Why Do I Keep Waking Up at 3AM? Cortisol, the HPA Axis, and How to Fix It

All right. All right. And we're live. So, uh, Dr. Rose, while we're waiting for people to start joining in here, why don't you give a brief little introduction on yourself and your background and your vast experience as a naturopathic doctor at Med Matrix? Sure. Um, I'm Dr. Sasha Rose and I've been practicing functional medicine for over 20 years now and, um, I'm one of the lead providers here at Med Matrix. um are yeah I mean we'll dive into the topic in a minute but probably nine out of 10 people that I see are dealing with some level of stress um in their lives and figuring out figuring out how to handle the stressors in their life. So I think this is a pretty pertinent topic for most people. Okay. Yeah. So today we're going to be talking about um the HPA access and how it relates to and can cause things like um low stress tolerance, weight gain around the abdominal area, poor sleep, feeling that that wired tired feeling and some of the root causes and um how we help patients kind of figure this out and then matrix. Um and yeah, before we got we do got to say, you know, none of this is medical advice. This is really for educational purposes only. If you want medical advice, you can you're welcome to become a patient here. We'd love to help you out. Um so yeah, with that said, we're gonna people are going to start rolling in here. U Dr. Why don't you give us like a 10,000 foot overview of like what the HPA access is and why it why it affects so much. Yeah. Why why is it important? Um so HPA stands for um hypothalamus which is in the brain. Um the P is for pituitary which is also located in the brain and adrenal A for adrenal. So it's basically um this axis meaning that it's a pathway right. So the kind of uh starting point is the hypothalamus and that um releases a hormone and that hormone um stimulates the pituitary to produce another hormone. I'll get into the specifics in a minute um to then tell the adrenal gland to produce cortisol. And most of us have heard of most people have heard of cortisol. Cortisol is kind of considered to be like the stress hormone. Um and that is made in the adrenal glands, but it's not made without um kind of being instructed to by the hypothalamus and the anterior pituitary. So um part of what we practice here is root cause medicine. And so um we yes we talk and we will be talking today about adrenal health but kind of uh we need to see it in the context of the the larger picture and and if we suspect that there is something going on with somebody's cortisol levels um too low too high disregulated uh we really want to kind of back up a little bit and just kind of look at that hypothalamus look at um the anterior pituitary, make sure everything's lined up where it should be, and then we can get to the adrenal glands and we can see um what's happening at that at that point. Okay. So, where does this all start? It starts in the hypothalamus. Um and so it um basically the hypothalamus um releases corticotropen releasing hormone. is called CR and that goes to the pituitary, the anterior pituitary specifically and that um anterior pituitary then produces um act which is adreninocorticotropic hormone. uh that then gets sent to the adrenal glands which then produces cortisol and cortisol is going to be kind of go up and down depending if we are in fight or flight mode or not. If we are um ide so yeah ideally cortisol is going to be highest in the morning we call it a dal rhythm. So cortisol ideally gets triggered to or is is triggered to then to be at its highest right when you wake up first thing in the morning. Um and it has a a mid a morning spike and then that drops between um 8:00 a.m. and then it drops pretty dramatically between 8 a.m. and noon and then between noon and midnight it continues to drop at a kind of gradual rate. um being cortisol ideally being at its lowest level when we are sleeping which ideally is during the night. Um so you could imagine if somebody has um uh night shifts for example or shift work um that that's going to be you know one reason why your cortisol levels can be disregulated. So, one thing that I because cortisol is one of the hormones that we test um on our initial panel. And so, one thing that I will that I'm always telling patients is um the time of the blood draw does matter because there's going to be if you come in at 8 a.m. versus 400 p.m. the normal reference for your cortisol level is going to be different. What can you just restate the connection between the HP access and cortisol simply? Yeah. So the HPA axis is basically kind of like it starts with the hypothalamus. It goes to the the messenger then goes to the anterior pituitary. Both of those are in the brain and then the messenger goes messenger hormone goes to the adrenal glands which stimulates the release of cortisol. So the HPA axis is kind of in charge of us having a um healthy cortisol or stress response. Okay. So yeah, we talk a lot about the mind body connection, right? So is the HPA access something that is really addressed in conventional medicine or is this something that's kind of like overlooked more often than not? So if there's um so there's so there's actual um diagnoses that people may have heard of like um Addison's disease is um an endocrine or hormonal disorder where the adrenal gland is not producing cortisol. So that's an actual di that's like a clinical diagnosis. the person who has Addison's disease needs to be on kind of synthetic cortisol for the rest of their life. The opposite is Cushing's disease which is um uh too much the adrenals are kind of putting out too much cortisol and so those are like physiologic uh endocrine disorders. um those are obviously recognized within um within conventional medicine. What we see much and those are both relatively rare. Um the the issue with them with the kind of verbiage I guess is that people often use the term adrenal fatigue, right? like um that's kind of thrown around in maybe the wellness community among some providers and that's technically not it's not really a diagnosis. It's not a cl an actual clinical diagnosis adrenal fatigue because if you actually