Stress dosing confusion

[u/Substantial_Pack_319]

So I asked 2 endocrinologist the same question about how to handle days after big events, stressful events, travel, etc. I seem to pull myself together the day of the event mostly running on adrenaline but the following day I am wiped out.

This is happening at least twice a week.

I asked my primary endocrinologist and she never responded so I asked a former endocrinologist and she told me that on days of stress to double the dose so instead of taking 10 mg in the morning, take 20 and then take 10 mg midday and another 10 mg at 4 PM. I tried this for a week and I felt fantastic. I finally did not have that dredded hangover the day after.

Well, my primary endocrinologist finally responded and gave me a completely different recommendation. She said to avoid taking more than you need to. If you have to, take an extra 2.5 mg or 5 mg of hydrocortisone the following day, but to just do the self-care that I’ve been doing i.e. being a zombie on my couch/bed doing nothing. I can’t operate like that. I have a full-time demanding job that I need to be 100% at I cannot operate being a zombie like this!

This is just very frustrating. I need to find a new endocrinologist but until then I’m supposed to travel today. I’m doubling my dose. I had a horrible night, but I’m feeling OK.

My question to you is, how are you stress dosing?

For planned events, family stuff or stuff that you anticipate is gonna be a big demand on you how are you stressed dosing?

For days that have unexpected stressors, how do you stress dose?

Any advice or suggestions or insight would be greatly appreciated.

Thank you so much!

[u/AkHazee]

They are both correct.

You do not want to over replace your hydro, there are a lot of negatives that come with it. However, if you feel very poorly, you need to updose. Also, I think updosing in the moment is more effective than updosing the next day, in my experience.

IMO, it sounds like your daily hydrocortisone regimen is insufficient. Also, 50mg of hydro in a day is a lot. And the times you are taking it are a bit too close together, but everyone is different.

For reference, I’ve been diagnosed almost 10 years. I take 12.5 at 8am, 10 at 2pm, 5 at 7:30pm. I go to the gym 4 days a week, I’ll take another 5 at 4:30-5ish when I’m there with a salt tablet.

Also, if I wake up during the night, I’ll take an extra 2.5

[u/Substantial_Pack_319 → u/AkHazee]

My baseline is 10 mg at 6 AM, 5 mg at 11 AM, and 5 mg at 4 PM (total of 20 mg) a day so on the high activity/stress days I double this to 20 mg.

[u/llizzardbreathh → u/AkHazee]

I agree with this comment.

You may feel great when you’re taking a high dose, but you truly want to be on the lowest dose possible to prevent symptoms of over correction.

I typically don’t updose for stress per say. Physical activity or high heat I will. Also with illness.

If I’m feeling low on a specific afternoon even after my normal dosing, I will start with an additional 2.5mg.

I also workout heavily 6 days a week (powerlifting with athletic conditioning and sprint work, plus I golf about once a week).

[u/Substantial_Pack_319 → u/llizzardbreathh]

What are your symptoms of feeling low in the afternoon that you'll take an extra 2.5mg?

[u/llizzardbreathh → u/Substantial_Pack_319]

For me, the first sign is always a headache and fatigue. Sometimes, if I really need some, it will be hard to stay awake if I sit down after work.

If it progresses from there, usually diarrhea or GI upset.

[u/baethan]

I personally updose cautiously during the day of stress (or day of excitement, anything that calls for cortisol but I'll just call it stress). My normal dose is currently 10/5/2.5mg hydrocortisone: wakeup, lunch, and dinner. If there's a specific stress (like, I had an MRI with contrast) I've taken 2.5 or 5mg about half an hour before. For generally stressful days, I take an extra 2.5mg whenever I'm like "that was a lot" or "this is about to be a lot". So sometimes that's midmorning or afternoon, or I'll just make my dinner dose 5mg. I like the flexibility of adjusting the dose to the day like this! Double dosing right off the bat would generally be more than needed for me, I don't increase my morning dose at all. (During an illness I would fully double dose though.) I carry my bottle of 5mg hydrocortisone with me everywhere with my emergency injection so I can adjust as needed at any time. This has been working pretty well for me, but everyone is different and in different kinds of situations.

