Adrenal Fatigue & Adrenal Insufficiency
The Adrenal Glands
This pair of tiny hormone secreting organs sit on top of your kidneys. They are orange in color and measure about a half inch tall and three inches wide. They weigh in at a mere 3-5 grams each. Gram for gram, the adrenal glands receive more blood flow than any other part of the body–including the heart and the brain. The body is a very efficient machine and so this relatively massive dedication of blood flow is an indication of how important these often overlooked organs are.
The adrenal glands each have two layers that secrete different sets of hormones. The inner layer (the adrenal medulla) secretes epinephrine (adrenalin) and norepinephrine. These two immediate “fight or flight” hormones are released in large amounts in response to sudden major stressors, low blood sugar and exercise. Together epinephrine and norepinephrine raise blood pressure, mobilize glycogen and fat stores to increase blood sugar, and dilate blood vessels in the large skeletal muscles to prepare them for major action.
The outer layer of the adrenal gland, (the adrenal cortex) secretes steroid hormones which are made from cholesterol. Cortisol is by far the major hormone product of the adrenal cortex. It is called a “glucocorticoid” because of it’s effects on raising blood sugar (glucose) in response to stress. Healthy cortisol levels have a natural diurnal cycle, with normal levels being highest around 7AM and lowest levels occurring around midnight. This morning cortisol high is intended to wake you up and prepare you for your day.
The adrenal cortex also secretes aldosterone (which helps raise blood pressure by preventing sodium loss in sweat and urine) and “androgen” hormones such as androstenedione and DHEA (dehydroepiandrosterone) which give adults the secondary sex characteristics of body hair, increased muscle mass, and increased sex drive. DHEA is also the primary building block for the major sex hormones: estrogen and progesterone in females; and testosterone and dihydroxytestosterone in males.
Cortisol: The Master Stress Hormone
Like epinephrine and norepineprine, cortisol is also released in response to stress. It gives the body an extra energy burst as well as making the body more tolerant to pain and inflammation—handy if the stress is likely to cause physical trauma as was so often the case before modern times. In moderation, cortisol bursts temporarily increase immune system function, help maintain higher blood pressure and regulate insulin levels. Unfortunately, this system was well designed for our hunter-gatherer ancestors for whom stress was probably rarer, realer and more short lived.
The body is not able to distinguish between real stress and the “modern emergencies” that include: constant noise, cell phone calls, dinging email and IM warnings, high-speed transportation, modern work, modern relationships, and the crush of people we experience every day in modern cities. When someone is under virtually constant stress, the adrenals do not get a chance to stop high cortisol production. Modern humans experience near-constant stress, and so high cortisol levels have become what we now mistakenly call “normal.” People with chronic pain also have especially high cortisol levels, because pain is a big stressor to the body. Frequent lack of adequate sleep also raises cortisol release, and excessive cortisol itself disrupts normal sleep patterns, creating a propensity toward staying up late and feeling very tired in the morning–no matter how much sleep was had. Because a tired person does not handle stress as well as a well-rested person, the cycle can easily snowball and get worse.
The adverse effects of chronically high cortisol levels lead down the road toward all of the modern health epidemics: diabetes, high blood pressure, heart disease, cancer and obesity. Chronically high cortisol levels also causes bone thinning (osteoporosis) and make muscles and connective tissue (tendons, ligaments, inter-vertebral discs) weak and fragile. High cortisol also slows cell regeneration and with it the body’s ability to heal and regenerate. Long term, high cortisol also depresses the immune system–which can make one more susceptible to colds, flus, other illness, cancer, and chronic infections like intestinal candida and Epstein-Bar virus. Chronically high stress and cortisol levels are also implicated in autoimmune disease and food allergies. Cortisol also hinders digestion by diverting blood flow away from the digestive tract and otherwise slowing the regeneration of stomach and intestinal linings. Long-term high cortisol also decreases cellular insulin sensitivity which is why type II diabetes and “truncal obesity” (abdominal weight gain) are so predominant today—even in children.
This sad and standard-issue modern life scenario of high cortisol levels assumes that the tiny adrenal glands can keep on producing cortisol endlessly. The problem is that they can’t, and the picture gets even worse when the adrenal glands begin wear out in four stages:
- Alarm Reaction
- Adrenal Fatigue/insufficiency
- Adrenal Failure (Addison’s Disease)
Adrenal fatigue occurs when the adrenal glands are no longer able to adequately hormonally respond to stress. Cortisol, DHEA, and other hormones are produced in abnormal amounts (either high or low) and adrenal fatigue sufferers experience many of the problems that come with chronically high cortisone levels. Adrenal fatigue is usually caused by chronic stress, whether that stress is mental, emotional, physical, or environmental (e.g. infection, exposure to toxins, nutritional deficiency).