have adrenal fatigue it means you have Addison's disease which again most of us do not. Um, usually when people use that term, what they mean is some type of um, dysregulation with cortisol, right? And so what you can have with and you know, usually the co original causes for some kind of dysregulation are going to be early trauma or chronic trauma. And we have a whole another podcast with Dr. Renard on that. Um so I I'll let people watch that one for really good information on on trauma and and its impacts. But um trauma um as I mentioned chronic um shift work or chronic kind of you know night night shifts that's going to disregulate chronic stress in general kind of spending years in what we call what many people are familiar with of fight orflight mode where you're kind of hypervigilant you're you you don't feel safe you never relax. that's going to affect over time your adrenal the ability of the adrenal gland to produce cortisol in the optimal way in that dural rhythm high in the morning low at night. Um so there's different stages of disregulation again which is sometimes um mislabeled or called adrenal fatigue. Um, the way that I first learned about it was if somebody's in kind of that sympathetic overdrive space where they're just they're they're always on, they're never their system is never relaxed, their adrenals are kind of being told to just produce cortisol all the time. That is going to that's like sympathetic overdrive. That's one that's like hyperactive, right? Or hyper adronergic state. And that can only go on for so long before then you get to the disregulated state where it's a little bit more cortisol is probably kind of low in the morning when it's supposed to be high. And in that case, someone is like having a really hard time getting out of bed in the morning. They're just it's just like feels almost physically impossible to get out of bed. But then come 8:00 at night, 9:00 at night, 12 midnight, they their cortisol is probably high when we want it to be low. And so there's a little bit of that wired tired feeling, right, where they know they should be sleeping, but that they're like they come into my office and they're like, "That's when I'm the most productive. That's when I get the most done." And then but then during the day they're dragging. So that's like dysregulation. Um and then the last stage is really like a hypounctioning or a low functioning stage where the adrenal glands are having a real hard time pushing out cortisol in an optimal way. And that's like when we do testing, we we do like a salivary test where we can map out the 24 the dal rhythm or the 24-hour cycle of cortisol. And that's where on that test I'm going to see it's going to be kind of flatlined, right? There's not going to be a morning peak and it's going to also just be kind of it's just going to be low all day, all night. And there's some pretty s usually some pretty significant chronic fatigue in those situations. People are rarely getting that second wind at all. Right. And what is this patient being told in conventional medicine before they kind of come see someone like you? Um you know, you're depressed. Here's a here's an SSRI. Um you just need to kind of get out more. Um what else? Maybe they're put on a stimulant. Maybe they're put on, you know, or maybe they're not really told much at all, right? like with with the the testing that conventional medicine usually offers, the testing that's usually going to be again kind of covered by somebody's insurance is usually not going to include um a hormone panel. It's not going to include a um cortisol test and it's certainly not going to cover like a salivary cortisol test. So, the person doesn't even have any information about their how their adrenals are doing or how that HPA axis is functioning. They're just they just know that they're exhausted all the time and they might be drinking a pot of coffee to get through the day, right? Yeah. What is like you do this? Well, I actually excited to hear your answer to this. Like um describe that patient to me like everything they're going through and I imagine there's actually a couple like avatars of this patient. Like there's probably the busy mom who's got the kids and job and the stress, right? And then there's probably the person who has health issues and then there might even be the busy executive. So can you kind of explain the different types of people that have lifestyles that lead to this kind of dis dysfunction and dysregulation? Yeah, I mean actually sometimes it's I like that like the avatar like sometimes it's the um it's the the guy in his late 20s who has a pretty intense job. He's kind of moving up the corporate ladder and he goes to the he also goes to the gym every day and he like works out like three hours a day before he goes to work. Um he's probably doing some energy drinks to get through the day and then his work day is just like boom boom boom. He's just like he's like in sales. He's just like he's just on all the time and he so 10 o'clock at night, 11 o'clock at night where physiologically it would be ideal for him to start winding down and going to bed, he kind of can't, right? like he's just he's just on whether it's the chemical stimulants or maybe what I would call kind of overtraining at the gym. His like he's just kind of asking so much of his adrenal glands like there's so much cortisol being pumped out. He's in sympathetic drive like all the time and he's going to feel pretty good for a little while and then he's not right. And then the sleep deprivation is going to get to him and the poor like physical recovery from the from the overtraining is going to get to him and it's going to kind of switch into maybe more anxiety than feeling like pumped up. Um, and things just kind of he Yeah, we need with with that cortisol regulation, we need the downtime, too, right? We don't we don't just need the energy that we get from cortisol. We need the parasympathetic part, not just the sympathetic. So, that's one example. That's kind of like high what we would clinically look at and be like, there's some high cortisol right there. Um, and then yeah, there is like the stressed out mom. There's the mom that