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The Metabolic Treatment
of Fibromyalgia
by Dr. John C. Lowe
Readers' Comments

Adrenal Glands
[Q&As are placed in reverse chronological order. In other words,
the latest Q&As come first. Earlier ones are further down the page.]

Latest Updates to drlowe.com

Adrenal Fatigue—A Real Disorder
No Matter What its Name:
A Response to Dr. Peter Hibberd

April 18, 2009

July 19, 2008

Question: Thank you for our phone consultation yesterday. I have an additional question for you. From what I am reading about adrenal fatigue, my symptoms seem pretty severe. I have read in several sources that there is no harm in replacing cortisol at a physiologic dose. If the body doesn't need it, it will not cause any harm if the patient weans off it slowly. But if the body does need it, signs of benefit will show fairly rapidly.

Here is what I am wondering. My ability to work is almost non-existent. I am having to put my head down on my desk at least every 20 minutes and am really struggling just to make it through the day. I know I am supposed to do the saliva tests, but I am extremely concerned that I’ll become worse while waiting for this process to take place. I am wondering if you’re willing to recommend that I immediately start the Cortef prescribed last week by the doctor who referred me to you for consulting? I believe doing a trial of Cortef [hydrocortisone] could be diagnostic in its own right, and I will then use saliva testing to regulate my dosing if I show improvement.

Dr. Lowe: Regarding your suggestion that you begin to use Cortef based on your symptoms, your prescribing doctor is the clinician who must authorize you to do an empirical trial of the medication. Based on clinical experience, I don’t think you're likely to harm yourself by a short empirical trial of Cortef, even if you actually don’t need more cortisol or if you have an excess.

However, in that my relationship with you is educational, I must point out an observation from my clinical practice. I have had several patients, all of whom had classic cortisol deficiency symptoms, who turned out to have high rather than low cortisol levels. We learned this as soon as we received their salivary cortisol test results. These patients immediately ceased taking cortisol, and some had to use cortisol-suppressing agents to produce a normal diurnal cortisol pattern.

The brief cortisol trial did these patients no apparent harm. In principle, though, considering the outside likelihood of adverse effects, you may want to err on the side of caution. A patient who decides to try cortisol empirically before we receive her cortisol test results stands some chance, low as it might be, of inducing cushingoid symptoms, such as increased belly fat.

Other cushingoid symptoms include mental and emotional lability. I know you’re suffering now, and I wouldn’t want you to worsen how you feel. Waiting for your cortisol test results is tough enough, but a risk in doing an empirical trial of Cortef—if you have high rather than low cortisol—is worsening any unpleasant mental and emotional effects you’re now suffering from.

When a patient adds cortisol to an already high cortisol level, she risks inducing damage to hippocampal cells in the brain. This can cause a loss of short term memory. Excess cortisol can also suppress immune function, making the patient more susceptible to infections. And as I explain in The Metabolic Treatment of Fibromyalgia,[1,p.487] long-term excess cortisol levels can cause a loss of bone mineral density.

Of course, I understand your sense of urgency. In view of the risks, you may be willing to take the gamble and use Cortef to see if it reduces or eliminates some of your troubling symptoms. If you decide to take the risk, however, you must have your prescribing doctor’s approval, as we must respect his province in this circumstance. If he and you decide to commence with a trial, I’ll be happy to help both of you decide how it affects you.

January 2, 2008

Question: I am a naturopathic doctor and have hypothyroidism and adrenal insufficiency. I’ve been taking medication for these conditions over the past several years. Despite experimenting with different dosages and combinations, I am yet to find the correct doses. I did feel well and stable for 18 months while on a combination of 50 mcg T3 and 15 mg of hydrocortisone.

After a large stress, however, I developed hypothyroid symptoms again. I increased by T3 to 70 mcg, but all that did was keep me awake and not relieve my symptoms. My doctor tested me and said that my TSH levels showed that I was hyperthyroid. Because of this, he lowered my dosage to 30 mcg of T3 and added 25 mcg of T4. I became severely ill on this and my health declined drastically over six months. My doctor refused to change the medication because now my TSH level was back to normal.

