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Clinical Pearls: How to Explain Adrenal Fatigue

Published 5 days ago • 3 min read

COMING SOON! The Functional Medicine Collective (a mentorship for clinicians who want more guidance on a "practical" approach to functional medicine).

The launch kicks off with a 2-day workshop followed by an "ask-me-anything" - click the button below to get notified when registration opens!

This week's topic: Adrenal Fatigue

An overview of today's email:

  1. What is Adrenal Fatigue?
  2. Can we test for Adrenal Fatigue?
  3. Practical clinical tips

1. What is Adrenal Fatigue?

"Adrenal fatigue" is based off a theory from the work of Hans Selye who used the term General Adaptation Syndrome in the 1930s-1950s to refer to the biological effects of chronic stress and many chronic diseases. The phrase, however, is often attributed to the chiropractor and naturopath James Wilson, who coined the term in the late 1990s.

The term implies that the adrenal glands are not producing appropriate amounts of hormones (particularly cortisol) to support optimal energy and recovery....but not to the degree we see in Addison's. The root cause is often attributed to chronic stress.

It makes sense that the adrenal glands (which are involved in our SNS response) could be attributed to a symptom like fatigue. However science does not support the term or the pathophysiology; the fatigue that accompanies chronic stress is a lot more complicated!

I encourage any clinician involved in functional or integrative medicine to use the term "HPA Axis Dysfunction" or "HPA Dysfunction" instead.

2. Can we test for Adrenal Fatigue?

The most common way to asses for HPA Axis Dysfunction is by measuring cortisol (via blood, urine, and saliva).

Blood testing: The least accurate way to evaluate for subtle cortisol imbalances, but good for screening to rule in or out overt disease such as Cushing's or Addison's. In all my years of practice, only twice has this persistently come back at a level that warranted endocrine follow up. Note, many naturopathic physicians will consider a level between 12 and 18 to be "optimal" - but I have not found great studies (or anecdotal evidence) to back this up.

Salivary testing: This primarily measures free (active) cortisol. However, only 5% of our circulating cortisol is in this form. Many in the naturopathic and functional medicine space say this is the most accurate test for evaluating what the cells and tissues can use. I find salivary testing to be most helpful when it includes the CAR (cortisol awakening response) or is just measuring the CAR.

**There are a small number of systemic reviews which estimate that 50% of the time saliva or blood tests do not correlate with fatigue and other purported symptoms of adrenal fatigue (one resource).

Urine testing: In functional medicine, a common method used to evaluate cortisol (and cortisone) metabolism (i.e. what the body has used or broken down) is dried urine testing. A few lab companies offer this, and this (along with a CAR), would be my preferred method of testing.

3. Practical Clinical Tips

Fatigue is real; adrenal fatigue is not (but don't say that to your patients!).

It is important to remember that cortisol imbalances are NOT a root cause (we have to dig into upstream causes). However, cortisol is often an easy way to assess the effects of stress on the body, which can drive patient motivation to make lifestyle changes.

Is testing valid?

  • Before recommending any cortisol test, I recommend making sure a patient is sleeping well and is starting to work on evening and morning habits that support the circadian rhythm of cortisol. Otherwise, the testing is a waste of money (in my opinion).
  • When we test for cortisol imbalances, the most common recommendation is to use specific B vitamins or adaptogenic herbs to address the findings. But if these work (without lifestyle guidance), it is temporary. And too often, I find patients take these supplements for months or years (and can never tell me if they have a benefit).
  • I rarely find supplements to be helpful in improving energy when cortisol patterns are low or borderline low. Clinical pearl: If a dried urine test shows more cortisone than cortisol, with low total metabolized cortisol, the primary root cause is that the body needs rest (and not a supplement to continue the burnout process).

I believe cortisol measurements can be helpful in showing patients the effects of their lifestyle on their health, but it is not simple. There are so many molecules involved in cortisol metabolism and activity, and at this time, we have no test that measures more than a few of these molecules at one time.

I hope this was clinically useful!

Stay well, and enjoy the week ahead.

Meg

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