Dr. Maki: Hello everyone, thank you for joining us for another episode of the Progress Your Health Podcast. I’m Dr. Maki. 

Dr. Davidson: And I’m Dr. Davidson.

Dr. Maki: So on this one, we have actually a question from Marisa. She reached out. Honestly, it was a very nice email. She just found one of our podcast and it was episode 69. I believe it was where we went into talking about sleeping with adrenal issues and after that, she sent a very complimentary email and she gives quite a bit of detail, but I felt like it was worthwhile for us to discuss. Not only that she took the time to send us the email but it is also because she does give some detail that I think as we were trying to here a lot of people can learn from her experience.

Dr. Davidson: And on episode 69, we talked about the adrenals and sleep and we have some kind of characters we deemed as part of the adrenal fatigue causing sleep issues. We have the zombie which sleeps all night and all day, could sleep forever 24/7, and then we have the vampire which tough, tough time waking up in the morning but come evening time. They are alive. So, vampire, zombie, and then what Larissa which I’m going to go into her question here in a second is a ghost. So, we have a ghost which is where you fall asleep just fine, no problem, but you wake up in the middle of the night whether it’s once for a couple of hours or several times throughout the night.

Dr. Maki: Yeah, right, and if you look at that, if you listen to that episode, we do kind of break up the ghost into two. The Poltergeist and the ghoul which are two different versions of a ghost. Because of those subtle differences like you said and I don’t remember which one it is, now I have to go back and listen to myself. So which one is the one that wakes up for long periods of time?

Dr. Davidson: So that was what we named the ghoul because you wake up and you’re like roaming the halls as we say on their maze, basically roaming your smartphone in the middle of the night for an hour or more because you’re wide awake. Where the poltergeist is kind of like a little Gremlin, a little mischievous will just wake you up all night. You’re up hour later, I’m up for five, ten minutes, fall back asleep, then I’m up. So you’re waking up here periodically throughout the night. Unfortunately, we do have some people that are a combination of poltergeist and the ghoul, but in terms of being a ghost, being a zombie, being a vampire, on that episode when we’re talking about the adrenals were really talking about the diurnal curve of Cortisol.

Dr. Maki: All right, so I’m a ghoul right and it’s safe to say that you’re definitely a poltergeist.

Dr. Davidson: I have been in the past, I’ve gotten better but being a perimenopausal female, if you look at pretty much overall perimenopausal females, they fall more into the ghost category where younger people fall more into the vampire category and then just very fatigued, very adrenal stress chronically adrenal stressed people over a long time. They end up turning into a zombie. So, if we were to really go into it, the vampire the ghost, will eventually at some point if you don’t do some intervention can possibly they all turn into zombies at the end of the day. So that’s a really neat episode, so as we’re talking about Marissa and her question if you aren’t quite understanding, you can always go back and listen to podcast number 69. So, we wanted to give you a little background as weird as we’re going through it, but basically like I said, the sleep issues on episode 69 come from the cortisol levels, the diurnal curve of cortisol where in a perfect world, your cortisol comes up nice and early in the morning. So, your bright-eyed bushy-tailed and then it stays up and comes down and then really nicely comes down very low in the evening time, so that we can fall asleep and stay asleep. And then that cycle is happening every day.

Dr. Maki: Yeah, right. And putting those characters to it is a little bit of tongue-in-cheek sort of way so they’re memorable so you can identify. Like you just said, when I was in my 20s, late teens and twenties, I was a total vampire. I used to work at a hospital night shift because I was just awake all the time, but then I could literally sleep all day and I did that for a long time. You actually turn me into a non-vampire because you’re always been kind of up early in the morning, and I just eventually kind of followed suit, but I was a proverbial night owl for pretty much my entire 20s even into my early 30s, I think I was a vampire.

Dr. Davidson: We’re not making fun, it just seems easier to talk about adrenal fatigue One, two, three, four, five A, B, C, D. All that is just putting a little bit of some character to it is memorable for somebody to remember and we’re not saying all the ages, early as vampire midlife is perimenopausal females are ghosts and then eventually everybody turns into a zombie. I don’t want to be so distinctive is that like for example, my sister-in-law, she’s a total vampire and she’s in her early 50s. She can’t get up till noon and stays up till 3, even though she says “I really, really don’t want to do this. I really need to wake up earlier. I just can’t”, and it really is because she is a true vampire. She’s turned into a vampire because of the way her cortisol levels are. So in a vampire, your cortisol levels are low in the morning which is why you can’t get up and you want to sleep and you have this relationship with snooze over and over and over but come nighttime, you can’t even remember why you were so tired in the morning because you finally feel awake and alive.

