have adrenal fatigue, however the two are not the same.

For more information on Chronic Fatigue Syndrome go to this page.

Adrenal fatigue is one cause of fatigue. Is is not the only cause. The concept of adrenal fatigue is only useful within a holistic framework. Many different things can make someone feels tired.

Some of the more common triggers of fatigue include:

Infection
Heavy metals
Environmental toxicity
Candida and yeast
Viral infections
Lyme and confections
Poor immunity
Poor digestion
Anemia
Other hormonal issues
Structural / physical injury

Often several of these factors are working together to cause fatigue. It is important to support the adrenal glands, but this is often just one part of a larger picture.

Adrenal Supplements And Adaptogens

Adrenal Supplements And Adaptogens

Image of adrenal supplements, pregnenolone, dhea, glandular, licorice and oats.

Adrenal Supplements and Cortisol

The hormone cortisol plays a major role in regulating our stress response and energy production. Too little cortisol results in fatigue and often blood sugar problems.Adrenal supplements can be used to help boost cortisol production. Many of these actually have a balancing effect, raising cortisol when it is too low, and calming it down when it is too high. Herbs with those properties are called adaptogens.

This article reviews different types of adrenal supplements. For a more general discussion about adrenal fatigue follow this link.

DHEA and Pregnenolone.

In order to make cortisol and other hormones such as testosterone the body must first make them from cholesterol. The most difficult step is the first one, converting cholesterol into pregnenolone. It is still common for people to think that cholesterol is “bad.” However, without cholesterol you can’t make your hormones. In fact, low cholesterol may be associated with fatigue.

Both DHEA and pregnenolone are used as adrenal supplements. Pregnenolone may be converted into either cortisol or DHEA and other sex hormones. If DHEA is taken as a supplement, it will only be converted into the sex hormones.

Diagram Shows the Conversion of cholesterol into cortisol, DHEA, Testosterone and Estrogen

DHEA and pregnenolone is not appropriate for everyone.

These supplements can aggressively push hormone production. Hormones should be tested before starting supplementation. DHEA in particular can have many side effects, especially those related to high androgens (male hormones) and estrogens, as it can be covered downstream to both. Acne and hair loss can easily result from taking too much DHEA.

These only raise  hormones. Since they don’t help to balance out elevated hormones these are not adaptogens.
 

DHEA and pregnenolone are usually taken together. Taking a lot of one and none of the other may simply deregulate the overall hormonal picture even more. Pregnenolone will feed the cortisol pathway. DHEA can be converted into testosterone.

You may see these adrenal supplements are commonly sold in doses far higher than needed. For women who will benefit from DHEA, typically doses such as 5mg a day or less are sufficient. However, DHEA is often sold in doses of 25mg per pill or higher.

Supplementing with pregnenolone and DHEA for most people is best done with a health care professional. Lab tests should be run to monitor hormone levels.

This is typically not the first option I would try, but can be helpful in certain cases with lab tests.

Adaptogens

Adaptogens help if cortisol is is too high or too low. When taking in the morning it improves energy. At night it is calming and improves sleep.

For most people adrenal adaptogens are the best adrenal supplement to use. Their adaptogenic function makes then helpful for a wide range of people and low chance of side effects. Since they will not force hormone production in the way that DHEA and pregnenolone does, hormone lab tests are not needed.

When adrenal adaptogens work best

  • To help with the stresses of over day life. Long work hours, emotion stress and toxic exposure are some common examples of such stress.

  • For people with more severe/chronic fatigue – as an adjunct to a more comprehensive plan that is correcting their problem at a more causal level. For example, someone with chronic Candida, may take adaptogens for brain fog and fatigue – but it will not work that well unless the candida is also addressed.

When adrenal adaptogens will not work well

In complex cases such as Chronic Fatigue Syndrome more is needed than adenal support. Go to the page on chronic fatigue for more information. Adaptogens may be useful in these cases. However, they won’t work well just by themselves. Sometime a more holistic approach is needed. The adrenals need support, but so does the immune system and detoxification.
 
  • Cases of more severe fatigue, chronic fatigue syndrome, fibromyalgia, chronic viral infections. In these situations the cause of symptoms needs to be more directly treated, then simply covering up fatigue with an energy supplement. Typically this means working more directly on the immune system and/or detoxification.

  • Multiple chemical sensitivity. Some people are so sensitive to different stimuli that even tiny amounts of supplements that are safe for most people make them work. Adrenal supplements may make some people feel “speedy”.

