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clear search termsWide Awake to Stay at 4am?
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 PCP will not test T3 and T4). 5’4″/153lbs, menopausal several years now. Lots of work-related stress. Dialing down sugar and flour in diet has 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 6:30am. It’s only 2 hours before she should wake, but I know we want healthy cortisol spike at 6am. 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!
SAFM Response:
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. And we just cannot see that in TSH-only labs!
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 (and only then, thriving). Most often what we see at play in hormone “imbalances” is not the result of a true dysfunction in the body but rather the body’s logical and perfectly executed response 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) and yet that are seeking a life experience that is more in line with 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 each 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. Is there any sleep apnea? 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 is perhaps not too certain, then melatonin will be suppressed with cortisol surging to prepare to help you fight or flight or hide 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 an 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:
- Ensure optimal sleep hygiene. Even though this client falls asleep without trouble, our experience in the few hours before bedtime does have an effect on priming melatonin release. We want to avoid full-spectrum light, loud noises, eating rich or sugary foods, and alarming or over-stimulating activity (e.g. evening news or crime show on TV, paying bills). I’m happy to share a patient handout that details several key aspects of this lifestyle choice.
- Supplement with magnesium threonate right before bed. This particular form of magnesium specifically helps to increase magnesium in the brain. The amino acid threonine is well taken up across the blood brain barrier and is a precursor to glycine, which acts as a calming neurotransmitter.
- Explore stress and the importance of effective stress management. You mentioned this client’s significant work stress. There may be others. Many times we can become adapted to stress and lose sight of the magnitude of what we are experiencing or allowing into our lives. Work with your client to identify activities she is open to exploring that can help to calm the mind e.g. meditation, gratitude journaling, prayer, yoga, tai chi. Help her to understand the importance of prioritizing activities that balance the messages her body is receiving about the status of her world. In order to allow optimal, sustained sleep, her body needs to experience that her world is more safe and secure. Help her also to understand the importance of self-talk and rumination (her thoughts!) which the body is always “listening to” as part of its effort to learn the status of our world and how it can best help us to survive.
- Consider the impact of physiological stress. Sometimes whatever mental/emotional stress is at play for a client is not the dominant driver for an aggressive CAR. Instead, their body is on high alert due to sources of physiological stress e.g. exposure to allergens (e.g. pets or mold in bedroom), unacknowledged food sensitivities that are consumed regularly, simmering infectious dynamics (viral load due to immunosuppressive effects of stress?), exposure to toxins (consider personal hygiene/beauty products), sleep apnea.
- Progressively reduce intake of stimulants (especially after noon) and alcohol. You’ve already made some strides here with sugar. Be sure to consider chocolate as well as caffeinated beverages. Despite beliefs otherwise, I have seen many times that the 11am or 1pm cup of coffee does indeed have a negative effect on sleep quality and duration.
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The DUTCH test has indicated estrogen dominance for my patient. She has a long history of constipation we are meanwhile treating which I believe has led to estrogen dominance.
She falls asleep initially but feels she is never “all the way” asleep. She often feels wired and out of it as a result. What suggestions do you have for immediate relief to promote deep sleep?
This post may be of interest to you:
https://schoolafm.com/ws_clinical_know/sleep-remedies-that-work-neurotransmitter-and-hormones/
Also, since you did DUTCH testing you likely have the cortisol and melatonin data – this may be particularly informative in uncovering what is contributing to your client’s trouble with deep and rejuvenating sleep. Another point that comes to mind right away, is that constipation can be a symptom of serotonin insufficiency – if that’s the case you will want to think what is the root cause for that – and serotonin is a direct precursor to melatonin.
My 42-year-old male Client is going to bed at 8 pm and wakes up consistently at 4 am. He does not have caffeine past 10am. Notable external stress factors (work, etc). What is the best way to check his CAR?
The best way to check CAR is with the DUTCH test such as this one:
https://dutchtest.com/product/cortisol-awakening-response/
You may also be interested in this educational video:
https://dutchtest.com/video/understanding-the-cortisol-awakening-response/
Could you please explain the process of how prescribing melatonin can backfire? I can guess that if melatonin production is not the issue at play recommending it would not be the solution but … does it affect natural production in the body? I would love to understand this deeply to feel confident explaining this to patients… it seems more and more people are taking melatonin for sleep as it is something they can buy over the counter and feel it is something “natural” they can take for a better sleep.