Dr. Maki: And then might not be till like midnight.

Dr. Davidson: Yeah, exactly.

Dr. Maki: Usually after 10 o’clock and now they feel alive and it’s midnight when you should be sleeping and now they finally feel awake. That process and I think with all three of them, but certainly with a vampire and the ghost for sure, if you want to speak in a physiologic language, it’s what they call a reverse diurnal curve, the curve has flipped. So, instead of having high cortisol in the morning and low cortisol at night, you have just the opposite. You have low cortisol in the morning and high cortisol at night and it just completely flips upside down. Now if everybody went camping for a month, that’s a long time to go camping. But if you were in the woods for a while, no ambient light, no cell phones, nothing, which in some ways is kind of little anxiety-provoking even thinking about that to some extent because we’re so attached to our devices that most of those problems would just disappear because there’s nothing that would interfere with those normal circadian rhythms.

Dr. Davidson: Exactly and honestly camping is always very peaceful and relaxing so, taking that stress of life and away from your adrenal glands would definitely help that diurnal curve so that cortisol comes up in the morning and comes down. But for Marisa, her question that I want to read is she’s saying “Hey, I’m a ghost.”

Dr. Maki: Yeah, right, right and she did say that it kind of describe her to a tea. And just from experience, that’s why we kind of put them together that way because we see these patterns over and over and over, and unfortunately when you go see I have a sleep study or goes to your endocrinologist or your gynecologist or your GP. They’re not going to tell you that you act like a ghost or you act like a vampire. So, it’s just a different sort of way for people to identify and once you identify, now what the problem is,

being a vampire is not a diagnosis, but the term adrenal fatigue or adrenal dysfunction is too broad of a topic because there’s a lot of issues and symptoms that show up underneath that umbrella that I think people are not clear with both the patient on the patient side and certainly on the practitioner side. Now granted, in our world being in functional medicine and being naturopaths, the adrenal issue is pretty clear, but conventionally, they don’t even believe that unless you have Addison’s disease, they don’t even believe that any of these problems even exist. So they definitely happen a much more of a functional practical level than an actual diagnosis. So for a lot of people that are trying to get results or trying to get some improvement, that’s a really challenging thing to do.

Dr. Davidson: Absolutely. I mean, we always want to work on sleep and when you look at adrenal fatigue, it’s not just about sleep. There are so many issues that go under adrenal insufficiency, adrenal dysfunction, adrenal fatigue. But you’re right, your typical conventional doctor, you got to love them. They probably aren’t going to view it that way if you go in and say hey, I have trouble sleeping or I wake up in the middle of the night for an hour and a half. They’ll probably say hey join the club, me too, here’s some medication. 

Dr. Maki: Yeah, right. Yeah, and we’re not fans of any of the sleep medications because we think that they kind of provide fake sleep and even some of the other anti-anxiety medications and other things they use for sleep, those have kind of a slippery slope where once you start going down that path then you’re going to have some issues there on a long-term basis. If you’re on a plane or if you’re traveling somewhere and you maybe have some jet lag, okay, fine, use them very sparingly, but that’s why we’re going to talk about this just because I think that it’s a lot of people can relate to it, especially with all the stressful things that are going on these days.

Dr. Davidson: So let me go ahead and read you Marisa’s question or her email. It’s a little long, but I think it’s actually it’s very complementary. So, I’m blushing and I love her already with what she says because she says, “I truly appreciate what you’re doing to share your information to the public exclamation mark, exclamation mark. You’re helping many people learn about their body.” She’s so awesome. Thank you, Marisa. And so now it says, “I wasn’t sure the best place to ask this question or where you are or where you may answer it, but I found your podcast after I’ve been digging into how to repair adrenals. I was elated once I found your podcast number 69 adrenals affecting sleep. The ghost defined me to a tea, and I wanted to learn more about how to get better for my symptoms as you so clearly described. My main concern is that I wake up almost every night at 2:00 to 4:00 a.m. My neck is tight and my heart is beating a little heavier. 