works, you know, a full-time job, has three kids, is head of household, might be caring for an aging parent along the way, and um and you know, somehow in there is driving the kids to soccer practice and picking up the groceries and trying to do it all. And she is dragging like she is exhausted, right? She is um you know, she's the one that I'm having the conversation with who's like, "I haven't been able to fit exercise in. I can't remember the last time I actually exercised." And she's like, "And I'm gaining weight and I can't seem to feed myself anything other than the chicken nuggets that I feed my kids every day. I don't and and hers is less of that kind of it's it's blended. It's it's kind of morphed into this fatigue at this point. and she is doing everything. She's productive. She's getting stuff done. Um, and if you just met her running into her at a dinner party, she would seem totally fine, but inside she's exhausted and um can sleep eight hours and still feel exhausted. Yeah, we hear that all the time. Yeah. Um on the patient coordinator end, million-dollar question though, like what do you do? Like what does that what does that mom do? What does the dad do? like what is the person in that position where they have all these life responsibilities and they're they have to work, they got to take care of the kids, they got to, you know, take care of the house. Um they can't just stop, you know, I mean, they can't just go a week silent retreat and reset. Like how do they how do you actually help this person and get them balanced? Yeah, it's a great question and it's not easy and it's going to be a little bit different for each person which is kind of where we excel, right? We kind of take the time, we have the time to really personalize it. Um, one thing that I like to say to people is just what you said, which is that we can't necessarily change the external circumstances of our life. Like we have these things that feel like stressors right now. We have these responsibilities. We don't always have control over changing those, but we do have control over our internal response to them. Now, sometimes it does take somebody making some decisions and having some boundaries and cutting things out that she doesn't or he doesn't have to do. Um, and, you know, working with a coach or somebody to kind of prioritize and actually like prioritize her own health, which general generalization here, but women have seem to have a harder time than men doing that. where we come in is how do we optimize sleep? How do we support the adrenal glands? Um in and in terms of optimizing cortisol regulation. So that salivary test that I mentioned is sometimes a good baseline. Um again, we get we do on our initial blood work, we do kind of test it in the blood and then if I want a full 24-hour picture, I will order that salivary um salivary test which gives me an idea of what's happening in the morning when this person is waking up, what's happening at night when um she or he should be sleeping. We might do some botanical medicine. There's some great um there's a category of botanicals called um adaptogens or adrenal adaptogenic herbs and those can kind of have either a calming effect or a stimulating effect depending on where the person is in that gradient of dis of cortisol dysregulation. Those can be really beneficial. Um, we have some peptides that are also really good for um, neurotransmitter balance, cortisol regulation, safe even if somebody's already on a an anti-depressant, totally safe to take it to take those peptides with those medications. Um, and then we're looking at other like, you know, nutrition wise, like is again, is this person in this in this kind of I'll call it a dysfunctional relationship with caffeine, right? Like completely dependent on caffeine and yet they have to keep consuming more and more to even keep their eyes open. Like we do need to work on that, right? We do need to figure out other ways for them to um feel productive. So there's there's kind of coaching along those lines, looking at sugar intake, kind of these things that are they're going to in the moment because they're exhausted um or addicted but really not serving them. So okay, nutrition wise um and yeah, even even physical movement like the guy that's addicted to go to the gym that I would say is overtraining, like that guy could probably use a yoga class or a Pilates class. He's going to hate it, right? He's going to be like that. I'm not sweating. What's the point? Like his nervous system, his adrenal system, he needs movement like that. So the busy the busy executives, the moms, like that's where yoga is less of a fitness thing and more of a mind thing for those people. It can be it can it can be fitness for sure, but you're getting the breath work in. You're getting like you're tapping into that relaxation part, not just the boom boom like kind of the classic like I'm just going to keep pushing my body as hard as I can go. I'm just going to kind of sweat and I'm just going to exhaust myself, right? Like that's kind of the American way. And we need a balance. Like we need that. We need to sweat and we need to push ourselves, but we also need like the deep breathing and the stretching and um for mental, emotional, and physical well-being. But it's the people that like really resist. Those are the ones that need it the most. Yeah. You know, I I hate to insert myself in Oh, do you fall into that category? Well, no. I mean, I I definitely am the the guy in his 20s who works like, you know, 70 hours plus a week, gets up early, works out. Like, I definitely fall in that category where I should have some cortisol issues. But if you look, when I did the cortisol test, it was pretty much perfect. Pretty normal. I noticed I have this ritual every Sunday. I go I do a sauna and ice bath and then I meditate for like an hour. And I just realized when I do that every Sunday, it's just like I just feel so much more balanced throughout the week. And I just did it because like it just felt good and I feel good throughout the week. But that's probably what's happening kind of under the hood that I didn't even realize the benefits of that. Um and I do realize when I don't