On my own, I added two grains of Armour per day and improved very quickly. Under the care of another doctor, I’m now on 4 grains of Armour per day and 15 mg of hydrocortisone. I’m fairly stable on this combination, but my weight is a problem, and I’m concerned about it. When I was on 50 mcg of T3, my other symptoms (depression, anxiety, fatigue, muscle pain, hair falling out, poor concentration, insomnia) cleared up. My weight also fell back to normal, and I maintained the lower weight. But this time, after my episode of hypothyroidism, my weight hasn't come back down. This is troubling because I follow an excellent health program. I eat a perfect diet, take nutritional supplements, and I’ve done practically every healing regimen in the natural medicine world. I exercise very hard with weights and cardio—one hour in the morning four-to-five days a week. Then I do a very brisk walk for an hour most evenings. Despite this regimen, I’m in constant pain. And my weight has stayed higher than normal. I have a layer of fluidy, fatty, flabby, cellulite type of fat over my arms, belly, thighs, and butt. It doesn't seem to shift no matter how hard I exercise. Is it possible that I need more T3 to get rid of the pain and flab? I love your work. Thank you in anticipation of your reply.

Dr. Lowe: I am sorry you’ve had the health problems you describe. Whenever I hear from a clinician such as you, I regret even more the confusion that reigns in the field of clinical thyroidology. You’re by far not the only clinician perplexed about how to use thyroid hormone effectively to alleviate problems such as your pain and fat.

When you went through the severally stressful time you mentioned, you most likely needed to temporarily increase your cortisol dosage rather than your T3 dosage. And by increasing your T3 dosage, you may have worsened the cortisol deficiency induced by the stress.

When the adrenal cortices are functioning well, stress causes them to substantially increase their secretion of cortisol. In my opinion, during stress, the person on physiologic cortisol therapy, as you’re on, should mimic what the adrenal cortices do during stress. The person should take more cortisol than during tranquil times.

During the stressful time you experienced, it’s highly likely that your need for cortisol markedly increased. By increasing your T3 dosage, you may have sped up the clearance of cortisol through your liver. This would have decreased the cortisol available to your cells at a time when you needed much more than usual. You said that at this time, you again developed symptoms of hypothyroidism. It’s possible that the symptoms were actually those of a cortisol deficiency. That’s likely if the hypothyroid-like symptoms included fatigue, muscle weakness, lower tolerance of stress, and low blood pressure upon standing up.

Armour works well when the patient takes a high-enough dosage. It’s possible, however, that you aren’t taking enough. On your dosage of 4 grains, you’re getting 36 mcg of T3. This is only 4 mcg less than when you felt well and stable on 50 mcg. However, the difference may be substantial for you as an individual.

The problem I see in cases such as yours is a black hole of sorts: how much of the T4 in the Armour (152 mcg in the 4 grains) do you absorb and convert to T3? We don’t know. Some studies indicate that while we absorb almost 100% of T3, we absorb variable amounts of T4, for example 80% or 85%. But how much of it ends up converted to T3 and bound to T3-receptors is a mystery. Because we never know how much T4 is effectively used by one’s body, I believe that using T3 is preferable. The relationship between symptoms or symptom relief and the T3 dosage is far clearer than with T4. More T3 dosage might also reduce or relieve your pain by inhibiting substance P production, by repressing the preprotachykinin-A gene, which codes for both substance P and its receptor.[1,p.732]

I hope, doctor, that you’re soon able to relieve your pain and lose your excess fat. I suspect that you can do so by raising your T3 dosage a small amount. Also, if you experience any prolonged or intense stress, I hope you’ll consider that temporarily increasing your cortisol dosage is the proper course of action.

Reference

1. Lowe, J.C.: The Metabolic Treatment of Fibromyalgia. Boulder, McDowell Publishing Co., 2000.

February 22, 2007
Question: My doctor diagnosed low cortisol and has me taking 20 mg of cortisol each day. I am concerned about taking too much, but she told me that 20 mg is a safe dose. What are the symptoms of too much cortisol so that I can watch for them? How much cortisol is too much?

Dr. Lowe: I have included below a list of the symptoms, signs, and test results when patients have severe excess cortisol. Keep in mind that factors other than excess cortisol can cause most of these symptoms, signs, and test results. Because of this, just because you have one or more of these features doesn’t necessarily mean you’re taking too much cortisol.