If I focus on my breathing, I can go back to bed shortly thereafter. But some nights it does take a little longer. I may wake up another time or two after that as well. Is this hormonal or adrenal? All of my hormone levels are low.” So it’s actually pretty great, Larissa goes into her hormone levels here. “So all my hormone levels are low, except for progesterone is healthy at 169. I’ve taken a saliva test with normal cortisol levels. My TSH is high, the thyroid-stimulating hormone is high at 5.3, my free T3 is 3.2. My free T4 is 1.2. I also take Armor Thyroid 60 milligrams and my vitamin D level is 60.” 

Marisa goes on to describe she’s a 44-year-old female, her blood sugar is typically in the 80s in the morning when she checks it which is amazing. And then that which is also pretty amazing as she eats mainly vegetables but still focuses on all food groups. “I’ve been focusing on my adrenals for the past two months and have been sleeping at 9:30 at night and sleep for about eight hours. I do exercise every other day, but take it easy not to wipe myself out.” Body weights and walking which is the best thing you can do for your adrenals because you’re not pumping that cortisol all crazy with cardio. Anyway, that was my comment, not Marissa’s. Marissa goes on to say, “I also take ashwagandha and practice meditation”, my comment, love meditation, “–and breathing exercises. Again, any guidance on what to look for is appreciated. All the tips you mentioned for how to help on the podcast. I’ve been already doing for over a year.” And she does say that she takes the Pharma Gaba and the L-theanine which is what we also talked about on episode podcast 69 which helps her get back to sleep, but it doesn’t help her from waking up.

Dr. Maki: Yeah. So a lot of detail, we really appreciate that in this context. Now disclaimer, well, of course, we’re not giving any medical advice, Marissa, of course, is not a patient of ours, this is intended to be educational. So, people that are having similar situations, in our patient base, women that are in perimenopause, so basically women in their 40s, this is kind of a would you say a fairly common case for us.

Dr. Davidson: She’s 44 years old, typically, perimenopause can start anywhere in your late 30s or even to your late 40s, everybody’s different. But right around the mid-40s is when you start to see those female hormones change, so definitely as me speaking as a perimenopausal female myself, is sleep is probably one of the first things that you notice and basically it’s no trouble falling asleep. I mean go to bed in a second but give, 3 to 4 hours later after you’ve been sleeping fairly well, you’re up and then from there on it’s either you’re up for an hour and a half, and then when you finally do go back to sleep, it’s not the greatest sleep, but then you got to wake up or you’re just up periodically throughout the night. So when you look at someone’s sleep schedule in their mid-40s, they really only get about four hours of good sleep, which is definitely a sleep debt.

Dr. Maki: Yeah, right and what we’re trying to do with pretty much every patient, no matter if they’re in their teens, 20s, 30s, 40s, 50s, it doesn’t matter. The sleep in the first 30 days is or maybe even the first three months is what we’re trying to focus on because as you said a few minutes ago, everything falls off the sleep tree. Your insulin sensitivity, your cortisol balance, your energy, your mood, your weight. Everything is going to come off of that and sleep and now granted that’s a midpoint, right? We all know sleep is important, but how do we get there is really the challenge. How do we actually achieve good quality sleep? Our intake forms with a patient, I always ask as a letter grade. If you had to give your sleep quality a letter grade, what would it be, and invariably women just like Marissa always grade their sleep somewhere between an F to a C minus. I’m usually it’s an F or a D on which is part of the reason why they’re coming to see us because they can’t seem to figure it out or improve it anyway and our goal is to get them to a good solid B on a nightly basis. What does that look like? That looks like they go to sleep at a reasonable time. What does a reasonable adult bedtime for most people? 

Dr. Davidson: Well, I have a child’s bedtime at nine o’clock or maybe even a little earlier.

Dr. Maki: A little earlier.

Dr. Davidson: Yeah. I like to wake up early. But I would say a reasonable adult female bedtime, ten.