do that and I work all day Sunday, like I I feel like I'm behind. I just feel like I'm always trying to. So um yeah, interesting stuff. Um that's a perfect That's a perfect example. Yeah. Um, so let's talk about coffee. Something a lot of people I love coffee. What is a what what does a healthy relationship with coffee look like? Caffeine, too. You know, let's throw energy drinks in there. I know a lot of people drink those. Yeah. Um, I mean, I think energy drinks have some other issues. um we see a little bit, you know, when people kind of become a little bit more addicted to those, you do start to see some like impacts on your kidneys and um your liver potentially, which we don't usually see with coffee, but um usually if somebody everyone's different, okay, everybody responds to caffeine differently. Part of that is that we all have um different uh metabolic pathways primarily in the liver. So some of us um react pretty strongly to a small amount of caffeine, right? So you everybody had knows that person who even a small amount of caffeine will give them the jitters and other people who again can you know at least they say they can drink a half a pot of coffee and then they can go take a nap. So that's largely genetic actually like how we kind of handle caffeine, alcohol. Um, so there's not one sizefits-all in terms of what's the right amount of coffee or caffeine for every person. Is there a hard though? Is there like a hey, if you're drinking four cups of coffee in the morning, like that's Yes. I don't know that that's good for anybody. I mean, that to me is dependence, right? Like that to me is that you probably do have like a cortisol dysregulation issue. You probably are your sleep probably is not optimal and you are relying on that. Um, usually if somebody has one to two cups, I'm like, that's probably fine. And they don't, you know, and we're not dealing, they're not coming to me because of anxiety or insomnia. One to two cups is usually kind of in general a healthy amount. Okay. Sorry, I didn't mean to cut you off there. You're saying what what was that what you were saying when you were say to my clinical practice? Yes. that usually if they if when I ask them about um c coffee or caffeine intake and they tell me one cup in the morning, maybe a half a cup, you know, but nothing um and they say that they fall asleep pretty well, they stay asleep pretty well and again they're not dealing with high levels of anxiety or panic disorders, then usually that tells me that their body is handling that amount of caffeine fine. Gotcha. Okay. In your clinical opinion, when should most people stop drinking coffee? At what time of day? Um I think in general I think around noon. Other people maybe 3 pm. Um this is assuming that this is somebody that does not, you know, is not working third shift or does not have to be kind of at their most productive and alert at um 8:00 p.m. at midnight. So those people are the exception like the nurses, the truck drivers, the etc. like they can't follow these rules, like they they need to kind of be on a different schedule. But for those of us who want to be asleep between, you know, 10:00 and 11, 10 and midnight, and we want to be waking up between 5:00 a.m. and 7:00 a.m. Um, usually stopping caffeine either by between between by noon or 3 p.m. if you're not as sensitive to it. Okay, here's a wild question in the show notes. Um, how does gut dysfunction play a role in the HPA HPA access and balance? So, essentially like how does our gut affect our ability to deal with stress? Right. Yeah. So, part of it is the HPA axis. Part of it also is something that we talked about I think in the estrabolome um podcast which is about more um neurotransmitter specifically serotonin and serotonin receptors and the the high number of serotonin receptors that are in the gut. Um, so that is gonna that those neurotransmitters are gonna be a big part um of the stress response in addition to cortisol and these more um adrenal um hormones. So um that's just to kind of have the broader the broader context of it. Um, but I think that part of it is um, well, part of it's a little bit more of I guess I'll go back a little bit to liver which is part of the digestive system and the liver is in charge of producing metabolizing cholesterol. We actually need cholesterol to make pregnenolone which is like the mother hormone that gets broken down into both our sex hormones. It's testosterone, estrogen, progesterone, DHEA and our adrenal hormones. Uh DHEA is actually an adrenal hormone uh DHEA and cortisol. So, you need cholesterol. You need your liver to be functioning well, which is a huge part of the digestive system, impacted, as we know, by the gut microbiome. It's all kind of interrelated. If the liver is functioning optimally, it's going to produce cholesterol and therefore we're going to get kind of the raw ingredient, the raw ingredient hormones to then get optimal levels of cortisol. So, um, that's kind of one in addition to the more the neurotransmitter serotonin piece. That's kind of partly where the where the gut uh HPA axis comes together. I will put in I will say one thing too and this is another topic for another day but you know sometimes we when people are on medications that are chronically lowering their cholesterol we wonder about the the impact it has on the body to then produce some of these hormones, right? Like if you're kind of lowering the cholesterol, you're potentially making it a little bit harder to come up with pregnentolone and therefore all of those hormones that come after that. What other medications might affect the HPA access? Um, that's a good question. Um, well, I mean, I think that sometimes the sometimes medications that are given for like the right um reasons can have sometimes negative um consequences. So sometimes some of the medications given for ADD and ADHD, so the stimulants, they can make it, you're kind of in some ways putting the body into that um hyperactive HPA axis, kind of that um hyper sympathetic drive, right? That's what makes you kind of alert, productive, focused. And it's like a false way to do that. And that's going to kind of confuse the a your natural axis. Um sometimes