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The Cortisol Awakening Response with Dr Carrie Jones

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The Cortisol Awakening Response with Dr Carrie Jones

Did you know the quality of your cortisol awakening response can reflect your overall general health?

In this episode Dr Carrie Jones provides an in depth look the cortisol awakening response, and its importance to our health. Carrie discusses the different types of impairment to the cortisol awakening response and how that presents in a patient, when to test it, and natural remedies to get it back on track. 

Covered in this episode

[00:40] Welcoming Dr Carrie Jones
[01:54] The cortisol awakening response (CAR)
[04:57] Contributing factors of an impaired CAR
[10:17] How to change the CAR
[15:27] How the seasons and where you live affect the CAR
[20:11] CAR and general health
[24:43] Shift workers and CAR
[26:47] When to test the CAR
[30:32] How the CAR might contribute to inflammatory conditions
[33:58] Medications that interfere with the CAR
[38:20] Sleep hygiene 
[42:48] Natural remedies to assist sleep
[45:50] What to expect from Carrie at the 2020 BioCeuticals Research Symposium


Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook. Joining us on the line today is Dr Carrie Jones, who's an internationally recognised speaker, consultant, and educator on the topic of women's health and hormones. She graduated from the National University of Natural Medicine where she also completed her two-year residency in women's health, hormones, and endocrinology. Later she graduated from Grand Canyon University's Master of Public Health program with a goal of doing more international education. She's the medical director for Precision Analytical, creators of the DUTCH hormone test. Carrie, I warmly welcome you to FX Medicine. How are you?

Carrie: I am fantastic. Thank you so much for having me on.

Andrew: Now, you and I met at the Genomics Summit, Methylation and Genomics Summit, two years ago, so I'm glad to be speaking to you again. And I'll be glad, very glad to be meeting you again at the 8th BioCeuticals Research Symposium in Melbourne in 2020. That should be fun.

Carrie: Well, I don't know if you remember this, but we sat next to each other, and you had the most wonderful sense of humour, and I thought “we're going to be friends.”

Andrew: Uh-oh. Now, today, we're going to be talking about something which really piqued my interest, and that's the cortisol awakening response. Now, this is very different from standard cortisol testing as I know it. So what exactly is the cortisol awakening response?

Carrie: It is not something to do with gas. So, we call it the CAR. It's actually a natural release of cortisol that happens in your body when you wake up in the morning and open your eyes. Now, we're all familiar with the way cortisol is made throughout the day. We're all familiar with how our body works off of a circadian rhythm or cortisol goes up and then it comes down. But what I don't think people realise and what I'm going to really touch on in my lecture is how the cortisol awakening response occurs within that first 20 to 30 minutes of waking up. So when you wake up in the morning, and you open your eyes, and light comes in, your brain tells your adrenal glands, "Okay. It's go time. We need to make a lot of cortisol really quickly.” And if you can't do it quickly or you do it too quickly and you make too much cortisol, you end up with a lot of symptoms, you end up with things for everything from, like, anxiety and depression, all the way to inflammation, worse inflammation, worse blood sugar response, worse energy levels, not feeling resilient. You can increase your risk for autoimmunity. So, focusing on that first 30 minutes of your day when we're testing cortisol can actually set yourself up for the whole rest of your day and a whole number of health outcomes that you want to pay attention to.

Andrew: Could this partly explain the controversial topic in diabetes of the Somogyi effect, the Somogyi phenomena?

Carrie: It is part of it. I think it's part of it. Yes. I think it's part of it.

Andrew: Right.

The relationship between histamine, oestrogen, progesterone and cortisol by Georgia Marrion. READ ARTICLE

Carrie: And the reason I say that is when I'm looking at testing, and people can have an early spike in cortisol. So they may still be asleep, but the communication between the brain and the adrenal is inappropriate, and so they can have an early spike in cortisol which can actually then increase glucose production or glucose creation. And when they wake up, they can have elevated levels of blood sugar. Whereas the opposite can happen. if you have somebody who doesn't have a very strong awakening response, their cortisol production is actually quite weak, it's quite low, maybe it goes down, which can happen in some people. Now, you actually have the opposite effect. You don't make a lot of cortisol in the morning, you're ridiculously tired, and you have all sorts of blood sugar issues, because you've woken up fasting, but your body isn't actually breaking down, like, your fatty acids to make glucose in the way that it's supposed to, because it's not getting an appropriate signal from cortisol to do so. So, these people often wake up hungry or hypoglycemic or shaky. So you can actually swing either way depending what your awakening response is doing.

Andrew: There are so many questions here to go into. I mean, cause or effect, I guess there's a first one.

Carrie: Right, right. And it depends. So, like, let's say... The classic example is when I'll ask somebody, "How do you do in the morning? Tell me about your morning. Do you have energy in the morning?" And they'll go, "Well, yeah. After about two hours and two cups of coffee, I feel normal, I feel human again.”

Andrew: Right.

Carrie: I'm like, "All right. I can say, that’s pretty standard." I'm like, "I can tell you right there, you do not have a healthy awakening response," because your body, your brain is supposed to switch from conscious, meaning my eyes are open, and I've recognised my alarm is going off, and I need to get up, to alert within that 30 minutes, sometimes 60, but research says more like 30. So, if you're struggling in the morning, that means, that tells me that your awakening response is low. Now, what can cause a low awakening response? The list is actually really quite long, but the number one thing is sleep irregularity. People who have sleep apnea…

Andrew: Yep.