Dr. Maki: Yeah, right. So people work late into the evening, they get home. They got to decompress. Maybe they got to cook dinner. They got to take care of the kids. They got to do whatever, they have to have a little bit of time for themselves, right? And a lot of times people are waiting to get tired. They’re waiting to get sleepy and then that’s why they end up staying up for a few extra hours than they do need to so instead of going to bed at 10:00. They’re going to bed at 11:30 midnight or sometimes even later than that. So, we usually say between 10 O’clock in the morning until five, six in the morning when people have to start getting up that’s roughly about an eight-hour window. We want them to have a nice chunk of sleep. So, roughly three to four hours in the beginning part of the night, if they do wake up, preferably one time, no restroom if possible, then they’re able to fall back to sleep quickly and they sleep again for another three or four hours. That maybe best-case scenario for some people to say you’re going to sleep eight hours straight like in Marissa’s case, that might not really be realistic, but as long as the time that you are waking up is short, you roll over, you reposition, you go back to bed, you drift back off and now you get another nice few hours. From an adrenal perspective, from just good quality sleep perspective, now we’re in the ballpark.

Dr. Davidson: So, Marisa is saying that her saliva test for her cortisol levels were almost normal. And in those in those tests are great, saliva tests are extremely accurate for testing your cortisol levels, but the reference ranges can be a little bit vague because what I tend to find is that especially with the ghost is that their cortisol is actually pretty good in the morning which is why they get up and get going. It drops in the afternoon, which is why ghosts tend to want to get everything done by noon or 1:00 in the afternoon.

Dr. Maki: It’s you. You’re done by noon.

Dr. Davidson: I’m a morning person. But they have that cortisol that drops and then it looks what you’ll see on a cortisol test saliva test for that for the ghost is you see that it drops in the afternoon, but the cortisol is normal in the evening at bedtime. So it goes where you say, “Hey, it’s normal.” But really what happens is when you see it deep in the afternoon, but it comes up to normal in the evening time. That means that it’s bouncing all night long, which is why the sleep isn’t very well and so I would love to have a look at Marissa’s cortisol test because I bet her cortisol at night is normal, or maybe even just a tiny bit elevated, and that’s why she’s saying that her neck is a little tight, that her heart is beating a little bit heavier is when you have those catecholamines or adrenaline cortisol, the stress hormones in your system, that’s what it’s supposed to do.

Dr. Maki: Yeah, right, and when you are stretched a little thin, right? Maybe you’ve got some stress at work you’re at over-exercising. She says she’s exercising every other day, so she’s clearly not pushing yourself physically too much when there’s not necessarily enough cortisol to go around, her blood sugar is listed at 80. I’d be curious to see if she in the past if she’s ever had any low blood sugar symptoms. Shaky, jittery, headache, that hangry feeling, needing food right away. I would probably bet in the past, she probably has. That is very often an indication of low adrenal function. People that get dizzy, they sitting down on the couch, on the kitchen table, whatever, or maybe their desk at work, they stand up really fast to go do something and all sudden, they get a little dizzy. They have to hold on to something to kind of catch their bearings, that’s also a sign, we call that postural hypotension. It’s another sign of low adrenal function. So if that’s the case, that’s why in the middle of the night, she’s having literally a little bit of adrenaline released into her bloodstream, which is why her heart rate increases and her neck tightens up because it’s like an unnecessary sympathetic response at her body really can’t help it so when there’s not enough cortisol go around, for whatever reason, the body dumps in a bunch of adrenaline unnecessarily and you start having these physiologic changes as a result of that.

Dr. Davidson: And just we’re talking about the adrenals with Marisa. So definitely those adrenals we want to balance that cortisol. Bring bring it up more than likely probably that afternoon, late morning afternoon bring it down at night while she’s sleeping, but there’s probably a little bit of an impact on her adrenals coming from her thyroid because her TSH the thyroid-stimulating hormone is pretty high up there, it almost five and a half at 5.3 that’s showing that her thyroid level is still probably on the low end and low thyroid is going to put more of a stress on those adrenals because they work together so finely tuned.