um some again some of the anti-depressants, some of the anxiety medications are going to interfere with that normal hypothalamic pituitary adrenal road. um it's going to kind of mask things and um kind of put the body I think in this chronically disregulated state with the person not really being able to tell anymore because symptoms are somewhat masked. Okay. Gotcha. How often do you see that in your clinical practice with patients? A fair amount. I mean, um, medications for anxiety, medications for ADD, medications for depression are pretty are prescribed pretty commonly. I think sometimes you've heard me talk about the toolbox. I think that's one of the unfortunately for a lot of providers in our current health care system, that's what that's kind of some of the only tools available to them or what they feel is available. And it's it's an easy prescription. and somebody comes in um depressed, anxious, tired. Um that's that's the go-to, right? Yeah. And why is that? That's all that's the only thing in the toolbox, right? So, they toolbox I think a lot of people functional medicine and it just it because it's common sense, right? It's like you don't want to cover up things with drugs. There's no there's nothing in life that you want to just cover up and postpone till later. It's like every time you do that when you ignore issues they get worse. So I think a lot of people are confused like why like why what we're doing is not more mainstream. So like why is that? Are you saying why is why is why is our form of medicine not mainstream or why is mainstream medicine the way that it is? I guess both because I guess that the the that answer one kind of answers the other. Yeah. So I mean bigger context of kind of you know why in conventional medicine in the insurance model why are people why are the visits 7 minutes long 15 minutes long. Um and really they're just kind of what you know that there's just inherent limitations there. um versus you know our visits which are 60 minutes and 30 minutes and we can kind of again somebody comes in with fatigue. I have the the beauty of time to not just look at the blood work the results of the blood work and look and like get into their health history but really really like figure out for this individual person like what is it right? Is it a is it a micronutrient deficiency? Is it a cortisol dysregulation issue? Was there early childhood trauma that has not been resolved? You know, is are they currently in a in a living situation where they don't feel safe? Is it um nutrition? Like there's so many I have the time to kind of like figure that out. Conventional medical visits do not have that. And so um we just Why is that not the norm yet? It doesn't fit into the insurance model probably is the simplest answer. Okay. Gotcha. And most people don't know, but why is the insurance model like like why why is it that way with the insurance model where it doesn't you know fit? It's it's all about economics. I mean it's productivity. So the more you know the more billable hours, the more billable procedure, you know, it's all about kind of um out of one, say one provider, one physician's hour, how many um how much can you bill for? And you're going to bill more if that provider sees six people an hour versus one. Yeah. Okay. Gotcha. Um, so let's talk a little bit about the way your immunity I got two I got. Yeah, let's talk about this first. So like someone who has adrenal fatigue or is that someone who's going to get sick more often, have immunity issues, and you know, kind of vice versa, someone who has a really good immune system, is that someone who doesn't have adrenal fatigue? So, it's it's this idea of um like when I first learned about this, it was like the different stages. And again, adrenal fatigue is not really the clinical term, but it's kind of I think it does give us an idea of what we're what we're kind of talking about, even though it's not technically the right terminology. What stage of adrenal fatigue is this person in? If it's a hyperactive um HPA axis, hyper like like high cortisol output um that person is going to basically um you know that could be due to chronic physiologic stress, inflammation, infection um like I said overtraining, early trauma. So what we're going to see potentially is like the elevated salivary or serum cortisol. um that person is gonna like if that goes on for a long a long time, they're probably going to start getting infections more frequently. So, there's going to be a little bit of more likelihood to get infections. Okay? Over time, if that goes on for like a long time, it's going to again the adrenals aren't going to be able to sustain that and so you're then going to get that hypoactive HPA axis or low cortisol output. Um, and that's more of like the long-term like burnout, really feeling depleted. Um, you're gonna on again on the serum or the salivary test, it's going to be low or especially in the morning, it's going to be low or what we call like a flattened cortisol curve and low stress tolerance. um even things like low blood pressure, low blood sugar, um obviously fatigue and um that person too might not have the best immune, you know, they might have a hard time as well. They might get sick, but it's going to be a little bit more of like it could actually turn into more of like an autoimmune. M it's not that they're getting frequent acute infections, but they are more prone to more of a chronic autoimmune. Like it's kind of it's gone a little bit deeper. I guess we think of like an acute infection is a little more superficial. You kind of get over it. Whereas autoimmunity is a deeper dysregulation in the immune system. Okay. Um what about the relationship like uh earlyhood trauma versus trauma given you know something traumatic happening in life. So how does earlyhood child trauma play a bigger effect on the HPA axis than you know trauma later in life adult trauma? Yeah. Well, your um your system is still forming your your neurotransmitter regulation, your um the the stress response, like it's all malleable in your early years. It's all you're you're learning, right? Like the the the um the pathways are not yet set. And if an ear if a young