Chapter 7. Adrenal Fatigue the Ignored Epidemic of Modern Civilization

Section Three: Chapter 7.

Adrenal Fatigue the Ignored Epidemic of

Modern Civilization

Ignored by mainstream medicine, adrenal fatigue is a common problem seen routinely every day at any busy medical office. The paramount symptom is fatigue unrelieved by sleep.  Other symptoms include craving for salty foods, hypoglycemic episodes, decreased libido, stress intolerance, light headed upon standing, depression, loss of memory and cognitive decline, allergies, sinus problems, and prolonged recovery from flu-like illnesses. The basic underlying cause is low cortisol output by the adrenal glands.

A Self-Help Book for Chronic Burn-Out called Adrenal Fatigue

The definitive book on this topic is entitled, “Adrenal Fatigue”, by James L Wilson, PhD, a self-help guide for all of us chronically stressed out members of the "rat race" suffering from this new 21st century epidemic. (1)  In his book, Wilson outlines how to diagnose and treat adrenal fatigue, a syndrome not yet recognized by mainstream medicine and it should be.   I found Chapter 10 on physical signs of adrenal fatigue the most useful.  This chapter describes the findings on physical examination such as the unstable pupil, blood pressure reduction upon standing, and Sergent's white line test. 

Cortisol Testing

Chapter eleven of Wilson's book covers the different cortisol testing methods available for cortisol in saliva, blood, and urine, as well as the ACTH stimulation test.  Wilson favors the four sample salivary cortisol test as the easiest and most convenient method; with the added advantage that salivary testing can be done at home without a doctor's prescription.

Another chapter in the book covers treatment and recovery from adrenal fatigue with modification of diet and lifestyle, and diet, avoiding food allergies, and the use of hormone supplements and dietary supplements.  He also weighs the use of Cortef (cortisol) vs. adrenal cortical extracts. 

Results from Years of Chronic Stress

Adrenal fatigue is the net result of years of continuous high cortisol output by the adrenals caused by chronic stress from job, family, illness, injury, and poor diet and lifestyle associated with high-tech modern living. After years of chronic stress, the two small triangular supra-renal glands poop out, and we become another casualty of adrenal fatigue, the 21st century epidemic. Since mainstream doctors can't seem to help, either ignoring the syndrome, or prescribing SSRI anti-depressants for it, this self-help book may be a life-saver.

Why is Cortisol Important?

Cortisol is the stress hormone, and is produced in response to stress. Cortisol is important for blood sugar regulation.  Cortisol mobilizes glycogen in the liver to maintain blood glucose levels.  Symptoms of hypoglycemia are common in low cortisol adrenal fatigue.  Also low blood pressure or inability to maintain blood pressure upon standing is also a common symptom.  Another physical exam finding is an unstable pupil response to light. The pupil at first contracts and then after a few seconds opens and closes.

The Adrenal Glands Make the Cortisol

The two small triangular adrenal glands are located just above the kidneys and secrete the hormone cortisol in response to stress, physical, emotional, or traumatic stress.  The adrenal glands make the hormone cortisol.

What is Cortisol? It's the Stress Hormone 

Cortisol is a steroid hormone, and like all the others it is made from cholesterol.  Cholesterol, in turn, is made from Vitamin B5 and Acetyl CoA.  The manufacture of steroidal hormones can be best understood by referring to a steroidal pathway chart.

Salivary Cortisol Test: 

Although cortisol can be measured in a blood sample, the best way to measure cortisol levels is with 4 saliva samples taken throughout the day.  There are literally hundreds of medical research studies validating the usefulness of salivary cortisol measurements.  A recent study showed that low early morning salivary cortisol is associated with chronic fatigue syndrome in women.(8)  We use a 4 sample salivary kit that has a cotton cylinder that is placed under the tongue to collect the sample.  Collecting a sample with this kit is much easier than the older method of spitting into the tube.

Nutritional Supplement Program for Adrenal Fatigue and Recovery

The keystone of the treatment program is a nutritional supplement program to restore adrenal function that includes vitamin C, B5, magnesium, biotin and adaptogenic herbs.  Recovery takes about 6 weeks.

Cortef for Severe Cases of Adrenal Fatigue

In very severe cases of adrenal failure, Cortef tablets are available and produce a dramatic improvement in clinical condition.  For more information, see the classic book, Safe Use of Cortisol by William Mck Jefferies.  (41)  Cortef is the name for bio-identical cortisol which is widely available at the local drug store.  Synthetic forms of cortisol such as prednisone and dexamethasone are not recommended as they can be associated with adverse side effects.