Carrie: …can really affect the ability of that communication between the brain and the adrenals and the amount of people with sleep issues. And they don't even maybe realise it, you know, they wake up several times in the night, they don't hit their deep sleep, or they're mouth breathers. 

Andrew: Yep.

Carrie: They snore in their sleep. They have sleep apnea, right? All those things can suppress a proper awakening response.

Now, you have the opposite. Let's take the opposite person. The person who I say, "How's your morning?" and they go, "Oh, my gosh. I get up in the morning and I'm immediately fight or flight. I'm immediately anxious. My heart is racing. I jump out of bed. I'm running around like a chicken with my head cut off. I'm trying to get my kids ready. I'm trying to get ready for work. I've stressful text messages that are coming through. I'm fighting with my spouse. It's a mess." But what I know is that in that 30 minutes, their cortisol production goes way up, because that's anticipating the fact they're about to have a chaotic morning. We just repeat patterns as humans, right? 

Andrew: Yep. Yep.

Carrie: The brain goes, "Look, here, she's going to wake up just a stressed-out mess, so let's just go ahead and really ramp up that cortisol production, really get that adrenaline going so that we can help the person deal." But, of course, we don't feel helped, we feel anxious, and we feel like we've panicked, and we feel like we're running around, running late and, you know, yelling, and we have a short fuse and no patience. And so that anticipatory stress is what sets us up for the rest of the day. So it can go both... Again, it can go both ways.

Andrew: Okay. You talk about...

Carrie: But there are lots of other reasons, lots of other causes.

Andrew: Yeah. Just a little point on how humans repeat patterns and also how we adapt. What happens or how quickly do we re-adapt, say, when people go on holidays, and that stressful morning flight or fight response isn't there? Is it continued?

Carrie: So this is a really interesting question, yeah, to ask people. So, I will ask my patients, "When you go on vacation, how do you feel?" And it's really insightful when they say things like, "Well, it takes me four, five days to relax, but by then we're already having to come home." But if they go on a long holiday, you know, if they're gone for four weeks, let's say, and they'll say, "It takes you four, five days to relax, and after that, I'm so much better." Four or five days in the grand scheme of the human lifespan is not that long, right? And so I'm like, "This is good. This is wonderful that it only takes you four or five days to break the pattern to reset into the body that we are on holiday, we are not in fight or flight, we do not have anticipatory stress. And from moving forward, we can do this in a healthy manner." But most people don't have four, five days.

Andrew: Yeah.

Carrie: Right? Or they'll say, "Well, I'm a control freak. I'm type A. I can kind of relax, but not really." And so that pattern is really ingrained and takes a lot more work to try to relax them, to try to let that pattern go, to get their cortisol awakening response to be less dramatic than somebody who says, "In four or five days, you know, I'm back to normal." Now on the flip side, if you've got somebody who's really, really low and they go on vacation, they may find that they sleep a whole lot. They'll say, "I spend the first four or five days literally doing nothing. I read, I relax, I take naps, I sleep, and then I start to feel a whole lot better." What they're doing is they're recharging the body, essentially. They are really getting that circadian rhythm back where they're supposed to be up in the morning and down at night, but you have to charge the batteries, you have to really heal the brain and heal the communication from the hormones in the brain down to the adrenal glands. And so vacation can be wonderful or a holiday can be wonderful for either end of the spectrum, because in the end, they both come out and they go, "Oh, I feel so much better. I have much more resiliency. I feel restored. I feel, you know, better than I was. I'm a whole new person." The problem is, on either way, they go back to reality…

Andrew: Yeah. Yeah.

Carrie: …and they fall right back into the same trap.

Andrew: I mean, the big question there, of course, is how do we change people? How do we help people to change an old habit, to break an old habit to reform new ones?

Carrie: Absolutely. And it starts with... When it comes to the cortisol awakening response in particular, it starts with that circadian rhythm. It starts with that light-dark cycle. So, what I advise people or suggest to people, is at night before bed, you want to take advantage of the darkness. You want to be off your screens. You want to be off your phone, off your tablet, off your TV or wear those glasses, those blue light blocking glasses that will at least help minimise the effect of the blue light that's stimulating to your brain. And then in the morning, you want the opposite. In the morning, you want the light exposure. I want you to go outside and enjoy the natural sunlight for 5, 10, 15 minutes. I want you to open up your blinds or your curtains and flood your room with natural sunlight.

Andrew: Yeah.

Carrie: I want you to go buy a full-spectrum light box off the internet and turn it on in the morning as soon as your alarm goes off. I want it to fill your room with full-spectrum light, not fluorescent light…

Andrew: No.

Carrie: …but full-spectrum broad light, right? And I want to just retrain the body that we go down at night and we are up in the morning, because what I find is that so many humans, it's really difficult to change our stress. It's really difficult to change our jobs. It's really... you know, we can't get rid of our kids.
There's a lot of stressors in our life. They just are what they are, and we have to deal with them the best we can. 