person does not feel safe and so they are in they don't feel safe in their own home they don't feel safe at school they don't feel safe wherever say they don't have a safe place then that's what is learned and that's what is embedded and we are wired to survive and part of how we survive is that high cortisol output. It's that being hypervigilant. It's staying alert. It's looking out for danger. And that becomes wired. That becomes embedded. And that's just how that person's going to later in life. They might be they might know intellectually, rationally that they are now in a safe place. But those formative years were formative and it takes a lot. It can take therapy, medication, you can go into the different kind of ways to unlearn that and for that person to be able to feel safe on a not just like a mental level, but actually like those physiologic changes where we actually see the cortisol start to regulate again. And we see, you know, the cortisol is now able to drop at night where for the first two decades of this person's life, cortisol was high all night long because they had to stay alert. And it it takes time, but we can, you know, we can do it. We can start to regulate that. And the person can physiologically, physically actually feel safe. Yeah, man. I mean, it's great that you're talking about this because I think a lot of patients kind of go to conventional medicine and they, you know, are brushed off or that is not talked about and they never actually get better because they never talked about, we say this all the time, it's kind of cliche, but the root cause of like why someone doesn't feel the way they want to feel in their health, right? And it can be it can be frustrating because they are like, I'm in a happy marriage and I have an amazing life right now and I I know that I am not in danger and yet why do I go to bed at night and I lie there with my eyes wide open? Yeah. All right. Um let's see here. I got a couple more show notes. I guess for this question um let's give some context. So what is mitochondrial dysfunction first? Um mitochondrial dysfunction. So the mitochondria is what's called an organel. So it's um one of the parts of a cell. So every cell has like but there's like a nucleus. Well, there's also a mitochondria. And mitochondria is um kind of most well known for energy production. So um if you know if you go back to your days of biology we know we learned about like the a you know how ATP is produced that's all done in the mitochondria. Okay. So what is what does mitochondria dysfunction mean? Like if you see a patient also how can you tell if a patient has mitochondria dysfunction? Just curious. So, um, well, sometimes if there's chronic fatigue, again, it's that's a tough one because there's so many causes, but sometimes there's like literally not being enough energy produced on a cellular level. And that is often um kind of a it can be for different reasons but it can be a micronutrient deficiency like that production of ATP needs certain co-actors certain ingredients um and if those are deficient in the diet or if somebody is taking a medication that is depleting the mitochondria of those necessary ingredients then it's going to be there's going to be suboptimal energy production and that's going to impact all aspects of somebody's health um including maybe energy. So um sometimes with chronic fatigue when we're trying to really again trying to practice root cause medicine figure out why we want to look at cellular health and look at mitochondrial health. Um and what was the second part of your question? What do you I guess how do you um how do you know how do you know anecdotally like hey I'm tired but how how can you test or know more certainly that someone has mitochondrial dysfunction? Yeah. So there are some advanced tests that kind of can um where we can kind of assess um whether it's um there's some genetic tests that can show us kind of what's happening at that level of the mitochondria. There's again some u micronutrient tests that can tell us um what's happening with that energy production and we can therefore kind of deduct that um there's an imbalance in the mitochondria and um I think those are those are kind of the big ones. Okay, gotcha. Um, now how now that we have context and what mitochondrial dysfunction is, how does that intersect with HPA access imbalance? Say that again. Like how does your how does your mitochondrial health related to the HPA access? Um, so so part of it is that if um if if stress is chronic, right? And so um uh and so cortisol is is really high most of the time. You're going to kind of um burn through a lot of that cellular energy, right? You're going to kind of um stress, for lack of a better term, the the mitochondria. So the mito so basically you're kind of like burning through all of that energy that the mitochondria is producing or that the pathways within the mitochondria are producing and eventually kind of um without without that proper balance that's when you you're going to kind of lose that energy production on a cellular level. So, um, kind of burn through it, I guess, is kind of the the easiest way to to think of it when when stress is chronic. Okay. You're kind of going to dep you're going to get you're going to become depleted on a mitochondrial level, on a cellular level. Okay. Gotcha. That was a good explanation. Thank you. Um, hey guys, everyone in the comments, we appreciate you for those who've been sticking around. Uh, we're going to try to do a little bit of Q&A here. This one's going to be a little shorter today. So, if you have any questions you you want to ask Dr. Rose, um that can be broad, comment them right now and we'll get to them. Uh whether you're on YouTube or Instagram, um shoot those over right now. Um so, let's start talking patient case studies. So, why don't you give an example of a couple patients who have had um HPA access dysregulation, adrenal fatigue that um you actually helped as far as like with a more functional approach. If you could just explain like you know the background, what they had tried and then versus like kind of like where they ended up that would be great. Sure. Um so I have a patient who