Dr. Maki: Yeah, and she’s on medication already and her TSH is still 5.3. So she’s undermedicated and more than likely with a TSH like that with medication, she probably has Hashimoto’s, she probably has the antibodies either anti-TPO, anti-thyroid globulin. Now that doesn’t necessarily add too much complexity to it, but it gives an idea. Hey, there’s an immune system issue going on here very very common to see a TSH a high normal or kind of stubbornly high and granted there is definitely an adrenal connection to that. Now typically, in a person that got a very active lifestyle, they’re doing all the things right. She’s doing a lot of things, right? We would expect their TSH to be low and normal like right around one even maybe even below one, very common to see that in women particularly women that are exercising a lot. So heard having a TSH of 5.3 which is actually abnormal, average range only goes up to 4.5, I would say huge red flag, but it tells us that hey there’s something going on here. So in a case like that, we would actually switch and increase her medication, we want that TSH to be lower. Now, her free T3 isn’t bad at 3.2. That’s pretty reasonable. So this is a case where we would actually pay attention to the TSH, even though just because obviously it’s too high so that number definitely needs to go down.

Dr. Davidson: So those of you probably already know but to those that may not, is a thyroid-stimulating hormone as a signal from the brain and it works in a negative feedback loop that if the TSH is high that means the thyroid function is low and reverse if someone has a very high thyroid or they have Graves disease or hyperthyroidism, then you see that TSH almost non-existent. So that’s why when you see Marisa’s TSH high at almost five and a half that distinctively says, “Hey, she’s got hypothyroid.” Maybe even Hashimoto’s, she’s probably under dose so, the first thing would be readjusting that thyroid also treating her as an individual not just numbers on a piece of paper, but it’s definitely a signal to say, “Hey, we got to work on the thyroid as part of our treatment plan.”

Dr. Maki: Right, so adrenals definitely supporting adrenals in the morning by raising cortisol in the morning. It automatically lowers it at night right because all hormones in the body have a cycle to them. They rise and fall rise and fall rise and fall. Hormones are never static except when we dosed them in menopause. That’s the only time that hormones become somewhat static is because they’re just not producing as your progesterone anymore. That’s an exception, but pretty much all the other hormones, insulin, cortisol, female hormones, testosterone, they all oscillate over the course of a month in a year and a lifetime. So, by supporting adrenal function in the morning, trying to raise in the morning and lower it at night, eventually, that reverse diurnal curve comes back into balance. So, usually dosing adrenal type things whether you’re using glandulars, you’re using licorice or other adaptogenic herbs you’re doing that in the morning up until noon, so you get a nice rise[?] to the cortisol and then you’re using other herbs and other things like she said Pharma Gaba, L-theanine. There’s a bunch of other things you can do.

Dr. Davidson: [inaudible]

Dr. Maki: Yeah, there’s a bunch of other things you can do. Ashwagandha, you use that night, Magnolia. There’s a bunch of other herbs you can use to lower it at night and now eventually, it takes a while, eventually, that pattern starts to reproduce itself. Now she did say or hormone levels are all low, except her progesterone. What do you think about that?

Dr. Davidson: Well, it’s interesting because Marisa is 44 years old. So she’s probably still cycling, so she’s having a period. So when you do a blood test for hormones,  or even a cortisol test or any test, that’s one day of your 28-day cycle. We don’t know where she is in her cycle. So she could have been in the early phase. That follicular phase day 1 to day-12. She could have been in the luteal phase from day 14 to day 28. We don’t really know, but typically most women right around their mid-40s have a drop in progesterone. It’s pretty much across the board. And when you drop that progesterone that tends to cause cortisol to come up at night which is why perimenopausal females have trouble sleeping in the middle of the night. It’s not hot flashes like in menopause. It’s not night sweats like in menopause. Its perimenopause with the estrogen is fine, maybe a little lowish, but the progesterone is low. So even though she says hers is healthy and that it’s normal. They’re at 169. I’m not so certain and of course, I don’t not really sure what the units are with that 169. Usually, it would be interesting to see, but I would say when did you have that test for your progesterone, and I really think it’s probably low. 

Dr. Maki: Yeah, right. I don’t think that it’s actually the opposite. It says that it’s healthy but in a 44-year-old woman, that’s just really unlikely especially if she’s having some sleep issues, especially if she’s living an active lifestyle and has just even normal stress like everybody else because this is the kind of situation we see over and over and over and over. So I disagree with the progesterone as you do, it is a little bit of a miracle what alumina thyroid the type, the right dose of the thyroid and some bioidentical progesterone can do for a woman like this.

