(Another sample entry from our Q&A Treasure chest, a database with hundreds of entries to support students with their patient and client work. Unlimited access is included as part of our Core 101 Semester program.)
A question from a Practitioner:
A 57 year old female client and I have been working together for 2 months. Pretty good primary food, taking levothyroxine, but persistent hypothyroid symptoms (TSH mid-norm, but doc will not test T3 and T4 – we’ve discussed at length the option of seeing a functional medicine doc). 5’4″/153lbs, menopausal several years now. Lots of work-related stress. Dialing down sugar and flour in diet have helped drop some pounds as well as sugar cravings. It has also eliminated daily bloating as well as significant bouts of IBS. Food is in a good place…. Just recently, I raised the issue of sleep as she’s always said it’s “pretty good”. I probed about more specifics and learned that she goes to sleep fine but usually wakes up at 4am no matter when she goes to sleep.
She is usually in bed around 10:00ish and asleep by 11 at the latest. Sometimes she can fall back asleep at 4am, but most days when her mind gets going (work-related stress) she just watches the clock until she gets up for the day at 6am. I wasn’t sure what to do about this since it’s only 2 hours before she should wake and we want healthy cortisol spike at 6am. Melatonin? Consistent night sleep, when it occasionally happens, obviously makes her feel like a million bucks. Would love to help her have better sleep more consistently! As always – thanks for your thoughts!
Good for you for addressing so many high-impact areas with this client! I particularly appreciate your awareness of the need to check her actual thyroid hormone levels, as many people are not well-served with optimal levels of T3 using T4-only medication due to poor conversion.
As we know, persistent challenges with sleep often point to hormone “imbalances”. Hormones are messenger molecules in the body that help to communicate the status of your world (within and across tissues/systems) and coordinate a body-wide response that promotes survival. Most often what we see at play in hormone “imbalances” is not the result of a true dysfunction in the body but rather a logical and perfectly executed response by the body to a person’s lifestyle that is promoting undesired consequences that the person doesn’t like. Often, individuals are making choices that keep the body in a place of prioritizing survival (sympathetic dominance) vs. thriving (parasympathetic balance). At least in the US and the western world, we have an epidemic of people chronically making “sympathetic choices” (e.g. crap food, stress, toxins) and wondering why they aren’t having a “parasympathetic experience” (e.g. vitality, quick healing, fertility).
There are many possible contributors to this habit of awakening at 4am (after just 5-6 hours of sleep). For example, moderate stage Insulin resistance can lead to low blood sugar dips overnight that the body has to rescue itself from by sending a surge of epinephrine. A hypothyroid state can promote insulin resistance. Or perhaps an unacknowledged physical disturbance such as the furnace kicking on at a specific time with noise/heat or the neighborhood street cleaning machine passing by. Or she could theoretically have insufficient melatonin synthesis which could be related to inadequate precursor serotonin…maybe an issue with optimal activated Vitamin B6 availability. Traditional Chinese Medicine acknowledges that there is a time of day during which specific organ system is most active; a 4am awakening falls in the middle of the Lungs’ greatest activity, perhaps pointing to an oxygen, congestion, and/or infectious dynamic. All of these may be worth exploring.
However, I believe what you describe is a classic early and aggressive Cortisol Awakening Response (CAR). If the body has been weathering very stressful circumstances, then the morning cortisol surge is anticipating more of the same in an effort to protect you. After all, melatonin and cortisol are both hormones and compete with one another in the name of survival! If your body believes you are safe, then it makes sense to allow you to experience ample melatonin and much lower overnight cortisol to allow deepest rest and optimal healing. However, if your body believes your world is threatening and your survival perhaps not too certain, then melatonin will be suppressed with cortisol surging to prepare to help you fight or flight as needed. A multi-sample urinary hormone test (e.g. DUTCH) would give clear insight into melatonin and cortisol levels, but in this case, I recommend getting started without it (unless the client needs data as proof of the need to make lifestyle change).
The education, inspiration, and empowerment you provide your client by helping them to fully understand this dynamic can be life-changing. I specifically would not recommend melatonin because and early/aggressive CAR is going to wake her up regardless, and excess melatonin might cause her to feel groggy and sleepy on top of being awake too early. A key principle is that the early morning Cortisol Awakening Response in the body is being conditioned by the level of stress during all the rest of the hours of the day. I would focus on five key areas: