Adrenal Fatigue Progression

By: Michael Lam, MD, MPH

Stage 1: Alarm Reaction (Flight or Fight response)

What are the first stages of adrenal fatigue, how adrenaline and your hormones effect your body.

In this stage, the body is alarmed by the stressors and mounts an aggressive anti-stress response to reduce stress levels. Some doctors called this the Early Fatigue stage.

Typically, there is an increased ACTH from the pituitary gland that stimulates the adrenal glands into full gear to mount a retaliation response. The adrenal medulla is stimulated to secrete more epinephrine, and the total cortisol output from the adrenal cortex is increased from the excitatory stimulus. There is a corresponding reduction in the DHEA production. During this period, the body needs cortisol to overcome stress, so the production of cortisol is therefore increased. After some time, the adrenals will experience difficulties in meeting the body's ever increasing demand for cortisol.

Stage 2: Resistance Response

With chronic or severe stress, the adrenals eventually are unable to keep up with the body's demand for cortisol. As such, the cortisol output will start to decline from a high level back to a normal level, while the ACTH remains high. With protracted ACTH and adrenal fatigue, less cortisol is produced due to the adrenal becoming exhausted. While the morning, noon, or afternoon cortisol levels are often low, the nighttime cortisol level is usually normal. Anxiety starts to set in, and the person becomes easily irritable. Insomnia becomes more common, as it takes longer to fall asleep. There is also frequent awakenings as well. Infections can become more recurrent. PMS and menstrual irregularities surface, and symptoms suggestive of hypothyroidism (such as a sensation of feeling cold and sluggish metabolism) become prevalent.

A phenomenon called pregnenolone steal (also called cortisol shunt) sets in. Cortisol production becomes the predominant pathway of hormone production as the body favors the production of this hormone. Other hormones such as pregnenolone, DHEA, testosterone, and estrogen are less favored and their production will decline. As a result, total pregnenolone output is reduced but, the total cortisol output continues to be maintained at a normal level. Careful analysis of the daily diurnal cycle of cortisol shows a dysfunctional pattern of abnormally low cortisol in the morning. This is a time when cortisol is needed the most. Nighttime cortisol is usually still normal.

Stage 3: Adrenal Exhaustion

Despite rising ACTH, the adrenals are no longer able to keep up with the body's increased demand for cortisol production. This may happen over a few years. Total cortisol output is therefore reduced, and DHEA falls far below average. The nighttime cortisol level is usually reduced as the hypothalamic-pituitary-adrenal axis "crash" and the body is unable to maintain homeostasis. Early in this stage, mild symptoms characteristic of the first and second stages of adrenal fatigue continue to worsen and become persistent or chronic. As the condition gets worse, multiple endocrine axis imbalances tend to occur. This is commonly manifested in the form of ovarian-adrenal-thryoid (OAT) axis imbalance in females and adrenal-thyroid axis imbalance in the males. As the body continues its downward path of impaired function, it gathers steam. Gradually, the body becomes severely compromised in trying to maintain the fine controls of homeostasis. Normal equilibrium is therefore lost. The body enters a state of reactive disequilibrium.

In the later stages of adrenal fatigue, anxiety can be an overwhelming symptom

Your body will try its hardest to maintain equilibrium with the activation of the autonomic nervous system (ANS), but its crude response and damaged receptor sites along with impaired metabolic, clearance, and detoxification pathways give rise to paradoxical, unpredictable, and exaggerated outcome. Reactive sugar imbalances, fragile blood pressure, postural hypotension, heart palpitations, POTS, dizziness, anxiety reactions, being "wired and tired", periodic adrenaline rushes, fragile fluid state; such as hypersensitive dilutional hyponatremia, sudden onset of anxiety, and a sensation of impending doom are common. There is a strong mind-body connection. No system is spared as every thought process invokes a physiological response. Many of these symptoms represent what is known as a "reactive sympathoadrenal response". This response is the result of over-activation of two components of the ANS - the sympathetic nervous system (SNS) and the adrenomedullary hormonal system (AHS). Collectively, these two components constitute the sympathoadrenal system (SAS). When the SAS is over-activated due to stress, the body is bathed in a sea of adrenaline and norepinephrine. These two hormones are responsible for many of the above mentioned symptoms.

Finally, as the body's key hormones, such as cortisol, falls below the minimum required reserve for normal function and output fails, the body may down-regulate the amount needed in order to preserve what is on hand for only the most essential body functions. This near-failure state is quite serious and requires professional attention. This is a state of extreme low energy as the body tries to conserve to survive. Nutrients that are normally helpful may be blunted in their action and may backfire with paradoxical responses being the hallmark. Traditional macro-nutritional approaches may be helpful, but the clinical outcome overtime is often blunted and may fail if the body continues to decompensate. In such a case, a carefully titrated micro-nutitional program may be necessary to facilitate the restoration of equilibrium.

Stage 4: Failure

Eventually, the adrenals are totally exhausted.When adrenal fatigue has advanced to this stage, the line between it and sub-clinical and clinical Addison's disease, also called adrenal insufficiency, can be blurry.

Typical symptoms of Addison's Disease may start to emerge. Fatigue becomes extreme, with weight loss, muscle weakness, loss of appetite, nausea, vomiting, hypoglycemia, headache, sweating, irregular menstrual cycles, depression, orthostatic hypotension, dehydration, and electrolyte imbalances. The body appears to have lost its normal homeostasis and is breaking down. If not attended to, the natural progression of this condition may be fatal.

The Adrenal Fatigue progression chart detailing your the stages and effects of AFS

[Click to expand]


© 2011  Michael Lam, M.D. All Rights Reserved.

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