Dr. Davidson: Yeah, absolutely bioidentical progesterone not conventional or any progestins or any of that garbage but bioidentical progesterone would be really nice and also some people we have a lot of people that can’t take progesterone, they’re sensitive or unique or whatnot is possibly doing some not necessarily hormones but like herbs that help stimulate the luteinizing hormone which then stimulates progesterone which we probably could go on an hour about luteinizing hormone follicular stimulating hormone all that. But really like Vitex, and chaste tree berries a beautiful one that stimulates that can help kind of augment progesterone. I find evening primrose oil, which doesn’t have any hormones in it seemed to sort of balance that a little bit as well. So that might be a nice option.

Dr. Maki: Yeah right. Evening primrose contains gamma-linolenic acid, which is an omega-3 fatty or which is an essential fatty acid. Not omega-3 It’s actually an omega-6 but it’s in that category borage evening primrose. Those are all contained Gamelin again linolenic acid, which has some very significant anti-inflammatory properties also using GLA in the dry eye and that has been coming up. There’s a kind of a tangent. There’s a product that people have been using for a long time called bio tears. And one of the main ingredients in that product is Gamelin is a source of gamma-linolenic acid. So just that’s what like for example PMS, PMS is in some ways kind of an inflammatory process. So you take those essential fatty acids and helps to kind of tone that down a little bit and it actually has an effect on certain and inflammatory enzymes. We’re not going to go into right now, but certainly can be helpful in a situation like this.

Dr. Davidson: In the Pharma Gaba and the L-theanine, so I kind of use those a little bit differently l-theanine, I’ll use in the evening and I use l-theanine all day if you’re stressed out you get an email or you have a chronic issue going on of stress, L-theanine can really calm you. If you have a speech to give you can take L-theanine right before, it doesn’t decrease performance, but it just kind of brings down the anxiousness, it brings down that stress. So that’s a nice thing for people to take if they’re kind of stressed out and they have a lot of things on their mind at night. I love Pharma Gaba because that helps bring down that cortisol and relaxes you sometimes I’ll use Pharma Gaba more in the middle of the night. 

So if you’re waking up at 1:30, 2:30, 3:30, you can take a little Pharma Gaba to help you go back to sleep quickly, but then you won’t make you feel groggy or tired if you have to wake up five, six, or seven but so I would say maybe it might not be a bad idea for somebody in Larissa’s case like this where the Pharma Gaba is helping her get back to sleep, but it’s not keeping her from waking up is like we had talked about earlier is doing some other kind of relaxing or calming adrenal supplements. I like phosphatidylserine, that’s a great one to take in the evening time to kind of help keep you sleeping, but just on a side note, as a female in her 40s myself right now, we’re like late 40s, but getting, getting to the late 40s but I wish a lot of us and we’re girls we have smaller bladders. It’s really hard to not have to go to the bathroom once a night unless you’re stop drinking water at 6:30. And then you’re dehydrating you wake up a little dehydration headache. So, I would wake up go, to the bathroom, lay back down, and then go back to sleep. And that’s I think that’s reasonable.

Dr. Maki: Yeah, right. Like I said earlier when we’re trying to get someone, we’re not going to get them necessarily if they’re already having sleep trouble getting quality sleep is probably not going to happen, but that one time of night where they have to wake up and if they do have to use the restroom as long as they get that chunk before and the chunk after, that way, they’re getting as much uninterrupted sleep as possible. That’s the key to be able to get down to those proper restorative stages of sleep that are necessary and we need to get what three to five of those cycles a night and if you’re waking up every 90 minutes or every hour, you’re not going to get to any of that restorative sleep and now that’s going to spill over as we said, and then everything else that we do. Another little trick or another little clinical pearl is using another amino acid besides L-theanine. I like to use it in addition, I like to use glycine, especially if you’re waking up in the middle of the night with those racing thoughts, You wake up, you’re panic, you’re thinking about your to-do list the next day and all the million things you got to get done. Glycine is in a powder form, not capsules, but in a powder form so you can control the dose of a little bit more effectively that can be a great way to, again, have an effect on cortisol kind of calm the mind and now that adrenaline response doesn’t happen the middle of the night.