is um she's either 69 or 70 but somewhere around there and she came to us primarily because of chronic fatigue right like years of just feeling fatigued. Her story is that she um married relatively young. She had four children. She um kind of did it all in those early years. You know, I think she had a part-time job. She raised four children. They're all grown now, obviously, and um kind of powered through, you know, and then children are gone. Um life is slower and she kind of realizes in her 60s, early 60s, just how tired she is. And again, kind of classic. Doesn't matter if she has a Sometimes she sleeps well, sometimes she doesn't sleep well. Doesn't seem to matter. She's just kind of dragging all the time. She can get up for breakfast. Um, and then after breakfast, she can just go back and take a nap. Um, she uh can't hasn't hasn't had answers, right? Like again, went to the doctor, everything is normal. um not really given any just you're getting older basically. It's just age, right? Like don't expect to feel like you did when you were 30. You're you're 70. Um and she comes to us and um we saw on that initial blood work, we saw that um her cortisol was low and we saw that her vitamin D was low and we saw that her uh B12 was low. Um we also saw that some things were normal when we're looking at fatigue like her thyroid panel was totally normal. it really wasn't her thyroid that was causing the fatigue. So, we did further we did the salivary test um on her and it came back and it was flatlined. There was no it was a flattened curve. So, she was not getting that spike in the morning that she needs and she was low even lower than she should be the rest of the day. And as I'm getting to know her over these visits, we start kind of talking about early, you know, kind of early childhood. And turns out she had a pretty dysfunctional family growing up. Um, some trauma. Now, in that generation, there wasn't a lot of, you know, for a lot of people in a lot of families. And the culture, I would say even 20, 30, 40 years ago was like you just kind of suck it up and you deal with it. You push it under the rug, you get on with your life, right? it wasn't we didn't have kind of the awareness at that time of um really kind of dealing with trauma like that and and processing it. So she never had those tools. She just went, you know, she raised her kids and she kept on going. And so part of it was just kind of her identifying that that she most likely had had by the time I saw her, she had kind of moved through those stages of adrenal fatigue. she had gotten to the point where her adrenals were no longer even making cortisol. Um, and so part of it was a referral to a really good psychotherapist. Um, and then improving some of the micronutrients. Um, the B12, the vitamin D. I always call that kind of like lowhanging fruit. It's like really easy to do. It can make a real difference. Um, and some of those adaptogenic herbs, right? those adrenal adaptogens um were really helpful for her. Uh I think that was the gist of it. I think she hadn't she felt had felt so tired she wasn't really moving her body. We like I had her just start to do some gentle walking, some gentle stretching, nothing too much, but enough to kind of start her um with some kind of movement. Yeah. And then over the next few visits, like wasn't overnight. It wasn't like she came back to me three months later and said she felt like a million bucks, but she did, every time I see her, she does feel more and more energy and she is kind of working through some of that stuff and she is just starting to kind of kind of come into herself a little bit more and um just walk through the day with more with more energy. So, that was kind of an example of targeting the cortisol piece um and trying to help rebalance that HPA axis. Gotcha. Great one. Thanks for sharing. People like that question. Um, okay. Let's see if I can put this up here. There we go. Cool. Um, how would you recommend when someone has gone through all the conventional medical doctors and haven't saw it or found resolution, where would you recommend they go next? You mean other than here? Yeah, it's probably get um I guess yeah, it's hard for me to say. I mean, I feel like, you know, if you're not if you if you're not in in the area here, if you're not in Maine or New Hampshire, then um finding a functional medicine practice where you can get more testing and where people are trained to dig deeper and where you're going to have, you know, an hour with the provider um right off the bat, for example. And so, um, hopefully in that hour you can start to kind of unpack things a little bit. Cool. Uh, Ryan is in New Hampshire. Ryan, yeah, we can take patients from New Hampshire. Um, you would just have to drive to our South Portland office to do um the initial lab testing and the body scan and then um the follow-up appointments can actually be telealth. Um, and we do have a satellite office in North K, New Hampshire that we can do blood draws at uh for follow-ups. Um, so yeah, and actually with that, that was actually perfect timing. Um, we do have a special. We love when patients, non-patients take time to actually educate themselves about this stuff. So, if you click that link right now, it's in the comments. Um, let's see if I can do this, too. I can put a QR code up. If you scan the QR code or click the link in the comments, um, you can actually get $200 off as a new patient. We don't normally discount it that much. If you book a new patient consult, free consult before 7 PM using that link, you can get the $200 off, but it's it stops at 7 PM sharp. So, um, definitely if you are on this and you're interested in becoming a patient, you don't have to be like, I want to become a patient. Like, if you're just curious, you want to talk to someone from our team, see if we can help you. Um, just click the link below. Team's awesome. Um, and yeah, I would definitely recommend doing that. Um, all right. We got one more question here and then we're going to call a wrap. I'm going to add this to the stage. Uh, Dr. Why don't you read this? Um, and also guys, just for context, we can't give like specific advice for you as an