A normal circadian rhythm cortisol pattern is one in which there is a rise before waking (before 7-8 AM), and then a gradual decline throughout the rest of the day(26). Twelve patients had recognized circadian patterns of cortisol fluctuation, which will hereafter be referred to as Cortisol Pattern 1 (CP1). Of the twelve with CP1 whom were classified in the “normal” pattern, six had normal values at all four test time points, as well as normal total cortisol values or burden. Thus, of the 29 total charts reviewed, only 21% of the patients would be classified with normal cortisol values as well as normal patterns. The remaining six patients with a “normal” pattern of cortisol secretion (high waking and then decreasing over the rest of the day) had abnormal values at one or more time points.

Seventeen of the 29 total patients fell into our classification of dysregulated circadian cortisol patterns.

This consisted of patients with cortisol patterns that did not decrease in slope over the course of the day. Fourteen of these 17 patients had cortisol values out of normal range at one or more time points, or in total cortisol burden. The dysregulated patients’ cortisol plots fell into three distinct patterns, which we will hereafter call Cortisol Pattern 2 (CP2), Cortisol Pattern 3 (CP3), and Cortisol Pattern 4 (CP4).
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Patients grouped into CP1 begin with a burst of cortisol between 7 and 8 AM (between 13-23 nM), and drop off slowly throughout the day. Normal values are considered 4-8 nM between 11 AM and noon, 4-8 nM between 4 and 5 PM, and 1-3 nM between 11 PM and midnight. It is notable that with the group of patients who presented with normal patterns, there was a large range in cortisol levels they excreted at any specific point. Those patients classified with CP2 tended to have abnormal circadian cortisol levels, higher in the late morning (11 AM to noon), compared to higher waking levels. Their levels then dropped off or stayed the same later in the day and at midnight. In contrast, patients grouped into CP3 had peaks between 7-8 AM and a more significant drop at noon. This created a second “mini” peak on the graph between 4-5 PM, though the levels are actually closer to normal. Patients assigned with CP4 fell into a distinct pattern of increasing between 11 PM and midnight. While a normal value falls between 1-3 nM for this time point, these patients averaged 15.4 nM (SD 8.3). One of the patients had extremely high cortisol levels at two time points, including time point 4 (between 11 PM and midnight). If the data is reanalyzed without this patient, the average cortisol value is still high with an average of 6.75 nM (SD 2.06).

Typically, the highest cortisol value of the day occurs at the waking time point. Yet, of the patient charts reviewed, if levels were low at all, they were low at this time point. One patient with low total cortisol had consistently low cortisol levels, except the late night point, which is typically the lowest cortisol level. There were three patients who had consistently high cortisol levels, and two of these also had high total cortisol values.