But what I do find is what I'm so excited about with the symposium in 2020 is that you're going to cover all the basics, you're going to cover how you're going to eat for your health, you're going to cover how you're going to sleep for your health, and how we can just reset these natural normal patterns so that when chaos happens, when stress happens, we're more resilient and we can handle it. If you sleep healthy for eight hours, if you hit all your stages of sleep and you wake up feeling restored, you're going to handle your stressful day better than somebody who is up all night or can't hit their stages of sleep or goes to bed way too late and then gets up way too early. They're not resilient, and they're not going to be able to handle their day.

Andrew: You know, I hear this word over and over and over again, resilience. And it seems to me to be the key. How do we restore or even give somebody resilience when they haven't had it or when they've lost it?

Carrie: I was talking to a colleague of mine a couple days ago, and I have a tracker that I use, and it helps me track my sleep. And he said, "You posted a picture, and it says you average between two to three hours of deep sleep at night. I average about an hour a night. How do you do that? How do you hit two to three hours of sleep?" And I said, "Well, I do a number of things for sleep. One of which is that the majority of your deep sleep when you're looking at your phases of sleep, your deep sleep is where you restore and you heal. It's where your brain activates something called your glymphatic system, with a G, your glymphatic…

Andrew: Yep, yep.

Carrie: …and it's where it clears out debris, and it heals cells, and it gets rid of the bad cells, and it circulates hormones, and it moves stuff around and it feeds the cells. It does all this great stuff, but it only does it in the deep sleep. The deep sleep is also when men make testosterone. It's right then. Men don't make it in the day, like we think. They make it in the deep sleep at night. And so our deep sleep is really imperative. And I said most of the deep sleep in humans is done in the first part of sleep, which is why the researchers, the circadian rhythm researchers, advocate that people go to bed somewhere by like 10:00 or 11:00 at night," and he goes, "Oh, no, no, no. I go to bed at 1 a.m.

Andrew: Whoa.

Carrie: “Sometimes 2." And I said, "Well, you're missing your deep sleep."

Andrew: Yeah.

Carrie: Now, he'll get up at 7, and he'll get up, and he's like, "Well, I do get like six to seven hours of sleep." I said, "No, it doesn't count." You have a built-in, born-with circadian rhythm in every cell in your body, and they want you to be in bed by 10:00 or 11:00 at night. And if you just simply adjusted when you went to bed, it'll take time," because he's got a pattern at this point. If you can go to bed at 10 or 11 at night, it will help increase your deep sleep. 

Andrew: Right.

Carrie: And that's just his example. That's just one example. And I know people listening to this are guilty as charged. I know people listening to this are like, "Well, I try to go to bed at 10…

Andrew: Yeah.

Carrie: “…but then I'm on my phone or then my kid comes in and they're thirsty, or I'm doing work, my kids are in bed, and it's my power hour. I stay up so I can work on my computer when the house is quiet, so that's when I do all my catch-up." I'm like, "I know. I get it. I 100% get it. But you're doing it at the risk of your health. You're doing it at the risk of your sleep, which is then affecting your awakening response, which is affecting your resiliency."

Andrew: Yeah. What about things like seasonality with regards to how light penetrates the room? Humans are, unfortunately, economically wired to regularity, because we work.

Carrie: That is true. And where you live in the world. 

Andrew: Yeah.

Carrie: Where I live in the United States, we are historically greyer and rainy a lot of the year. And so even in the summer, even if the sun is supposed to be out early in the morning, it may not be, it might be a rainy day. And so in that case, you have to buy your lights, you have to buy your brightness. So that's when I was talking about those broad-spectrum or full-spectrum light boxes. And they're not very expensive, thankfully, and there's some wonderful ones on the market. And I tell people to buy one, and when your alarm goes off in the morning, you hit the button, have it right next to you, and turn it on and fill your room with that full-spectrum, that broad-spectrum lighting, because it can make a world of difference. And now a lot of companies have jumped on the alarm clock bandwagon of making an alarm clock that is a full-spectrum light that gradually gets brighter…

Andrew: Right.

Carrie: …as you get closer to your alarm. So, if you wake up at 6 in the morning, it might start to get brighter and brighter by about 5:45 until it's maximum brightness at about 6 a.m. to get you out of bed. And for some people, that works really, really well. In fact, my best friend has one of those alarms, and she swears by it. She said it's made a world of difference in her morning energy.

Andrew: Speaking of alarms and sound waking us up, I'm interested by the examples of, you know, the sine wave, the square wave, you know, the sort of the klaxon sound, which for teenagers does not work, and yet a soothing, more alpha wave-driven piece of classical music can wake them up, something like Pachelbel's Canon in G, these more soothing sort of sounds and then gradually increasing that sound. It's really interesting.

Carrie: I mean, the teenage brain, in general, it's just fascinating...

Andrew: Yeah, what happens?

Carrie: ...as it continues to develop. Right.

Andrew: But do you find that, you know, when we're talking about the cortisol awakening response in that flight or fight response, sometimes they have to change that type of alarm?

Carrie: Interestingly, research says that alarms do not affect the awakening response.

Andrew: Got you.

Carrie: So the startle response should not affect it. If you do it the same five days a week, Monday through Friday or whatever your work schedule is.

Andrew: Yeah.