Other Useful Interventions For Adrenal Fatigue:

Avoid excess caffeine, refined carbohydrates, alcohol and sugar.
Get plenty of sleep.
Take steps to reduce stress with gentle exercise, meditation, and yoga.
Bioidentical hormones as determined by lab profile.

Cortisol's Relation to Thyroid Function - Avoiding A Common Pitfall

Low cortisol level adrenal fatigue will induce a protective state in which the body’s metabolic rate is reduced in order to cope with low cortisol levels.  The body compensates by reducing thyroid function by shunting thyroid hormone production into the reverse T3 pathway, the inactive form of thyroid hormone.  This creates a functional low thyroid state which will show up on thyroid labs.  Treating the patient with thyroid hormone under this scenario is a common error and a pitfall to be avoided.  Giving thyroid hormone to a patient with low cortisol adrenal fatigue will only make the patient feel worse.  The low adrenal function must be addressed first before attempting to raise thyroid levels.  This is done with a salivary cortisol test and a nutritional supplement program over 6 weeks as described above.  In the event the patient is already taking thyroid hormone medication which doesn't seem to be working or is not tolerated, this is a red flag that most likely cause is low cortisol adrenal fatigue.  Once this is addressed, the patient will do well with thyroid medication.

For More Reading:

Another excellent book on adrenal fatigue is, “From Fatigued to Fantastic”, by Jacob Teitelbaum MD.(43)  Also recommended is the article, “Diagnosis and Treatment of Hypothalamic-Pituitary-Adrenal (HPA) Axis Dysfunction in Patients with Chronic Fatigue Syndrome (CFS) and Fibromyalgia” by  Kent Holtorf M.D. (44)

Articles with Related interest:

Adrenal Fatigue by Jeffrey Dach MD

References for Chapter 7. Adrenal Fatigue

(1) http://www.adrenalfatigue.org/  Adrenal Fatigue by James Wilson, Smart Publications; January 25, 2002.

(2) http://coastherbal.com/web_standard/adrenal_stress.html THE STANDARD Adrenal Stress: Measuring and Treating Thomas G. Guilliams Ph.D.

(3) http://www.spinelife.com/pdf/AdrenalStress.pdf THE STANDARD Adrenal Stress: Measuring and Treating Thomas G. Guilliams Ph.D.

(4) http://www.medaus.com/p/200,516.html Saliva Reference Summary  ZRT Laboratory (3-12-01) METHOD VALIDATION.

(5) http://advan.physiology.org/cgi/content/full/31/1/110
ADV PHYSIOL EDUC 31:110-115, 2007 TEACHING IN THE LABORATORY A laboratory exercise to illustrate increased salivary cortisol in response to three stressful conditions using competitive ELISA
Mark F. Haussmann, Carol M. Vleck and Eugenia S. Farrar

(6) http://www.biovit.hr/ibl/saliva/cortisol_e.pdf  Cortisol Physiology / Effects of Cortisol

(7) http://www.jacemedical.com/store/low_cortisol.html
The Medical Evidence for Low Cortisol in Chronic Fatigue Syndrome!

(8) http://www.cdc.gov/cfs/publications/clinical_10.htm
Attenuated morning salivary cortisol concentrations in a population-based sample of cases with chronic fatigue syndrome and well controls. Nater UM, Maloney E, Boneva RS, Jones JF, Reeves WC, Heim C.
Journal of Clinical Endocrinology & Metabolism 26 December 2007

(9) http://ajp.psychiatryonline.org/cgi/content/full/162/4/807
Am J Psychiatry 162:807-809, April 2005 Brief Report Enhanced Early Morning Salivary Cortisol in Neuroticism . Maria J. Portella et al

(10) http://archpsyc.ama-assn.org/cgi/content/full/57/1/38
Low Salivary Cortisol and Persistent Aggression in Boys Referred for Disruptive Behavior Keith McBurnett, PhD; Benjamin B. Lahey, PhD; Paul J. Rathouz, PhD; Rolf Loeber, PhD Arch Gen Psychiatry. 2000;57:38-43.