Adrenal fatigue can be described as occurring in four distinct stages: defined in terms of hormone output. Although poorly recognized by the allopathic medical system, adrenal fatigue can be easily measured with blood or saliva tests. Below are the four stages in detail:
Stage 1: Alarm Reaction
This is what we commonly call the “fight-or-flight” response and is a healthy reaction in which the body reacts aggressively to a stressor, or stressors, and mounts a strong anti-stress response to overcome them. The adrenal glands increase their output of stress-mediating hormones including cortisol and DHEA and at this stage the output is well within the gland’s normal capacity. At this stage no major symptoms are present after the immediate event and physiological dysfunction is undetectable.
Stage 2: Adaptation
With chronic or severe stress, the capacity of the adrenal glands to cope is eventually exceeded and they begin to struggle to meet demands for cortisol and DHEA production. In stage 2, cortisol levels are constantly elevated but DHEA and Pregnenolone levels start to decline and this imbalance causes the symptoms that begin to emerge at this stage. The individual will still be able to carry out their normal routine but they likely to experience increasing levels of highs and lows, and have more fatigue at the end of the day requiring more rest and sleep to recover. Unfortunately, with higher cortisol levels sleep itself becomes less refreshing, so the person often wakes up tired–a key adrenal warning sign.
Most people in stage 2 also experience some degree of hypoglycemia following meals. Other symptoms that may also appear include: anxiety, irritability, and insomnia. Coffee and other stimulants begin to become very attractive to people in stage 2, and the majority of working adults in the modern world are probably in stage 2.
Stage 3: Adrenal Fatigue or Adrenal Insufficiency
If the sources of stress are not reduced, adrenal function will decline. At this stage, the adrenal glands are unable to keep up with the body’s constant demands for cortisol, and this too now begins to decline: both DHEA and cortisol may now be low on diagnostic tests. The decline in cortisol production is usually gradual, but steps must be taken to avoid progression to stage 4. At stage 3 the body slows down, or begins to shut down, many of its non-essential functions (e.g. sex drive and reproduction) with the main focus on the conversion of energy for survival. The patient will experience increasingly severe aches and pains, muscle weakness, easy infections easy & slow to heal injuries, loss of exercise tolerance, and more distinct brain fog, insomnia and depression. Toxins may also build up as the body’s detoxification processes slow. In the adrenal exhaustion stage people will almost certainly be struggling with daily living and may even be unable to take care of themselves. Most fibromyalgia and chronic fatigue patients have distinct adrenal exhaustion.
In the exhaustion stage, thyroid function and (T4-T3 conversion) may also start to decline and bring with it even more symptoms such as slowed metabolism, weight gain, lower body temperature, constipation, reduced resistance to cold, depression, and more irritability and brain fog. Adrenal exhaustion patients are almost invariably self-medicating with heavy caffeine use–which only steepens the downfall of the adrenal glands. Standard allopathic medical care for the complaints of those in adrenal exhaustion usually involves: prescription stimulants, anti-anxiety medications, sleep drugs and powerful antidepressants. Of course, it is easy to see that all these measures are merely masking symptoms, missing the cause, and ultimately only making matters worse.
Stage 4: Adrenal Failure
Eventually, the tiny adrenal glands can become exhausted and stop functioning. It usually takes many, many years and an extremely driven person to reach the ignominious failure stage. Almost all patients will seek medical help before adrenal failure becomes a serious possibility. At this stage, the patient’s condition is akin to adrenal insufficiency (Addison’s disease). In adrenal failure, hormone output is so low that there is a high risk that even essential metabolic processes cannot be maintained. Most people never get this far because advanced adrenal exhaustion will take someone out of the modern rat race before full-on failure can develop.
The recent advent of high-carb/low-nutrient food, highly stimulating prescription drugs (Prozac, Effexor, Adderall, etc.), anti-anxiety and sleep medications and supercharged caffeinated beverages combined with especially stressful lives have unfortunately made adrenal exhaustion and failure more accessible and more likely in everyone.
What You Can Do
If you feel that you are experiencing the symptoms of adrenal fatigue, consider getting your adrenal hormone levels tested. Where-ever you fall on the scale of adrenal fatigue, in today’s world it pays to take care of your adrenal glands with adequate sleep, relaxation, exercise and nutrition. In my experience, many people further along the adrenal fatigue spectrum would also benefit from prescription herbs and targeted, high-dose nutrients (“nutriceuticals”).