Carrie: Now, what will change it, though, is if you have to shift your alarm for something. So, for example, if you have to catch a very early flight, and you've moved your alarm clock to get up an hour or two earlier than normal, that will affect it. And most people feel that. Most people say, "If I have to get up at 4 in the morning to catch a flight, I feel terrible, or I feel sick, or I feel hungry, I feel hypoglycemic, I feel anxious." I definitely have people that say, "Why do I feel this way at 4 in the morning but not at 6 in the morning?" I'm like, "Well, first of all, nobody should have to get up at 4 in the morning. But second of all, it's because you've affected your awakening response.”

Andrew: Right.

Carrie: It's a new time, and so the brain and the adrenals didn't... You consciously knew you had to get up at 4 a.m., but your brain and your adrenals didn't. So they have an agreement that you get up at 6 a.m…

Andrew: Yep.

Carrie: …and at 4 a.m., you've thrown them them off, and so they have to react very quickly."

Andrew: Sometimes, though, when I get up, like, I don't like getting up early, but when I do get up early, I love being up early. You know how we all snuggle into bed, our body temperature relaxes up and reduces, lowers, and we get into that beautiful restful sleep, and then we're suddenly awake? That time when you think, "Gosh. Have I just gone to sleep five seconds ago?" And yet you wake up refreshed, but you don't want to get out of bed. Discipline.

Carrie: I mean, the feelings go into it, right? Exactly. Discipline is a great way to put it. I'm not an early morning person, but I'm like a normal morning person. I'm rather pleasant in the morning. I don't need coffee to be a nice person, and when my alarm goes off, I will get out of bed. And I know I have a healthy awakening response, because I've tested it. However, now that it's my winter where I live, when I wake up in the morning, like, my husband is there, my dog is there, I'm under warm blankets, it's dark outside, I don't want to go out of bed. 

Andrew: No.

Carrie: I know I'm supposed to. I'm a pleasant person, but why would I? Why would I get out of bed when, like, all my happy places are right there?

Andrew: That's right.

Carrie: And it's dark out? It does take discipline and motivational self-talk to convince myself, "Get up and go work out."

Andrew: Now, just moving on. So, what information does the cortisol awakening response give about your health in general?

Carrie: Oh, so many things. This is what I love about it so much. So, the cortisol awakening response has an impact on things like energy and resiliency and mood, which all are things that we've talked about. But it also has an impact on your cancer outcomes, on memory and recall, on autoimmunity. So, if somebody has a low awakening response, I know that they have a higher risk potentially for worse cancer mortality if they would develop breast cancer. I know they have a higher risk for autoimmune disease development, and I know they have a higher risk for problems with recall. And I know this because when it comes to cancer, they show that when a cortisol slope, so your cortisol is supposed to go up, like we talked about, and then down through the day…

Andrew: Yep.

Carrie: …but if you don't, if you flatline or have kind of a low slope, that you have a worst mortality. And I know that if you have a flat slope, if you're flat or down instead of going up, then your body struggles to kill your key cells that have failed something called central tolerance. So, when your body makes T cells in your immune system, it's really smart, it runs it through your thymus glands, not thyroid, but thymus.

Andrew: Thymus, yeah.

Carrie: And it checks it against everything in there, you have all the tissues in there, to see if any of them are autoimmune. And if you have a T cell that was accidentally created autoimmune, it gets pulled to the side and destroyed. And what triggers that destruction is the cortisol awakening response. So when people say to me, "You know what? I have Hashimoto's, and I thought it was under control, but now all my symptoms are back, and I feel worse in the morning," I am strongly suspicious that their awakening response goes down or is flat. Same with recall and memory. If somebody says, "I'm having a lot of stress, and I think I might get... I'm going through divorce, right?

Andrew: Right.

Carrie: I'm going through a divorce, my stress is through the roof, and I can't remember anything. Do I have dementia?" No. Cortisol can be quite destructive to your memory cells, your hippocampus cells. And your hippocampus is responsible for memory. But on the flip side, you need cortisol to help with recall. So, people, if you're listening to this today and the next day can't remember at all what Andrew and I talked about, you have poor recall, and I bet you have a cortisol awakening response issue. It's so fascinating. On this little 30-minute rise of cortisol in the morning, I can tell people so much about their health.

Andrew: Right. And are we talking hippocampal damage or restructuring? I'm thinking here about plasticity here.

Carrie: Yes, both. You can have both. So, if you have hippocampal damage, let's say you had traumatic brain injury, let's say you're a smoker…

Andrew: Yep.

Carrie: …let’s say you've gotten into a car accident, you're on medications that are suppressive, such as steroid medications, all of those things affect the hippocampus and the hippocampus controls the cortisol awakening response.

Andrew: Right.

Carrie: Same with the hypothalamus.

Andrew: Okay. So with regards to the hypothalamus, what about things like the reticular activating system? 

Carrie: Yes.

Andrew: Are we damaging that so that we're then leading to a chronic, you know, nervous restructuring of an organ?

Carrie: You could. You could, absolutely. And in that restructuring, again, it's survival, right? So, when the body is restructuring and changing plasticity, it's doing to help you survive, but it may result in you having an inappropriate awakening response.

Andrew: Okay.

Carrie: You will still survive. You won't die. You'll still wake up in the morning.

Andrew: Yeah.

Carrie: But it may not be as healthy and appropriate as you want it. Yeah.

Andrew: Right. Okay. So, getting back to plasticity. Can it be restructured so that you have a normal awakening response and your hypothalamus is reconfigured?