(11) http://www.sav.sk/journals/endo/full/er0298f.pdf
Iatrogenic Adrenal Cortex Failure in Patients woth Steroid Dependent Asthma in Relation to Different Methods of  Glucocorticoid Treatment,  B. KOS-KUDLA, Endocrine Regulations, Vol. 32, 99.106, 1998

(12) http://bbh.hhdev.psu.edu/labs/bbhsl/PDF%20files/klein%20et%20al.%20cortisol%20and%20naltrexone.pdf  Sex Differences in Salivary Cortisol Levels Following Naltrexone Administration LAURA COUSINO LARRY D. JAMNER, JANEL ALBERTS, MATTHEW

(13) http://bjp.rcpsych.org/cgi/content/full/184/2/136
Salivary cortisol response to awakening in chronic fatigue syndrome Amanda D. L. Roberts, PhD . The British Journal of Psychiatry (2004) 184: 136-141

(14) http://www.virginiahopkinstestkits.com/cortisolzava.html Cortisol Levels, Thyroid Function and Aging HOW CORTISOL LEVELS AFFECT THYROID FUNCTION AND AGING Interview with David Zava, Ph.D. Originally published in the John R. Lee, M.D. Medical Letter

(15)  http://www.drmyhill.co.uk/article.cfm?id=266 Common Hormonal Problems in CFS - Adrenal  Underactive adrenal gland (DHEA and cortisol) If the pituitary gland is underfunctioning then the adrenal gland will also underfunction. However the gland itself may fail as a result of chronic stress. 

(16) http://www.adrenalfatigue.org/qa.php James Wilson Questionnaires on Adrenal Fatigue.

(17) http://www.jacemedical.com/store/low_cortisol.html The Medical Evidence for Low Cortisol in Chronic Fatigue Syndrome! Jace Medical

(18) http://www.cdc.gov/cfs/publications/clinical_10.htm Attenuated morning salivary cortisol concentrations in a population-based sample of cases with chronic fatigue syndrome and well controls.
Nater UM, Maloney E, Boneva RS, Jones JF, Reeves WC, Heim C. Journal of Clinical Endocrinology & Metabolism 26 December 2007

(19) http://ajp.psychiatryonline.org/cgi/content/full/162/4/807
Am J Psychiatry 162:807-809, April 2005. Brief Report Enhanced Early Morning Salivary Cortisol in Neuroticism. Maria J. Portella et al.

(20) http://www.intlhormonesociety.org/ref_cons/Ref_cons_3_mild_glucocorticoid_deficiency.pdf
International Hormone Society . Uses of Cortisol references.

(21) http://archpsyc.ama-assn.org/cgi/content/full/57/1/38
Low Salivary Cortisol and Persistent Aggression in Boys Referred for Disruptive Behavior Keith McBurnett, PhD; Benjamin B. Lahey, PhD; Paul J. Rathouz, PhD; Rolf Loeber, PhD Arch Gen Psychiatry. 2000;57:38-43.

(22) http://www.drmyhill.co.uk/article.cfm?id=266 Common Hormonal Problems in CFS

(23) http://www.drpressman.com/library/view.html?id=78
The Use Of Adrenal Cortical Extracts In Adrenal Fatigue by James L. Wilson DC, ND, PhDWhat Is Hypoadrenia and Adrenal Fatigue?Wilson, James L. ND, DC, PhD. Adrenal Fatigue: The 21st Century Stress Syndrome Smart Publications, Petaluma CA, 2001

(24) http://www.ncbi.nlm.nih.gov/pubmed/12377295 Tsigos C, Chrousos GP.Hypothalamic-pituitary-adrenal axis, neuroendocrine factors and stress. J Psychosom Res. 2002 Oct;53(4):865-71.

(25) http://ajp.psychiatryonline.org/cgi/content/full/160/9/1554
Raison CL, Miller AH. When not enough is too much: the role of insufficient glucocorticoid signaling in the pathophysiology of stress-related disorders. Am J Psychiatry. 2003 Sep;160(9):1554-65.

(26) http://www.biodia.com/TechnicalCharts/ChronicStresschart.pdf
Chronic Stress Response Chart

(27) http://www.biodia.com/TechnicalCharts/SteroidalHormonechart.pdf
Steroidal Hormone Principle Pathways. (Understanding Pregnenolone Steal, the Preferential Pathway Under Chronic Stress)

(28) http://www.drlam.com/articles/adrenal_fatigue.asp
Cortisol (The Hormone of Death) ,  Dr. Lam.

(29) http://meeting.chestjournal.org/cgi/content/abstract/132/4/555 Chest 2007, Critical Care Sepsis: Markers. Wednesday, October 24, 2007 . SALIVARY CORTISOL IN CRITICAL CARE PATIENTS. Eduardo F. Sad et al.