Dr. Davidson: Oh, yes. Definitely Glycine and it doesn’t taste bad. It comes as a powder. I tell people to put it like in a water bottle maybe drink a little if they’re kind of having some racing mind before they go to bed. They could drink half of the bottle put it by their bedside table. So if they do wake up with maybe their hearts beating and they’ve got some thoughts in their head or feeling a little stressed out for waking up that morning, then they can just reach over and drink the rest of it.

Dr. Maki: Yeah, right. So, we’re kind of following through the way that we think about cases like this. So, we talked about adrenal function morning and evening. We talked about adding in some progesterone possibly, talking about switching and increasing her thyroid medication. Now, there’s nothing wrong with armor. There’s nothing wrong with MP thyroid. There’s nothing wrong with [inaudible]. Those are fine. We do use them quite often. We prefer to use compounded thyroid and in her case with her TSH, the goal for her TSH would be right about 1. So, when you’re switching medications like that, the conversion is not an exact conversion. So you just have to use a little bit of experience and switch an increased simultaneously and then tweak that dose over time. So probably takes about anywhere from a couple of months to maybe up to six months to get that dose right so, when you make that increase, you don’t overshoot the mark and she becomes overmedicated, but her TSH definitely needs to come down.

Dr. Davidson: I absolutely agree.

Dr. Maki: Yeah, so, one last thing that I think would be important just to mention, she says diet-wise, her blood sugar in the morning is typically 80 which is very good.

Dr. Davidson: It’s really good.

Dr. Maki: But it’s almost kind of borderline too low, right? It’s almost when you see, now granted, she fits the profile of where an 80 blood sugar is actually her normal, right? Because that’s where blood sugar is supposed to be in let’s say the 80s anywhere is usually a really good number. Now, occasionally, as I said a few minutes ago, those patients that have hypoglycemic type responses during the day. They go a few too many hours without food and the ones that have that problem know who they are, right? They cannot go more than three or four hours without food. But when in the morning when you see a fasting blood sugar and it’s in the 70s or even in the 60s, now, that there’s something going on there. So she’s right on the cusp of that of it being even though it seems normal, it seems almost excellent, it’s almost too excellent. And that’s where it kind of raises some red flags and cortisol’s main job in the body, cortisol’s number one job, it’s classified and we’ve said this on the other podcast, but it’s classified as a glucocorticoid. So, it is a steroid hormone that affects blood sugar. That’s what cortisol’s job is so, insulin will bring your blood sugar down and cortisol plus a few other hormones will actually bring your adrenaline as the other one will bring your blood sugar up. Okay. 

So if there is a lack of cortisol, there’s not enough cortisol to go around, that’s why your body kind of steps in there and dumps in a bunch of adrenaline and now becomes your cortisol rising is normal, right? We don’t become symptomatic from that, but your body dumps in some adrenaline because it doesn’t have any cortisol left. That’s where the symptoms come from. Now. We’re not necessarily physiologists and we’re just kind of talking this little bit off the cuff. So we’re not trying to be exactly accurate. This is more in a practical sense so people can understand we’re not trying to talk over anybody’s head. But we’ve all known someone that fits that kind of situation. I think Marissa, my speculation would be that she probably does fit into that to a certain extent and she says dietary. This is the point that I wanted to bring up. She eats mainly vegetables but focuses on all food groups. From my experience that she is probably under eating on a regular basis. You cannot sustain yourself by eating mainly vegetables. There’s not enough essential fatty acids or essential amino acids in that kind of a diet. Not to mention, she’s probably calorie deficient, and if you are in a chronic clerk[?] deficit on a regular basis, that puts a huge amount of stress on your adrenals. It’s almost invariable and that’s something, again, this exact age bracket is something that we see all of the time. We’re trying to do everything right, trying to eat less, exercise more, to maintain your weight because once you going to perimenopause, it’s very challenging to maintain your weight, and now that turns into its own problem on the back end.

Dr. Davidson: Exactly. I mean I can understand it. She’s 44 years old, she’s hypothyroid, her thyroids underdose. So she probably has to maybe focus a little bit more on vegetables to maintain her weight just because her metabolism might be slow just because of the thyroid, the female hormones, and the adrenals. So honestly, it doesn’t mean Marissa, stop eating vegetables, vegetables are awesome, they have lots of nutrients, lots of minerals, but if and as I said, you are focusing on all food groups, so she is mentioning that it might be maybe, like you said, maybe I’ll just make sure you’re not becoming deficient in the protein or deficient especially and the essential fatty acids.