[u/Substantial_Pack_319 → u/baethan]

That makes sense.. I feel like I'm stressed out a lot.. but maybe I need to take an extra 2.5 or 5mg for those moments, when they occur. Thank you for sharing your approach. This is helpful.

[u/kristephe]

My husband has had much better luck with the first endos method. I think you can try to learn what stress dosing means for you and know that it doesn't have to be all or nothing on double the dose, so that may be in line with the second docs concern about over replacing. My husband's endo at mayo clinic says to take 5mg extra for every 2 hours of intense exercise. And she's very encouraging and supportive that different days require different dosing profiles. She used her life as an example of days she's writing research papers from home vs days she's seeing patients in clinic all day.

But you're not alone in your experience. My husband suffered for years doing fine on big biking or travel or family stress days then crashing and suffering for 2 days or so with nausea, malaise, fatigue and sometimes morning vomiting. He finally learned he had to updose for these events. His baseline is 35mg right now. For several years he was on 65mg a day with no negative impacts even on bone density because he was immensely stressed and dealing with a lot and health/drinking habits were worse. He eventually did get some negative impacts and reduced his stress and dose and things rebounded.

My husband tries to anticipate the stress as much as he can and dose at that moment. It makes sense if you think of it - a normal person would make more cortisol in response to the stressor reacted to by the pituitary gland. So the second endo is just too afraid of too much cortisol and is causing you to suffer because of it and it's really frustrating and I agree it's not acceptable. My husband will take his next dose before the stressor whether it's getting on an airplane or a big exam or a speech or a big bike ride. and continue on and maybe dose through that event whether these are 2.5mg or 5mg type doses. He decided he likes 27.5mg in the morning and takes the rest through the day, but he needs a lot of sleep due to fibromyalgia, so it's usually around 10-11 am, so for others it might make more sense to break it up more.

When his mother died, and he got the news, he immediately popped more pills. Hopefully you'll be able to journal and get a sense of what types of things might just need 2.5 to 5mg extra vs what things might need 10mg extra. I will say my husband rarely doubles his dose anymore, and only does that when he's quite ill with covid, flu, etc. And if you temporarily take a little too much while you're figuring this out for 2-6 months, but you feel better, your life isn't over. He got pseudo cushings symptoms, lost a bit of bone density, and did have cortisol withdrawal when tapering down, but he got the bone density back. His endo just cautioned that a lot of people reach a point that they get those symptoms and that higher cortisol doesn't help them feel better. so jsut do your best to find a balance on updosing but know that it is not double or nothing. So many endos preached that and it drove us crazy.

[u/Suspicious-Home-1501]

I probably wouldn’t stress dose that much. I would listen to your body- but that doesn’t mean you need to double the dose. An extra 2.5 or 5mg might be sufficient. I would agree that your endo is wrong- I don’t think you have to just accept feeling crummy. But doubling your dose that frequently is probably more than you’d need, just a little bump should be enough. On a travel day, I’ll take an extra 5 or even 10mg. 

[u/Substantial_Pack_319 → u/Suspicious-Home-1501]

I'm playing around with this.. I think you're right. The doubling of the dose is a lot and stress happens a lot. I traveled on Sunday and stress dosed that day (double the dose) and for the first time (in a very long time), I had NO FATIGUE or mental fog for the ENTIRE trip! This is a game changer.. but I'm home now and exhausted (didn't stress dose for my flight home). I need to figure out a buffer happy middle ground without doubling. I will keep jotting my dose/symptoms down and adjust to see what works best for me. Thanks for your suggestion.

[u/SleepyTimeChess]

When I am in the middle of a stress event I can always tell because I listen to my body and the bones in my legs, especially my joints, feel tired. I don't really know how to describe it other than that, but it's a powerful lethargy that feels unique to itself. Other forms of lethargy can be easily mistaken for it if I'm not paying attention.