Carrie: Yes. Yeah. Plasticity is changeable, right? 

Andrew: Yeah.

Carrie: And so I tell people it takes time and effort, and if you're willing to put in the time and effort, you can change the pattern. I mean, just like if you get a new job and at your old job, you had to wake up at 7 in the morning, but in your new job, you have to wake up at 5:30 in the morning, you'll do it. You'll do it eventually. 

Andrew: Yeah, yeah.

Carrie: At first, it'll be really hard, really hard. And then eventually, it'll be your new normal. You've just changed your plasticity.

Andrew: Yeah. There was an interesting thing you said about cancer prognosis as well, and I'm interested there with regards to flight staff. 

Carrie: Yeah.

Andrew: They have an increased risk of breast cancer and melanoma, I think it is. 

Carrie: Yes.

Andrew: I remember there was... I always used to wonder, "Well, hang on. Are we talking about pilots here or are we talking about cabin crew with regards to ionizing radiation in the upper atmosphere?" So, with regards to mucking up our circadian rhythms and being on shift work and all of that sort of thing, is this why shift work and aviators, people whose time zones are mucked up all the time, why they have a worse CAR?

Carrie: Yes. Yeah. Oh, absolutely. And we see it all the time in testing. And we need our flight crew, right? We need those people. We need our night shift workers…

Andrew: Yeah.

Carrie: …to make the world go round. But, wow, do they have worse health outcomes for sure. 

Andrew: Yeah.

Carrie: And this is a huge beast, because they've just flipped their circadian rhythm. And especially if you're a cabin... Well, even pilots. Pilots are constantly, just as much as cabin crew, back and forth various time zones. They're 12 hours this way and then 12 hours that way. And their brain never quite has an idea of where they are, and it can really affect their cortisol awakening response in the long term…

Andrew: Right.

Carrie: …in the long term out. And it's really hard, too, because their schedule generally is not set…

Andrew: Yeah.

Carrie: …meaning they're not... There are some night shift workers who are night shift...

Andrew: All the time.

Carrie: Full time, all the time, right? And then there are others who are three... Like nurses, they're three days on and five days off. And so they're three days on a week where they are on from 7 p.m. to 7 a.m. and then the rest of the time they have off and so they flip to a normal schedule. And they're really challenging, their energy is challenging, their, you know, weight is usually challenging, their hormones are usually challenging. And I worry about their cancer outcomes.

Andrew: Yes. So, with cancer prognosis as well, so this is another interesting area. We talk about rest. We talk about exercise. Should we be measuring our cortisol awakening response, our CAR, at various intervals through our cancer treatment to just see how we're actually handling our cortisol?

Carrie: You can. I just… the only reason I don't, I tend to do it when I have people with cancer, and I don't treat cancer, but they come to me for just support. Then what I do is usually, I will treat them or I will do their cortisol awakening response at the end of their treatment, because when they're going through treatment, they have so much on their plate, they have so much that they're doing and so many appointments, that to add in periodic extra testing is sometimes just too...it's too stressful.

Andrew: Inconsequencial. 

Carrie: But I'm already trying to make them less stressed out, and just adding more in is making them more stressed. But what I am doing is I'm teaching them these basics anyhow. I'm like, "Hey, look, if you have a normal cortisol awakening response, your mortality improves, and I want your mortality to improve. I want you to live a long life. So, I need you through cancer treatment to be, again, off your screen at night, right, using blue light blocking glasses, using sunlight or full-spectrum light in the morning. I need you resting. I need you taking care of yourself. I need you not burning the candle at both ends, you know? I need you eating a healthy, rainbow-filled diet." All the things, whether I've tested them or not, because when it comes to long-term mortality, they are motivated in that. They're like, "All right, no problem. I'll look at the sun in the morning." Well, not directly. Don't look at the sun. Don't blind yourself. 

Andrew: No.

Carrie: Go outside. I'm like, "So, when you wake up, go outside, sit on your back deck for a little bit. Walk your dog or hang your head out the window."

Andrew: When would you definitely choose to test and when would you not bother and just do the normal things that we need to do anyway?

Carrie: So, I usually will work with... It depends. If their oncologist that they're using has a more holistic approach to them, then I will try to test them at least while they're going through treatment. I think that's a really good option. If their oncologist does not have any kind of holistic approach to them at all and thinks it's all bogus and doesn't want them doing anything else, then I will propose it to the patient. It's up to them. It's their health. 

Andrew: Yep.

Carrie: But at least at the very end, once they're released from the oncologist or at least if they're on watch, like, come back every three months, or every six months, whenever they're at…

Andrew: Yep.

Carrie: …I’ll say, "All right, now is the time. Now, let's test now that you've gone through treatment."

Andrew: What about in your general clinical intake? When do you think it's appropriate to test and when do you just do all of the good things that we should be doing, light exposure and things like that, and not bother testing? Like, when do you think it's appropriate?