Also bear in mind that what is too much cortisol for a patient is an individual matter: What is too much for one patient may be too little for another, and vice versa. Moreover, some patients’ tissues are partially resistant to cortisol, and they have to maintain a higher body level of cortisol than others to be free from cortisol deficiency symptoms and signs. Cortisol resistance is now a scientifically established disorder, but I don’t believe researchers have established the incidence in the population. If a patient suspects he has cortisol resistance, it is crucial that he work with a doctor who is knowledgeable about the disorder and experienced in working with cortisol resistance patients.

My treatment team has worked with some patients who over medicated themselves with cortisol. The patients developed the symptoms and signs of cortisol excess only after several months of taking very large daily doses—several times the 20 mg you’re taking.

As I said, though, how patients respond to different doses of cortisol is an individual matter. Because of this, it’s hard to say what will be excessive for any particular patient. However, it is important for patients to stay within the range considered “physiologic” rather than “pharmacologic.”

“Pharmacologic” refers to the large doses of cortisol analogues (such as prednisone) that doctors use—hopefully briefly—to suppress inflammation. Pharmacologic doses are often used to treat conditions such as severe acute asthma.

“Physiologic” refers to maintaining a body level of cortisol that the adrenal cortices would maintain, were they capable of doing so. One aim, then, of physiologic cortisol therapy is to give the patient just enough cortisol to make up for what his adrenal cortices should be but aren’t providing.

Because of individual variability, it’s best for each patient to work with a knowledgeable doctor to decide what is for that patient a physiologic dose. But I agree with your doctor: your dosage of 20 mg is mostly likely well within the harmless physiologic range.

Symptoms, Signs, and Test Results in Cortisol Excess
O Weakness	O Reduced resistance to infection
O Muscle wasting	O Edema
O Poor wound healing	O Easy bruising
O Obesity of the trunk of the body	O Purple striae (stripes) on the abdomen
O Fat pads above the collar bones	O Fat collection at the junction of the back of neck and upper back ("buffalo hump")
O Skin that is thin and atropic	O Plethoric (overfull, turgid, inflated) appearance
O Rounded "moon" face	O High sodium & low potassium levels
O Psychological disturbance such as mood swings	O Slender arms and fingers and legs and toes
O Glucose intolerance	O Excessive hair growth (hirshutism)
O Kidney stones	O Menstrual irregularities such as amenorrhoea (absence of periods)
O Osteoporosis	O High blood pressure

December 10, 2006

Question: I am a 46-year-old woman who has been hypothyroid for twenty years. The general practitioner who diagnosed my hypothyroidism put me on Thyrolar. I did well on that for years. When I saw an endocrinologist for another problem, she took me off the Thyrolar and prescribed Synthroid. She told me that Synthroid was the standard of practice. Within three months, I had gained fifteen pounds and was severely depressed. My general practitioner prescribed an antidepressant for the depression and told me to exercise more to lose the weight. Out of frustration, I found a new general practitioner, and he prescribed Armour Thyroid. Six weeks later, my weight was down and the depression was gone.

About a month after I started the Armour, a new problem came over me. My joints became swollen and painful. My finger and wrist joints are worse, but my shoulder and hip joints also hurt. A rheumatologist who gave me a cortisone shot, and the pain was gone for about a week. When the pain came back, he told me to take ibuprofen to keep the pain down. I’m doing that, but my joints still hurt and I’m afraid of side effects of the ibuprofen. Do you think I became allergic to something in the Armour? Should I switch back to the synthetic hormone in Synthroid to see if that makes the pain go away?

Dr. Lowe: I'm sorry you have joint swelling and pain, and that you’re confused about what brought it on. I think it is highly unlikely that you’re allergic to anything in the Armour pills. A way to eliminate that possibility, however, is to take an antihistamine that you know is effective for you. If the antihistamine makes the swelling and pain go away, stop the antihistamine. If the swelling and pain return, start the antihistamine again. If the symptoms again subside or fully go away, you can be confident that an allergy is causing the symptoms.

As I said, though, I think that’s not likely. I have two reasons for saying this. First, the rheumatologist’s cortisone injection stopped the swelling and pain for a time. Cortisone is an anti-inflammatory drug, and because it stopped the swelling and pain, the cause is most likely inflammation.