individual. So, Dr. Rose will kind of broaden it so she can answer it more generally and um because again, we're not giving medical advice. This is for educational purposes. Um, so this person asks, "Hello, I had blood work done recently. They showed my cortisol levels spiked at night when I'm sleeping and they slowly go down in the morning and then around 11:00 a.m. it drops right off. I eat very healthy. Um so again, this is what we would call um dysregulation, right? So there's like those three stages where there's cortisol's high all the time and not dropping at night. And then the other extreme is the hypo function where like that case that I just mentioned, she really had a flat line, no no bump up in the morning. And it sounds like this individual is kind of in the middle, right? So spiking at night when it's supposed to be low when they're sleeping and then um not it sounds like not getting that morning spike when you're supposed to get it. So, um, that's just an ex just a good example of the importance of kind of doing this testing. It sounds like it was probably I guess if it was blood I'm not sure how you got those on blood work. Usually it's salivary, but um, regardless, that's kind of a good example of that dysregulation. So, I mean, what to do about it? That's kind of what we just talked about. And um that's why it's kind of important to meet with somebody so you can get um a real personalized plan. Yeah, big guide book use the link. You can copy and paste it in your browser. Um and then like I said, just see talk to someone from the team, see if we can help. It's free conversation. Um and if we can't help or everyone at the office is really connected, we'll we'll do our best to kind of point you in the best direction. We just want to make sure you know everyone's getting taken care of. Um, okay. We Let's do one more for fun because this one's short. Um, and broaden this one up. So, diver severe diabetic uncontrolled for 18 years. What what like when a patient comes in and they're severe diabetic, uncontrolled for 18 years? Um, what's your like what what are you what what's going through your head? What are the things what are the blood markers you're looking at? What are the um Yeah, what's your strategy here? Well, we're looking at um the hemoglobin A1C, which is a three-month average. It's a three-month threemonth average of your blood sugar. That's the best um biioarker around blood sugar. We are also looking at insulin. So, if insulin is really um elevated, then that means that there's insulin resistance. And um uh yes. So, those are the most important ones. Um, I'm assuming uh I'm assuming type two, not type one with this individual. Um, and what's the next question? What are we doing about it or what what's Yeah, what's the strategy here? Well, I mean, I think initially it's somewhat it's somewhat not super different than hopefully what would be done in a conventional medical practice, which is, um, diet, exercise, um, and using tools to kind of get that blood sugar down, right? So there's um there's GLP-1 medications which are kind of some of the best I think and then there's your more traditional um maybe the person needs insulin maybe you know maybe even something like metformin um but um usually the approach is to kind of address that figure out why it's been uncontrolled is it a is it a behavior issue is there something else going on sometimes elevate chronically elevated cort cortisol can contribute to blood sugar dysregulation. Um it can it can be a part of it. So it's part of why it's important to kind of look at the whole hormonal picture, not just blood sugar, not just insulin. Um so that can kind of play a role. Um but usually my approach is, you know, let's try to get that that hemoglobin A1C as close to seven as we can. um and then figure out what's going to work kind of longterm long-term maintenance. Are there other factors going in? Are there is there that is there a behavior issue? Um is you know, but the sooner we can kind of get that control, the better. Gotcha. All right. Um yeah, that's a great place to end it. We're kind of time here. Um big big Kai. Um, yeah. Again, everything we do is really personalized. So, we're not going to be able to give you like an exact quote on like what it would cost. That's why we have the the discovery call in place. For those who are wondering, if you're curious about working with us as a patient, general cost looks like $3 to $500 a month uh throughout the year kind of for like that comprehensive care. Uh, it's kind of like a rough ballpark average. Um, but yeah, the the first step is definitely just that free call. And like I said, you know, the team if we can't if we're not confident we can help you, we'll we'll help you find another place that can. Um but yeah, with that, any um yeah, guys, if you're just joining us or you're again considering, copy and paste the link in the comments, scan the QR code in the live. Um Dr. Anything you want to take us home with, leave the audience with before we sign off? Um just that I a lot of people come in and they they say I think I started it this way. Maybe they say, "I feel like I must have really high high cortisol." And then we we're going over the blood work and their cortisol is either normal or low. And they're surprised because they're like, "I'm stressed out all the time. I thought my cortisol was going to be really high." And I hope that we have learned in this podcast that there's it's nuanced, right? And that there's different types of cortisol dysregulation, adrenal fatigue, um disregulated HPA axis issues. So, um, it doesn't mean that you're not stressed. It's just where are you in that continuum and, um, and I hope you also have learned that there's ways that we can start to balance that. That's awesome. All right, guys. We go live every two to three times a week. So, if you like this, you want to come to future ones, make sure you subscribe to the YouTube channel, to Instagram, wherever you're watching this right now. Um, and Spotify, Apple, you can watch recordings. We have so much great content around health. Definitely check it out. All right, guys. Have a wonderful evening. Dr. Rose, thanks for your time.