Carrie: It really depends on their symptoms and how motivated or not that they are. So, if they're really motivated, and they're like, "Let me just try the lifestyle stuff for a while and see what happens," then we go that route. But if they're really pretty symptomatic, I mean, if they come in, and they say, "Look, in the morning I... In the morning I have bad inflammation, my autoimmune symptoms are worse, I have depression, whatever it is. In the morning I have anxiety. In the morning..." then I'm like, "We need to test, because I need to know exactly what we're up against and whether or not we're going to use supplemental intervention, you know, herbs and nutrients and things like that or not." And then I'll test. But if it's just a person who's like, "Yeah, I'm generally tired. I generally have stress, and I just want to make myself better or I want to... I'm just here to generally improve my overall well-being," I'm like, "All right. Let's try the basics and wait on testing."

Andrew: Yeah. And we're talking about, I know this is very limited in the conditions that we've spoken about, but, you know, memory recall, autoimmunity, cancer, things like that. So these are all driven by inflammation. 

Carrie: Yes.

Andrew: So, what about other inflammatory driven conditions? Polycystic ovarian syndrome, hypothalamic amenorrhea, lupus. What about all of these, rheumatoid arthritis, for instance?

Carrie: Right. Well, when it comes to the female health, a lot of it is reproductive rhythm, right? PCO... I mean, obviously, there's, like you said, inflammation. But when we're trying to get a woman's cycle to come back, it's a reproductive rhythm issue. And so you can't fix your reproductive rhythm until you fix your circadian rhythm. And so there's good research to show that if you can correct... Even your melatonin... 

Andrew: Yep.

Carrie: Melatonin is obviously a big antioxidant in the body, but it is a big driver of your circadian rhythm. It's also a big driver of your reproductive rhythm. And so I'll tell people... I'll ask people, I should say, "How is your sleep? You have PCOS with irregular cycles. You have hypothalamic amenorrhea. You have just irregular cycles. It comes every 23 days, every 42 days. How is your sleep? Are you sleeping consistently?" And the number of women that go, "No," is astounding.

Andrew: Right.

Carrie: And so I'll say, "Well, let's start with your rhythm, your circadian rhythm while we're working on this other stuff, because if we can get your circadian rhythm rhythmic, it will help your reproductive rhythm become rhythmic." Now, not always, but often.

Andrew: Okay. So, you mentioned melatonin there. And melatonin is being used in small amounts for shift workers and for some other sleep disorders, things like that. In cancer, it's used in huge amounts. And indeed I've spoken to incredibly great practitioners who I love and trust who advocate quite high doses, 20 milligrams, and indeed that's what's used in, I think, mainly colon cancer.

Carrie: Breast as well.

Andrew: And breast as well, right? So, where does the dosing sit if you are going to choose melatonin as an intervention and indeed when would you choose melatonin as an intervention?

Carrie: With melatonin, the original research shows that we physiologically don't make as much melatonin as we think we do. So, physiologically, we make about 0.3 milligrams a day. 

Andrew: Yep, yeah.

Carrie: But, yeah, most of the supplements right on the mar-,...or most of the prescription is in Australia and United States over the counter are, like, 1 to 5 milligrams. You can get 1 to 5 milligrams.

Andrew: Yeah.

Carrie: And so I'm more of the physiologic dosing. I find that people do better when they're in the 0.3 to 0.5 range.

Andrew: Ah, this is interesting.

Carrie: Now, again, I don't do oncology, but my oncology associates do use 20 milligrams plus when it comes to cancer for its antioxidant effect. 

Andrew: Yeah.

Carrie: In fact, some paper I was reading recently said melatonin is even more powerful than glutathione, but yet glutathione gets all the press of being the popular antioxidant. 

Andrew: Yeah.

Carrie: So, I try to start with the physiologic baby dose. It's really real dose, but what's on the market is a baby dose.

Andrew: And what about other medications that might interfere? Opioids is a cracker.

Carrie: Yeah.

Andrew: Sleeping tablets, the benzodiazepines. I mean, there's one of the scourges of our society which, you know, there was a major advertising campaign some decades ago, because people were just relying on the black smarties in Australia.

Carrie: Yep. Yep. All of the other sleeping medications that will have you sleepwalking or sleep-doing things you don't even realise, it's so scary the number of stories I've heard.

Andrew: What about other medications, though, that might interact with the hypothalamus?

Carrie: There's an acne medication, we call it Accutane or isotretinoin.

Andrew: Right. Yes, yes. Roaccutane in Australia.

Carrie: Yep. I had a patient who... Actually, that's not true. I was consulting with the doctor on their patient, and the patient looked like they had Addison's disease. And the endocrinologist said, "It's not Addison's. It's not true Addison's, but I suspect it's the Accutane this woman is on." Had her stop the Accutane, retested after about, I want to say, four to six weeks, and her cortisol levels were normal again. And when I did the research, I found it mixed, in research, that Accutane can either have no effect or it can kill cells in the hypothalamus and subsequently affect cortisol production downstream. I don't see it affect hormones as much as I do see it affect cortisol. It can be temporary. Definitely, in this case, we saw the cortisol come back to normal, everything rebounded, and it was fine. Or it can be permanent long term.

Andrew: Wow.

Carrie: And since I've told this to women, men as well, when I lecture, I've had more practitioners come up to me and say, "Oh, my gosh. You know what? I've never been well since Accutane. I had so many symptoms after I took Accutane in their teens or 20s and didn't realise it."

Andrew: What about gonadotropin-releasing hormone agonists? Any effective there?

Carrie: I don't see that affect cortisol. I don't.

Andrew: Got you.