This resource will be of interest to you: https://examine.com/supplements/melatonin/research/#safety-and-toxicity_withdrawal. Excessive intake of melatonin can cause drowsiness/lethargy in the morning. I have seen this set up a vicous cycle where these individuals consume more caffeine/stimulants during the day and thus continually need the melatonin/alcohol at night (the upper/downer cycle), even though caffeine intake can impair the liver clearance of melatonin. We need melatonin levels to drop notably in order to allow the body to have optimal morning cortisol awakening response in support of a natural circadian rhythm e.g. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6057895/ . There is evidence (esp. in non-elderly population) of withdrawal effects after supplemental melatonin cessation (likely due to receptor adjustment effects, as we would see after the removal of almost any hormonal supplementation). It is also important to note that supplemental intake of melatonin will drive circulating levels much higher than they would naturally be, and this can have effects on insulin in vulnerable individuals e.g. https://schoolafm.com/ws_qa/melatonin-and-insulin-surprising-connections/ . There is also some evidence that High melatonin may also suppress fertility. And yes, exogenous supplementation does suppress endogenous production. This article may also interest you: https://www.ncbi.nlm.nih.gov/books/NBK550972/ .
if you did the cortisol test and found that the levels were low in the morning, would you address this the same way? The scenario I am curious about is low adrenals in AM but low normal/normal for other 3 readings?
This is an example of what can be done in this particular case – please note the specific details described in the article and WHY each solution is proposed. In general, the majority of these recommendations will apply to any morning cortisol insufficiency, but there may be modifications needed based on each unique root cause of the adrenal suppression and the overall situation of the client and the symptoms they report. The differences may also depend on which test you are talking about – there’s a difference between the CAR cortisol test and the ‘regular’ DUTCH adrenal test included in the DUTCH Complete panel. For more information on that we recommend visiting DUTCH website or contacting them directly:
https://dutchtest.com/new-dutch-plus-test/
I have a patient struggling with some anxiety and troubles with sleep, also likes the typical glass of wine at night… I decided to go with Magnesium Taurate for her in the hopes of promoting a better GABA/Glutamate Balance…would it have been better to recommend Magnesium Threonate?
No. There is no “right” answer. Either/both may be helpful, and we must maintain an attitude of exploration to see what is best for a given individual. The glass of wine may be contributing directly to her challenges, however, but causing glutamate surge after the alcohol is metabolized. This may be of interest to you: https://schoolafm.com/ws_clinical_know/the-interconnectedness-between-alcohol-and-sleep/. I would put particular focus on sleep hygiene. Look too at caffeine/stimulant intake, especially after Noon, which can still be having notable effects 10 hours later.
what about adrenal glandulars for Addison disease?
Do you think there is any chance the adrenals produce cortisol again?
Any chance of recovery?
Yes, there is some evidence of remission from Addison’s. This will, of course, depend on the unique triggers/mediators/severity of the autoimmune dynamic in a given individual, but the body does heal when drivers of disease are removed sustainably. For sure what is necessary is the need to supplement with glucocorticoids to help the body to function/heal optimally while the adrenals are struggling. A physician will need to ensure physiologic replacement of hormones, and glandulars could indeed help to support the healing process (but in tandem, not in isolation). These will be of interest to you: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3965278/ and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6851705/ .
Can glandulars be used in conjunction with thyroid medicine like Synthroid ?
First, I’d like to make a distinction that “glandular” can mean a lot of different preparations, such as thyroid, adrenal, pituitary, etc. and I assume that in your question you are asking specifically about the natural thyroid glandular supplement to be used with Synthroid (a synthetic, T4-only prescription drug). The simple answer to your question is it depends on the unique client situation and it should always be done in the collaboration with a prescribing physician. As you know, at SAFM we offer copious case study experience for this very reason, to get away from the black & white thinking and to be able to effectively apply the FM lens to each unique case. Second, there’s a difference between a ‘natural thyroid glandular supplement’ and a ‘natural thyroid extract'(NTE). The former, at least in the US, due to regulations is required to have the T4 hormone removed and typically has only trace amounts of T4 and T3. This type of supplement can typically be acquired without a prescription and it may be effective in some cases and provide enough gentle support to avoid the synthetic hormone drugs or the NTE all together. Even though the natural thyroid glandular supplements are… Read more »
I would like to know how you feel about using adrenal glandulars for treating very low cortisol and adrenal fatigue.
Sharon, we talk about this at length in the Adrenal and Thyroid: Myths and Truths class which you may check out here https://schoolafm.com/clinical-courses/ if you wish.
In short, we do recommend adrenal glandulars for severe adrenal insufficiency when it is confirmed by appropriate testing, such as DUTCH or diurnal cortisol in saliva.