My second reason for saying an allergy isn’t likely the cause of the symptoms is more important. That reason is that I've had many patients who had essentially the same history as you. They had joint swelling and pain after switching to a more effective thyroid hormone therapy. (Most often, patients had switched from a T4-only product, such as Synthroid or Levoxyl, a T4/T3 product such as Armour, Westhroid, or Naturthroid, or to T3 alone.) I then diagnosed a cortisol deficiencies through salivary free cortisol testing. Next, we corrected their deficiencies with physiologic cortisol therapy, and this eliminated their joint swelling and pain.

If you’re truly like those patients, what probably happened to you is this: Synthroid was not effective enough to keep your liver’s metabolism at a normal rate. Because of this, your liver sluggishly cleared cortisol from your blood. For some reason, the cortex of your adrenal glands can’t produce a normal amount of cortisol. But, using Synthroid and only slowly clearing cortisol out through your liver, you still had enough cortisol in your body to inhibit inflammation.

But when you switched to Armour, it sped up your liver’s metabolism. As a result, your liver began clearing cortisol from your body more quickly. But your adrenal glands can’t produce enough cortisol to make up for the larger amount your liver is clearing from your body. Because of this, the faster clearance has lowered your body’s cortisol too far. Having too little of this anti-inflammatory hormone has led to your symptoms: joints that are swollen and painful from inflammation set off the mechanical stresses of joint movement and weight bearing.

If a cortisol deficiency has caused your joint swelling and pain, switching back to Synthroid is not the prudent course of action. Synthroid might free you from the joint swelling and pain by letting your liver again clear cortisol from your body too sluggishly. But you would most likely gain weight again and sink back into depressed. What is prudent is to stay on Armour Thyroid, which is more effective for you. Then confirm that you have a cortisol deficiency, and correct it by using physiologic cortisol therapy.

December 14, 2003

Question: I took Armour Thyroid for a month. It relieved most of my hypothyroid symptoms, but then I began to have severe joint pain. I’ve now been off the Armour for six weeks. My old hypothyroid symptoms have returned, but the joint pain has stopped. My endocrinologist prescribed the Armour, and he was very surprised. He’s never had another patient who had this problem. I contacted Forest Pharmaceuticals, the manufacturer of Armour, and they said they had six other cases like mine. When the patients took Armour, they developed joint pain, and the pain went away when they stopped taking Armour. Forest also found a French study that discussed a correlation between hyperthyroidism and joint pain. My endocrinologist is going to let me try a combination of Synthroid and Cytomel. If the combination gets rid of my symptoms and I don’t develop joint pain again, we’ll know it was the Armour that caused the pain. Maybe I had an allergy to Armour. What do you think about all this?

Dr. Lowe: It’s within the realm of possibility that a patient could have joint pain as part of an allergy to some chemical constituent of Armour. But I seriously doubt that this was the mechanism of your joint pain.

The most likely mechanism is a cortisol deficiency stimulated by an effective dose of Armour. An effective dose of thyroid hormone increases the metabolism of the liver. Increased liver metabolism speeds the rate at which the liver clears various hormones, such as cortisol, from the blood. If the patient’s adrenal cortices aren’t capable of increasing their production of cortisol, the patient can develop a cortisol deficiency. Cortisol is an inflammatory hormone, and a deficiency of it can cause some tissues to easily become inflamed. Joints are highly susceptible to inflammation during a cortisol deficiency. The reason is that they’re often subjected to mechanical stresses, such a movement and pressure.

If a cortisol deficiency was the mechanism of your joint pain, I would expect an effective dose of combined Synthroid and Cytomel to induce the pain again. To validly test for this mechanism, you should use the same ratio of T4 to T3 as in Armour (a 4-to-1 ratio). You should also take as much T4 and T3 as you were getting in the dose of Armour when the pain occurred.

If the pain reappears while you’re using Synthroid and Cytomel, your next step should be adrenocortical testing. You should get several measures of your salivary cortisol through a 24-hour period. Possibly, you should also undergo an ACTH-stimulation test. In that test, you’ll have an injection of ACTH, and the change in your cortisol level will be measured. You should, of course, still be using Synthroid and Cytomel when you undergo the testing.

Your endocrinologist may order or perform the ACTH test. However, most conventional doctors still don’t test for levels of cortisol in saliva. If your endocrinologist isn’t familiar with the saliva test, we’ll be happy to order it for you. If we can help, phone us at 303-413-6003, or write to Tammy Lowe at Tammy@drlowe.com.