The “Cortisol Steal” Phenominon
The adrenal glands make three kinds of hormones: mineralcorticoids, glucocorticoids, and sex hormones. The mother of all of the hormones is Pregnenolone which is made directly from cholesterol. Cholesterol has a bad reputation for causing cardiovascular disease, but we are learning better now that it is absolutely escential and that high cholesterol is not the cause of heart disease. (Inflammation and oxidation stress are closer to being the real culprits, but that’s another story.) What happens in Stage 2 and 3 is that the hormonal precursors get diverted to making cortisol and the other important hormones like aldosterone (important for keeping sodium and blood pressure levels even) and DHEA (which is the upstream precursor other sex hormones like testosterone, estrogen, and progresterone) get stolen to make the cortisol. The body is smart though and instructs the liver to make more cholesterol from the sugars starches and fats we eat. It’s very common for stressed people to have high cholesterol for this reason.
The Thyroid Connection
The body will try to bring stage 2, 3, and 4 people back into ballance. One of the ways to do this is to slow down thyroid function. Thyroid hormone action sets the basic metabolic rate for every cell in your body from bones to brain cells and all the cells in your immune system. So the body is essentially using the thyroid as a brake to slow these stressed people down by making them feel tired, weak, cold and slow. Any sane animal would lie down and take a good break feeling like this. Modern humanity–not so much?
The common thyroid screening test (TSH) is pretty much worthless in looking for this thyroid connection. TSH comes from the pituitary gland and higher levels indicate that the pituitary master is screaming at the thyroid slave to make more thyroid hormone. The normal ranges for TSH ought to have been updated by the labs and hospitals 15 years ago. Most labs still say a TSH is “normal” if the number is between 0.5 and 5.0. This is basically abominable. The American College of Endocrinologists recommended that the upper end of the normal range ought to be dropped to 3.0. Recent laboratory guidelines from the National Academy of Clinical Biochemistry indicate that more than 95% of normal individuals have TSH levels below 2.5 mU/liter. NACB indicated that anyone with a TSH of 2.5 or higher was actually likely to be hypothyroid. For decades patients with a TSH in the range of 2.5 top 5.0 have been told over and over that there is nothing wrong with them and that maybe they are just depressed or that it is otherwise all in their head. Maddening and depressing.
What’s the right test to order to asses your thyroid function? I actually use four: TSH, FT4, FT3, RT3. Most modern MD’s actually have never ordered or heard of the fourth one: RT3. RT3 stands for reverse T3 and it is made along with T3 from the precursor T4. When the body is under prolonged stress and cortisol levels get high for a while, the body makes more RT3 to slow you down and give you all the classic hypothyroid symptoms: cold, tired, achey, frequent infections, constipation, dry skin, hair loss. What happens when you give someone with elevated RT3 the standard thyroid prescription (Levothyroxine, Synthroid, T4)? They end up making more more RT3 and gum up the works further. Poorly educated MDs usually throw up their hands at this point and will often try to give you an antidepressant to shut these patients up. What these patients really need is more straight T3 (cytomel, liothyronine) or a blend of T3 and T4 from prescription Armour thyroid or Naturoid.
Fixing up the thyroid levels will make these fatigued patients feel better, for a while, but let’s not forget who started the crash. The adrenals and prolonged elevated cortisol levels. This needs attention too, or else the additional thyroid support will just burn out the adrenals faster. Giving piles of thyroid hormone to an adrenal fatigue patient is like covering the check engine light with tape when there really was something wrong. Given alone it’s may not be much better for you than drinking coffee to feel better. Solution: treat both the adrenals and thyroid together and also figure out and address what the patient’s major stressors were in the first place (chronic infection, chronic pain, mold or toxic exposures, anxiety, psychological trauma, etc.)
I hope that reading all this was not stressful! If you have made it this far and would like to get your adrenal or thyroid hormone levels tested, I am available for private consultations and will listen to you and work with you to get you the help you need.
Dr. T.R. Morris is a licensed naturopathic medical doctor (ND). He is currently serving as faculty and consultant to the Institute for Functional Medicine (IFM). The IFM mission is to revolutionize medicine by teaching the latest genetic, nutritional, hormonal and other biochemically-based integrative medicine techniques to MDs and other practitioners looking for new tools to prevent and treat chronic disease. In the past, T.R. served as the medical director of a large integrative clinic and taught (genetics, physiology, biochemistry, microbiology, cellular & molecular biology) for 10 years for various medical programs in the Puget Sound. He sees patients in person (or long-distance via Skype consultations) from his home office in Seattle.
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