(30) http://www.ncbi.nlm.nih.gov/pubmed/6316831
Salivary cortisol: a better measure of adrenal cortical function than serum cortisol.Vining RF, McGinley RA, Maksvytis JJ, Ho KY. Ann Clin Biochem. 1983 Nov;20 (Pt 6):329-35. 

(31) http://www.ncbi.nlm.nih.gov/pubmed/2828410
Salivary cortisol measurement: a practical approach to assess pituitary-adrenal function. J Clin Endocrinol Metab. 1988 Feb;66(2):343-8. Laudat MH, Cerdas S, Fournier C, Guiban D, Guilhaume B, Luton JP.

(32)) http://www.ncbi.nlm.nih.gov/pubmed/11164057 Salivary cortisol patterns in vital exhaustion. Nicolson NA, van Diest R. J Psychosom Res. 2000 Nov;49(5):335-42.

(33) http://bjp.rcpsych.org/cgi/content/full/184/2/136 Salivary cortisol response to awakening in chronic fatigue syndrome.Roberts AD, Wessely S, Chalder T, Papadopoulos A, Cleare AJ. Br J Psychiatry. 2004 Feb;184:136-41. (FULL TEXT)

(34)) http://jcem.endojournals.org/cgi/content/full/86/8/3545
Hypothalamo-Pituitary-Adrenal Axis Dysfunction in Chronic Fatigue Syndrome, and the Effects of Low-Dose Hydrocortisone Therapy. The Journal of Clinical Endocrinology & Metabolism Vol. 86, No. 8 3545-3554 A. J. Cleare et al.

(35) http://www.annalsnyas.org/cgi/content/abstract/1057/1/466
Stress-Induced Hypocortisolemia Diagnosed as Psychiatric Disorders Responsive to Hydrocortisone Replacement, SUZIE E. SCHUDER Ann. N.Y. Acad. Sci. 1057: 466–478 (2005).  

(36) http://edrv.endojournals.org/cgi/content/full/24/2/236
The Neuroendocrinology of Chronic Fatigue Syndrome. Anthony J. Cleare. Endocrine Reviews 24 (2): 236-252, 2003, Full Text.

(37) http://crobm.iadrjournals.org/cgi/content/full/13/2/197 THE DIAGNOSTIC APPLICATIONS OF SALIVA— A REVIEW, The Monitoring of Hormone Levels, Eliaz Kaufman,Ira B. Lamster. Crit Rev Oral Biol Med 13(2):197-212 (2002)

(38) http://www.biodia.com/TechnicalCharts/SALIVARY_REFERENCES.pdf
Listing of about one hundred medical references on salivary hormone testing with hyperlinks.

(39) http://coastherbal.com/web_standard/adrenal_stress.html 
Adrenal Stress: Measuring and Treating, by  Thomas G. Guilliams Ph.D. The Standard, Volume 3, No. 1. Excellent review article on diagnosis, treatment of adrenal fatigue with salivary cortisol testing.

(40) Adrenal Fatigue by James L Wilson D.C., N.D., Ph.D. The 21st Century Syndrome reviewed by Jeffrey Dach MD.

(41) Safe Uses of Cortisol (Cortisone, Hydrocortisone) by William McK., M.D. Jefferies (Author) reviewed by Jeffrey Dach MD.

(42) http://jcem.endojournals.org/cgi/content/abstract/93/3/703
The Journal of Clinical Endocrinology & Metabolism Vol. 93, No. 3 703-709. Attenuated Morning Salivary Cortisol Concentrations in a Population-Based Study of Persons with Chronic Fatigue Syndrome and Well Controls Urs M. Nater, Elizabeth Maloney, Roumiana S. Boneva, B

(43) From Fatigued to Fantastic by Jacob Teitelbaum MD,  Avery Trade; 3rd edition (October 4, 2007).

(44) Hypothalamic_Pituitary_Adrenal_HPA_Dysfunction_Chronic_Fatigue_Syndrome_Fibromyalgia_Kent_Holtorf_2008.pdf
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Diagnosis and Treatment of Hypothalamic-Pituitary-Adrenal (HPA) Axis Dysfunction in Patients with Chronic Fatigue Syndrome (CFS) and Fibromyalgia (FM)  Kent Holtorf M.D.  J of Chronic Fatigue Syndrome,  V 14:3. (pub) 2008.

Author: Jeffrey Dach MD