Paradoxical symptoms are common in such cases. This is when a supplement that is supposed to do one thing, causes the complete opposite reaction. In such cases, patients may bounce around from doctor to doctor (and not just MD’s, this include people in natural health) just to be given one treatment plan after another that makes then worse and surprising the practitioner each time with extreme symptoms.

In these cases slow careful detoxification is important. The correct homeopathic remedy may do wonders as well.

People with multiple chemical sensitivities and paradoxical reactions much be treated accordingly. Most advice about what supplements to take for energy will rarely work in these cases.

Adaptogenic herbs for the adrenals.

This is a list of some herbs I most often for adrenals and poor energy. There are many other good herbs available. This list is not meant to be exhaustive.

All of these are good herbs. None are the best, nor are any of these good for everyone. For more information on a holistic herbal medicine intake see this page.

  • Licorice (glycyrrhiza glabra). Licorice has an extremely wide range of action. In terms of adrenal function, it acts like a weak steroid hormone (cortisol is the body’s primary steroid it makes on it’s own) which is one reason why it helps with energy. It is also a strong anti-viral. Often it is added to herbal formulas to help drive the action of other herbs. Another common function is to help soothe the digestive system. Regular licorice is used for energy, and “deglycyrrhizinated” or DGL licorice is sold for digestion. DGL has one of the active ingredients, glycyrrhizic acid removed. Therefore it will not have the stimulating effect of regular licorice.

  • Ashwagandah (Withania somnifera). Primarily used for fatigue and sleep. It is a strong anti-oxidant and can be used for other conditions such as to increase immunity, arthritis, hypertension, and hypothyroidism.

  • Rhodiola. A traditional Chinese medicine herb. Long used for, (and studied by Russians) increased physical stamina.

  • Kirin ginseng (Panax notoginseng) and American ginseng (Panax quinquefolius). These are similar. American ginseng is slightly cooling and sweat. Kirin ginseng is more warming. Both help with stress and energy. In Chinese medicine Ginseng was considered calming, and not stimulating at all. However, it helps the body handle stress, improving overall energy.

  • Siberian ginseng (Eleutherococcus senticosus). This is not a true ginseng. The name was simply applied to Eleuthrerococcus my marketers. Useful from people under prolonged stress from modern life style. People who are tired, with dark circles under eyes. Can help with sleep as well, but if not needed may be stimulating.

  • Rhemannia. A traditional Chinese herb. Helps adrenal and kidney function. At times it can be helpful when signs of weakness in the kidneys (needs to pee all the time, fear, sometimes heart palpitations.)

Glandulars

An adrenal glandular supplements is essentially the dried adrenal gland of and animal turned into a pill. This is not a form a hormone replacement therapy. Adrenal glandulars do not have large amounts of hormones in them. They work much more by giving nutritional support.

Often glandulars are more stimulating than herbs or other adrenal supplements. Some people feel much better on them. However others report feeling “speedy.” Since glandulars are only stimulating these would not be considered adaptogens.

Some people may with to avoid these products because they go against vegan beliefs. That is fine as we have many other ways to support adrenal function. Consider this information for the sake of completeness. No one should ever be told they have to take something that goes against their beliefs, unless there simply is no other option.

Vitamins and minerals

Vitamin C and most of the B vitamins are needed for proper adrenal function. Without these vitamins the adrenals can not convert cholesterol into cortisol. Like other supplements, some people feel much better on adrenal supplements high in B vitamins. Others may feel “speedy,” especially if they are the type who is often sensitive to supplements. Others may feel nothing at all.

In my office I’ll typically do kinesiology muscle testing against different B vitamins. The ones I see needed most often are vitamins B1, B12 and folate. An organic acid functional lab test can also pick up need for B vitamins. I wouldn’t normally run that tests just for B vitamins as it’s usually just as good to figure things out through in office testing and trying the supplement.

Other than cortisol one of the other major adrenal hormones is aldosterone. Aldosterone controls mineral balance. Without enough aldosterone people urinate more frequently, and this also means they are constantly peeing out their minerals. Magnesium may thus be low (often causes muscle cramping) but also sodium.

Sodium is often maligned for causing high blood pressure. Nonetheless many people with adrenal fatigue actually have low blood pressure. They are not able to maintain minerals. Having adequate intake of salt is essential to help the adrenals. Just make sure to get real sea salt, or eat vegetables that contain sodium like celery.

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