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By: Michael Lam, MD, MPH
www.DrLam.com

Introduction

The adrenal glands are the main stress control system of the body. Adrenal Fatigue is a decrease in the adrenal glands' ability to carry out this normal function. It is commonly caused by chronic stress from any source (including emotional, physical, mental, or environmental) that exceeds the body's capacity to adjust appropriately to the demands placed on it by the stress. Stressors that can lead to Adrenal Fatigue include anger, chronic illness, depression, surgery, high sugar intake, over exercise, sleep deprivation, chronic or acute infections including Giardia and H. pylori and root canal repair, just to mention a few.

Signs and symptoms of Adrenal Fatigue include tendency to gain weight and inability to lose it, especially around the waist, high frequency of getting the flu and other respiratory diseases with symptoms that tend to last longer than usual, tendency to tremble when under pressure, reduced sex drive, lightheadedness when rising from a prone position, brain fog, lack of energy in the afternoon, reliance on coffee to get the day started, fibromyalgia, chronic fatigue, craving for salty and fatty foods, hypoglycemia, chronic pain of unknown origin and feeling better during a vacation. None of these signs or symptoms by themselves can definitively point to adrenal fatigue. However, as a group of symptoms, in the context of an otherwise healthy person, they do form a specific Adrenal Fatigue Syndrome or picture, that is, of a person under stress and the body's failing physiological response to deal with such a burden. Adrenal Fatigue, as a debilitating condition, is not recognized by conventional medicine and is thus missed by most conventionally trained physicians.

Four Stages of Adrenal Fatigue

Adrenal Fatigue progresses through four advancing stages with increased severity of symptoms with each stage as illustrated below:

Stage 1: Alarm Reaction (Flight or Fight response). In this stage, the body is alarmed by the stressors and mounts an aggressive anti-stress response to overcome the stressors. This anti-stress response is mediated by an increase in anti-stress hormones like cortisol. The amount of anti-stress hormone required is well within the body's output capacity. Fatigue is usually quite mild and usually occurs in the morning upon awakening or in the mid-afternoon. No physical or physiological dysfunction is clinically noticeable. Normal daily function is expected, though peak performance cannot be achieved. Adrenal crash may have occurred but normally it is undetectable.

The adrenal glands are usually the first in order of endocrine function to breakdown in a stressful situation that has overwhelmed the body's normal compensatory response. Unfortunately, this sub-clinical state is seldom recognized as a pathological condition. Acceptable social compensatory actions such as coffee intake often mask the underlying problem: the adrenals are put into over-drive to cover up the early signs and symptoms of fatigue. The insulin-producing portion of the pancreas is also affected. Imbalance in blood sugar level results in low energy and this dysfunction is temporarily fixed by quick fixes such as high sugar content soda drinks, energy potions and high carbohydrate foods such as donuts. Many people even consider this state "normal" as part of living in the modern society. Those who require coffee to "kick start" the day may already be in this stage and not be aware of it.

Stage 2: Resistance Response. With chronic or severe stress, the adrenals are eventually unable to keep up with the body's demand for cortisol. Adrenal Fatigue now enters into Stage 2. Normal daily functions can still be carried out, but the sense of fatigue is pronounced at the end of each day as the body needs more rest than usual to recover. Despite a full night's rest, the body does not feel refreshed in the morning. Anxiety starts to set in and the person becomes easily irritable. Insomnia becomes more common, as it takes longer to fall asleep and there are frequent awakenings as well. Infections become recurrent. PMS and menstrual irregularities surface and symptoms suggestive of hypothyroidism (such as a sensation of feeling cold and a sluggish metabolism) become prevalent. The thyroid glands are usually affected at this stage. Sluggishness, feeling cold, and weight gain centrally, despite exercise and diet, are the predominant symptoms that usually bring the patients to their physicians for the first time. Thyroid replacement is routinely prescribed but ovarian hormones, synthetic or bio-identical, are also considered. However, the vast majority of patients who undergo such hormonal adjustment remain symptomatic over time and their treatments usually fail. Many people will visit their physicians for the first time at this stage. Conventional medical work up is ordered, but the test results are inevitably within range and patients are sent home with no concrete program for recovery. At this stage, many people are prescribed anti-depressants. The many warning signs of the body continue to be ignored, as most people will rely on more and more stimulants to keep their mood up. Those who require multiple cups of coffee to sustain them may well be entrenched at this stage without knowing it.

