This article is based on working with thyroid patients who have some level of cortisol dysregulation. Usually, this dysregulation is sub-optimal cortisol, that has been seen in an 8:00-9:00 am morning cortisol blood test, or in a saliva cortisol test. In some cases, the patients have simply described their symptoms to me, which have invariably included finding that getting up and functioning well in the morning is incredibly difficult. The term that is often used to describe how they feel in the morning is ‘dragging’. Often the patient does not start to feel better until the afternoon or evening.
For those patients with clearly sub-optimal cortisol, I usually recommend trying my CT3M protocol using T3. Even if they are on T4 or NDT medication in the daytime, a T3 CT3M dose can still be effective in improving cortisol.
For those patients who have not yet tested cortisol, I encourage them to actually test it properly in blood and saliva. It is always best to get actual test data when cortisol is concerned, as attempting to diagnose low cortisol just on symptoms can be difficult. For some patients, getting the right tests done can be problematic because of their situation or location. For these patients, a trial of CT3M can actually be the only viable diagnostic available.
In the majority of cases of low cortisol, I tend not to suggest much in the way of changes to the day time dosing strategy of the patient. However, the exception to this is for poor converters of T4 to T3. When thyroid patients have an FT4 level which is much higher in the reference range than their FT3 result, it is usually because these patients are poor converters. They may also have a high in the reference range rT3 result, which would tend to confirm this situation. The reasons for being a poor converter are many. They include thyroid tissue damage, and genetic defects, which I discuss in other articles. But there are many other potential causes. Whilst some causes of poor conversion might respond to intervention, there are some that will not and the only thing to be done is to manage the situation. Often this requires less T4 medication and added T3 medication.
Having introduced the basic background, let me talk about the very specific situation that prompted me to write this article. Some poor converters of T4, may be taking their T4, or NDT, in the evening or at bedtime. It is actually quite common practice for T4 meds to be taken at bedtime and many thyroid patients are convinced it makes them feel better. However, I believe these people are invariably fairly good converters of T4 to T3.
For the poor converter of T4 to T3, a bedtime dose of T4 can be the worst thing to be using. The reason for this is that by the time the T4 absorbs from the gut and gets to peak levels in the bloodstream, it will be the middle of the night. This is the time that the pituitary gland begins to slowly raise ACTH to stimulate the adrenal glands to produce more cortisol. The pituitary will begin to crank up ACTH so that in the last hour or two prior to getting up, the thyroid patient ought to have good cortisol levels. As I explain in my books, and other articles, the pituitary gland is known to have the highest concentration of FT3 compared to all our organs and glands. It ‘runs on FT3’.
When a poor converter of T4 to T3, uses an evening or bedtime dose of T4, they are basically risking the situation where rT3 is rising higher, and FT3 might even fall. As I have explained elsewhere, the T4 dose could lower TSH slightly, which will down-regulate FT4 to FT3 conversion. As conversion is down-regulated, FT3 could lower and rT3 could rise. This is entirely the opposite situation to that of using a T3 CT3M dose. For poor converters of T4 to T3, a bedtime dose of T4 (or NDT), may well have an ‘anti-cortisol effect’.
Now, this article is based on working with thyroid patients. It is not based, on a published research study, so I cannot provide any peer-viewed published papers. However, what I can say is that I know of thyroid patients who have had either clear low cortisol results, or obvious low cortisol symptoms, who have provided me with good evidence for what I have written here. They have simply changed the time that they take their T4 medication from the evening to the morning, and have immediately felt far better. This is without any other dosage changes at all. It is also possible that, if a thyroid patient was on a T3 CT3M dose, then the bedtime dose of T4 might be totally counterproductive.
Clearly, this article is only relevant to poor converters of T4 to T3, and to those that also have sub-optimal cortisol, or low cortisol symptoms. But for this subset of patients, it is worth them considering whether any bedtime dosing of T4-based medication might in fact be contributing to their low cortisol.
Best wishes, Paul