Carrie: I'm not saying it doesn't. I'm just saying I don't see it enough to know that I could comment on its pattern.

Andrew: Yeah.

Carrie: I do see steroids. I do see steroids affect cortisol quite a bit.

Andrew: What other medication classes are an issue?

Carrie: Those are the big ones, I think the ones we talked about.

Andrew: Yep.

Carrie: The opioids, the sleep, the benzos, the steroids. The thing with steroids I want people to remember is, like, even your nasal sprays, your inhalers, your topical cream, it can affect it.

Andrew: Right. Okay. There's a point in question. An asthmatic who is now... I mean, the guidelines have changed so that they're now on a chronic preventer, not just a reliever, and then an intermittent preventer. So, the new guidelines look at a long-acting beta-agonist plus a steroid all the time.

Carrie: Right.

Andrew: Yeah. So, with regards to the chronicity of necessary medication, let's say in a more severe asthmatic, they can't get off the steroid…

Carrie: Right.

Andrew: …or somebody with an autoimmune condition where, you know, the continuing steroid is appropriate, somebody with a gut problem, that sort of thing. How do you then correct the cortisol awakening response? How do you readapt it?

Carrie: I'm not going to lie. It's insanely difficult. And the reason is nothing is stronger than a steroid.

Andrew: Right.

Carrie: I can't put somebody on ashwagandha, Lithocarpus, B5, and think that it's going to top prednisone. It's not. Prednisone is going to win every time, and it is suppressive to the HPA axis. And so, it's really challenging. It's really challenging. And it requires the practitioner doing a lot of work to figure out why is their asthma so bad. What is triggering it?

Andrew: Yeah.

Carrie: Is it food? Is it environmental? 

Andrew: Yeah.

Carrie: Is it... Whatever it is. The same for a rheumatoid arthritis, rheumatoid arthritis person who's on prednisone all the time. Why do you have such severe rheumatoid arthritis? And let's work slowly and carefully to hopefully clean it up and see if their doctor is okay with them weaning off of prednisone. But until that time, it's really tough.

Andrew: So we've spoken about a few ways about waking up and how we should, you know, think about preparing ourself for sleep and getting enough restful sleep. But how important is sleep hygiene, and what sort of things do you advocate?

Carrie: I think it's critically important. And I advocate all the way from, as it starts to get dark out, which I realise, depending on the season, it might get dark at 5 p.m., and in other seasons, it gets dark at 10 p.m. And so I'm definitely advocating for people, you know, look, if you have sleep issues, if you have cortisol issues, I need you to be mindful of what you're doing at night, what you're reading, what you're watching on TV or your tablet. Is it stimulating? Is it scary? Is it the news? Is it all the things that are going to wind you up? Who are you talking to? Are you drinking alcohol? Are you drinking... Oh, drinking. Are you eating sugar? Are you repeatedly having heavy meals right before bed that are difficult to digest? Do you have digestive issues? Do you have heartburn? Do you have gas, bloating, constipation, you have parasites? All these things I'm taking into account all the way up to, tell me about your bedroom. Tell me about your bed. Who sleeps in bed with you? Do they snore? Is it kids, you co-sleep? Is it your animals? Do you need to get a bigger bed? How long have you had your mattress? Have you had your mattress since the day you got married 41 years ago?"

Andrew: Oh, that's a big one. Yeah.

Carrie: Like, all these things I'm asking, "Tell me about your pillow. When was the last time you changed your pillow?" And it's amazing, because people... It's so our normal... And I'm guilty as well. I'm not perfect at all whatsoever. But when I asked these questions, and... The mattress. How long have you had your mattress? And people go, "Oh, God. Twenty years," or, "Oh, wow. We got it here," and, "Wow, that was three moves ago," and, "Oh gosh, two children ago." And I go, "Well, maybe it's time for a new mattress. Tell me about your pillow." These things. "Tell me, you know, who sleeps in bed with you?" "Well, it's my partner. We co-sleep, so our child and two other dogs." And what size bed do you have? Maybe you need a bigger bed. Maybe you need to work on this. Maybe we need to reassess some of these things, because I understand you don't want to hurt their feelings and you want to do this as a family, but it's at the expense of your health. And if you're not healthy, you can't take care of your family.

Andrew: And how often do you get this disconnect between the partners? Lee and I, my wife and I, laugh about this all the time. She's quite a light sleeper. She needs perfect darkness. And forgive me, but I love watching YouTube funny videos at night. So, Lee is already asleep, and I get into bed, I've watched these videos, and I start giggling. And I'll just get this fist coming across the bed at me. So how often do you get this disconnect, and how do you address this difference in sleeping partners?

Carrie: All the time. All the time. I have partners that will say, "I go to bed at 10, and my partner doesn't go to bed until later. We have different..." Or, "I work the day shift, and they work the night shift…

Andrew: Oh, yeah.

Carrie: “…or they work swing shift." And so it's the same bed or just what you said, you know, I go to bed, I need complete... I have to sleep with earplugs. I have to have an eye mask. And my partner snores, and it's a real problem. And so it's a lot of education, and it's a lot of, like, trying to get them to see how this is affecting the greater good of their...not only their health, but their partner's health, their kids' health, even their pets' health…

Andrew: Yeah.