Stage 3: Adrenal Exhaustion. Adrenal Exhaustion refers to Stage 3 of Adrenal Fatigue. As adrenal function is weakened further, the body's need for adrenal hormones remains unabated if stress is not reduced. The adrenals are no longer able to keep up with the ever-increasing demand for cortisol production needed to overcome the stress and they become exhausted. Cortisol output starts to decline and this usually happens gradually. If the stressors are severe, an adrenal crash may occur, to be followed by a longer than usual recovery. The body enters into the stage where the primary goal is conservation of energy to ensure survival. Systematically, the body goes into a slow-down mode and starts to break down muscle tissue to produce energy. This catabolic stage results in the breakdown of muscles and protein wasting. Chronic fatigue is common and exercise tolerance is reduced. Concurrently, chronic fibromyalgia appears. Toxic metabolites begin to accumulate throughout the body, leading to brain fog and insomnia. Depression becomes severe and constant. As this stage progresses, metabolic, immunological and neurological single organ systems dysfunction characteristic of Stage 2 becomes chronic (Phase A). It then spreads to involve multiple organs (Phase B). This is evidenced by multiple endocrine axis dysfunctions, including the ovarian-adrenal-thyroid axis imbalance in females and adrenal-thyroid axis imbalance in males.

If not attended to, the body is further weakened and enters into a state of disequilibrium with loss of homeostasis (Phase C). As the body tries to repair itself with the limited tools it has, there are wild, exaggerated and paradoxical autonomic-driven reactions. These are characterized by adrenaline rushes, labile blood pressure, and hypoglycemic episodes after meals and anxiety attacks. A state of near adrenal failure (Phase D) eventually occurs as the body's pool of hormones reaches a level too low to prime the adrenals. Without sufficient levels of hormones, the body goes into a full-blown shut down mode to stop as much of the non-essential functions as possible to conserve energy in order to survive. Libido is suppressed, digestion slows down and metabolic rate declines to conserve body weight. Those afflicted find themselves bed-ridden most of the time, and have energy that will last for only a short time.

What separates Stage 3 from earlier stages, clinically, is that the patient often cannot function smoothly throughout the day, no matter how hard he tries. The adrenal function is constantly hovering around the adrenal symptoms threshold level and the smallest stressor will often trigger an adrenal crash. Not only is recovery time taking longer but the body never fully returns to the pre-crash baseline energy level. Something is wrong and the body's cry for help becomes louder. The productive hours of the day will progressively decrease and it is not unusual for those at this stage to have only a few hours of productive time a day, while the rest of the time is spent in bed resting.

Stage 4: Failure. Eventually, the adrenals will become totally exhausted. Patients at this stage will have a high chance of cardiovascular collapse and death. When Adrenal Fatigue has advanced to this stage, the line between it and Addison's disease, also called adrenal insufficiency, can be blurred. While the etiology of the two conditions may be different, the ultimate clinical presentations can be quite similar as they both represent a continuum of decompensation in adrenal function. At this stage, severe advanced adrenal crisis manifestation can be very similar and akin to an Addisonian crisis or acute adrenal insufficiency which, is a recognized medical condition. Symptoms of this include sudden, penetrating pain in the lower back, abdomen or legs, severe vomiting and diarrhea, dehydration, low blood pressure and loss of consciousness. Addisonian crisis is rare and in most cases, the symptoms are severe enough that patients often seek medical treatment before a crisis occurs. However, in about 25 percent of patients, the symptoms first appear during an Addisonian crisis. If left untreated, the Addisonian crisis can be fatal.

Although adrenal dysfunction and its various stages were recognized as distinct clinical syndromes since the turn of the 20th century, most conventionally trained physicians are still unfamiliar with this condition because it is difficult to diagnose through traditional blood tests. Most patients are sent home with anti-depressants after a short trial of hormonal replacement but this will usually fail.

Functional Decline Speed

Depletion and dysregulation of adrenal hormones such as cortisol and adrenaline are the primary symptomatic drivers of Adrenal Fatigue and crashes. Repeated crashes over time will invariably further weaken the adrenal glands. While the intensity of each crash will increase as Adrenal Fatigue increases, it is not a linear progression clinically. Many in Stage 1 and Stage 2 Adrenal Fatigue are not aware of their impending problems. Their daily activities will remain unchanged, as there is sufficient adrenal reserve to compensate for any transient energy low.

Many in Adrenal Fatigue Stage 3A and Stage 3B continue to hold their full time jobs. Extra rest is usually needed, but those with strong body constitutions can make it through for years. Decline in adrenal function is slow and steady and sometimes this is written off as the effect of aging.

For most, Adrenal Fatigue Stage 3C is a wake up call as moderate fatigue may become severe. The decline can be fast and furious and an adrenal crash can occur in a matter of hours. One can be bedridden for days, with slow recovery. Those who are constitutionally weak will have the most difficult time recovering. The decline in adrenal function is most rapid in this phase. The body's energy level comes crashing down like a waterfall. This "slow down" mode is new to most people whose lives have been active before and this is most unpleasant.

Interestingly, functional decline actually slows down in Stage 3D as compared to Stage 3C. There is already an extremely low level of hormones remaining and the body is rapidly down-regulating to stop most non-essential bodily functions to ensure survival. The body is in a "shut down" mode and is trying to get used to the low energy state. Most people will be bedridden at this stage requiring ambulatory help.

Any small stressor may trigger a drop below the level required for minimum basic adrenal function and this may in turn trigger adrenal failure, as shown in the following graphic representation. The above is summarized in the following graph:

functional decline

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