Dr. Maki: Yeah, right or just fat in general not even essential fatty acids, just a small component, but just fat calories in general, and just calories in general, right? I talk to people all the time to track your calories for a week. See what your average is and I guarantee you, she’s probably 1500 calories or less. With her exercise, four days a week, she needs to be over 2,000 calories a week. That’s really scary.

Dr. Davidson: You mean a day?

Dr. Maki: I’m sorry a day. Yeah, day, and now granted, you don’t have to necessarily be at 2000 calories every day. But basically, your weekly average or your average caloric intake overtime needs to be close to what that maintenance level is, and the more activity you do, the more calories you need to eat. And if you don’t, now, you’re putting a constant stressor on your adrenals that the body can’t really overcome. Literally, in starvation mode on a regular basis. That I think is a big component because she’s doing a lot of things right. I think that is a component that needs to be addressed.

Dr. Davidson: Something maybe to look at there.

Dr. Maki: Yeah. So I think we hash this one out. Hopefully, there’s some good information for Marisa to kind of think about and contemplate. We kind of laid it out and hopefully not we didn’t drawn for too much. But this one is I think challenging, right? It’s how it’s even talked about this as we’re preparing for it. It’s really difficult to try to get someone to sleep better when it seemed the waking up and that very specific time. Like how do you really approach that in an effective way? But as you can see, as we laid out, there’s a food component, there is an activity component, there is an adrenal component, there is a thyroid component, there is a progesterone a component, or a female hormone component. I mean that’s really complicated. That’s extremely complicated to get the net result of I to want to sleep better.

Dr. Davidson: And at the same time, you’ve got to look at it that way. You’ve got to look at it as the body as a whole not compartmentalizing different glands or GI system, your thyroid Endocrinology, everybody compartmentalizes medicine, I got my cardiologist, I got my gynecologist. I’ve got my GI doctor, I mean and that’s great. You got to have a healthcare team, but just like we kind of laid it out. You got to look at it this way.

Dr. Maki: Yeah, right. Now granted, she’s waking the middle of night. She’s having an increase in heart rate. She asks if it’s hormonal or adrenals well in some ways, they’re both hormones.

Dr. Davidson: It’s both.

Dr. Maki: It’s totally both and this is in some ways kind of a classic case one that’s hard to address. But at the same time, it’s kind of simple, and as I said, she’s doing a lot of things right just a couple of tweaks here and there and I guarantee you, her quality of sleep would go from probably C- to a B+ in a relatively short. Sorry, I didn’t mean to cut you off there. Do you have anything else to say we’ve been kind of taught[?]? This has been a little bit of a longer episode than we typically do.

Dr. Davidson: No. I was just saying, any of you listeners listening to this podcast, if you want to learn a little bit more about the ghost, the zombie, and the vampire with the adrenals and sleep because I know we tried to sum it up a little bit, you can always listen to podcast number 69, and I also at the same time wrote a blog on that too where you could go in there and read the article as well. I think it’s adrenal fatigue and sleep or something like that. 

Dr. Maki: And I show notes on our website. We do post up the transcription of the podcast on the website and you can actually download actual PDF of the transcription and the dashboard, the analytics, and I know that actually people read the transcription, probably saves them some time, they can just scan through it really fast. Now, we don’t edit the transcription very much. We don’t do too much there. It’s pretty much as we say it for the most part, so, if there’s any typos or things that don’t make any sense, we apologize ahead of time. But again, for people that are quick and like to read and scan and don’t have time to listen to a 45-minute podcast, or if you’re trying to pay attention. Another thing that I know that happens is people are trying to pay attention to the numbers, right? They want to see it in writing when we’re talking about a TSH of this and the free T3 of that and that’s hard to it’s hard to wrap your brain around those numbers unless you see it actually in person or people that I know will actually writing notes down as they’re listening to the podcast, so they can visually see what those numbers look like. So until next time I’m Dr. Maki. 

Dr. Davidson: And I’m dr. Davidson.

Dr. Maki: Take care. Bye-bye.