Carrie: “…it’s affecting everybody in the whole family when the sleep hygiene is not that healthy. When you're drinking two glasses of wine before bed, and you have dessert, and then you can't understand why you have hot flashes, and night sweats, and heartburn, you know, I can tell you, I can tell you why. 

Andrew: Yep.

Carrie: And so it's just addressing these questions and just mirroring it back to people, having some reality check is sometimes all they need, because that's what they've been doing for so long. And then when you go, "You know what? That's not actually working out, and here's what it's doing to your results and your resiliency and your energy and your pain and how you feel in the morning," and they go, "Oh, crap. All right."

Andrew: What about intermediate interventions, things to help you gain that restful sleep? One of my favourites, for instance, is Valerian. What other things do you use?

Carrie: Kava is a good one. Yeah.

Andrew: Yeah? Okay.

Carrie: Kava. My favourite is holy basil.

Andrew: Ah, yeah.

Carrie: I do holy basil at night before bed, which is Tulsi. I drink it as a tea. A lot of people will do, like, the sleepytime teas that have chamomile in it, Valerian. A lot of them have Valerian. It's calming down things. I don't know. Can you get this in Australia? Can you do L-theanine and phosphatidylserine?

Andrew: Yes. 

Carrie: I don’t know if you could…

Andrew: Now, L-theanine, you can get as an extemporaneous.

Carrie: Okay.

Andrew: Phosphatidylserine, you can get as encapsulated. Quick question about phosphatidylserine. I thought the initial dosing was...or the initial advice was, "Don't take it just before bed, because it can leave you wide." Is that correct or not?

Carrie: Not necessarily.

Andrew: Why?

Carrie: In fact, I find the opposite. I'd say most people find that phosphatidylserine helps them with sleep quite a bit…

Andrew: Gotcha.

Carrie: …because of its effect on ACTH from the pituitary.

Andrew: Yeah. I love phosphatidylserine.

Carrie: Now, you can. You can. When people say, "I take phosphatidylserine, so why?" and I'm like, "Okay, let's do something else. Let's move on."

Andrew: Yeah. And it was quite a high dose. I think it was at 400 milligrams used to reduce cortisol in athletes. Is that right?

Carrie: Yes. Yep. So, my dosing is generally 100 to 400. That's sort of where I go between.

Andrew: Great. What other sort of herbs and supplements are useful?

Carrie: I'm a big fan of Magnolia and skullcap. Passionflower. Passionflower, which is passiflora, they've shown in research to be about as effective as a benzodiazepine, so for people who are big into taking alprazolam or Xanax, if they switch to passionflower, that can be really helpful for them.

Andrew: There's a naturopath in Australia, I think, doing some research on passiflora at the moment for acute anxiety.

Carrie: I think that's really wonderful. Now, the other thing, too, is if you have a lot of inflammation, even taking something like turmeric or curcumin before bed…

Andrew: Okay.

Carrie: …can be really helpful, right? If you wake up in a lot of pain or if you lay down and have back pain, because maybe your mattress is terrible, or maybe just you've gotten in a car accident or sports or military, whatever it is, you have back issues, you know, taking something anti-inflammatory like turmeric, curcumin before bed might be really helpful if it can take the edge off, lower the inflammation, and then you can fall asleep and stay asleep.

Andrew: Right. And that's the trick, isn't it? Fall asleep and stay asleep.

Carrie: Yeah, most definitely. And when it comes to melatonin, if people get melatonin, I suggest they take it earlier in the night, rather than later, for most people, not all. But melatonin really starts to rise around 8 p.m. if you have a typical schedule. So, you want to mimic that natural rise, so take your oral pill about 8 p.m.-ish. 

Andrew: Yep.

Carrie: And so by the time it gets through the intestines and the liver and then out in circulation, it spikes when your natural spike occurs.

Andrew: Now, just a brief call-out, if you like, for the symposium for what you'll be teaching practitioners at the symposium, obviously, without giving too much away. But what sort of things will you be showing them how to change within their practices? What sort of things will you give them as take-home messages?

Carrie: Yeah. So at the BioCeuticals Research Symposium, there's really sort of three big things that I'm going to be touching on and helping people to understand. So, first and foremost is how the rise of the cortisol awakening response helps to determine someone's resiliency and then what we can do about it. And along with that, the number two thing is how the cortisol awakening response affects autoimmune disease, because autoimmune disease is really on the rise, and I want people to understand that by addressing this rise, cortisol awakening response rise, in the morning, they can have the biggest impact on their autoimmune disease. Now, lastly, which we haven't talked about, but the last thing I'll really go into is on oestrogen detoxification, and that's absolutely a passion of mine in getting phase one, phase two, and phase three oestrogen detoxification correct, because we teach it as one, two, three, but you actually address it as phase three, two, one. 

Andrew: Right. Yes.

Carrie: You go backwards for optimum benefit.

Andrew: Yes. The gut first, always.

Carrie: Always. Always. Always the gut. Yes.

Andrew: Dr Carrie Jones, thank you so much for taking us through the cortisol awakening response today. It's very important stuff for all of our patients. And I'm so looking forward to meeting you again at the 2020 symposium in Melbourne in April. And thank you for joining us on FX Medicine.

Carrie: Thank you so much for having me. I'm really excited for the symposium in 2020.

Andrew: It will be great fun. This is FX Medicine. I'm Andrew Whitfield-Cook.


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