Introduction to Adrenal Fatigue

One of the most common health complaints amongst adults today is the experience of fatigue and lethargy. These complaints, when combined with other symptoms such as difficulty with concentration, insomnia, inability to lose weight after extensive effort, feeling anxious, having arthritis, allergies, and/or difficulties with memory, signals that Adrenal Fatigue Syndrome (AFS) may be at the root of the problem.

Adrenal Fatigue has a broad spectrum of non-specific, yet often debilitating symptoms. The onset of this condition is often slow and insidious. Patients are told that they are stressed and need to learn to relax more. Yes, we all know that "stress kills" to a large extent. But, the question is how?

The real truth is that stress and Adrenal Fatigue are not a mysterious entity at all. Our body has a built-in mechanism to deal with it. Being able to handle stress is a key to survival, and the control center in our bodies is the adrenal glands.

Adrenal Fatigue Syndrome is one of the most prevalent conditions, afflicting almost every adult in one way or another. Despite effective diagnostic tools and treatment programs, most conventional physicians were simply not informed of Adrenal Fatigue and not prepared to take Adrenal Fatigue as a serious threat to health.

This condition was seldom considered as a dysfunction sickness. Instead, Adrenal Fatigue Syndrome was considered a condition whereby the cause is thought to be associated with stress, and no remedy was available other than to tell the person to "relax" and take anti-depressants. Over time, the condition worsens as the natural progression of this pathology takes its course if not reversed. Adrenal Fatigue Syndrome is not a medical condition recognized by mainstream institutions, and for good reasons. Invariably, the adrenal glands are structurally normal. Low cortisol, the most common associated finding, may be caused by factors outside the adrenal glands.

Adrenal Fatigue Syndrome should not be confused with another medical condition called Addison's disease where the adrenal glands are not functioning according to conventional endocrinologists' standards. While Addison's disease is often caused by an auto-immune dysfunction, Adrenal Fatigue Syndrome is largely caused by stress or by a host of other factors, including dysregulation of the HPA Axis, nervous system problems, immune system problems, and metabolic-nutritional problems. It is a complex condition with complex clinical presentation, depending on the stage of dysfunction. Those in neuroscience may prefer to label this condition Hypothalamic-Pituitary-Adrenal (HPA) Axis Dysregulation because of its strong association with dysfunction of the HPA axis. Forward looking endocrinologist may be more comfortable with calling this condition Non-Adrenal Illness Affecting Adrenal Function because of the associated low cortisol output which does not meet the diagnostic criteria for Adrenal Insufficiency.

Conventional medicine only recognizes Addison's disease as hypoadrenia. As such, do not be surprised if your doctor is unfamiliar with this condition. To put it simply, Adrenal Fatigue Syndrome is the non-Addison's form of adrenal dysfunction sub-clinically. Because many causes may be involved, Adrenal Fatigue Syndrome is technically a more accurate nomenclature than Adrenal Fatigue. The addition of "syndrome" implies no definitive cause. It would be up to the physician to determine the list of symptoms and signs appropriate to the syndrome.

We will be using the terms Adrenal Fatigue Syndrome and Adrenal Fatigue interchangeably because Adrenal Fatigue is the most commonly used terminology recognized and used by the public.

Signs and Symptoms of Adrenal Fatigue:

Other signs and symptoms include:

If you have many of these signs and symptoms, and you have ruled out other organic pathologies, it is time to consider Adrenal Fatigue as a possible cause. None of the signs or symptoms by themselves can definitively pinpoint Adrenal Fatigue. When taken as a group, these signs and symptoms do form a specific Adrenal Fatigue syndrome or picture of a person under stress. These signs and symptoms are often the end result of acute, severe, chronic, or excessive stress and the inability of the body to reduce such stress. Stress, once a "basket" term used by physicians to explain non-specific symptoms, undetectable by conventional blood tests, is not a mystery to the body at all.

The ability to handle stress, physical or emotional, is a cornerstone to human survival. Our body has a complete set of stress modulation systems in place, and the control center is the adrenal glands. When these glands become dysfunctional, our body's ability to handle stress is reduced.

Adrenal Gland Basics

The adrenal glands are two small glands, each about the size of a large grape. They are situated on top of the kidneys. Their purpose is to help the body cope with stress and help it to survive. Each adrenal gland has two compartments. The inner or medulla compartment modulates the sympathetic nervous system through secretion and regulation of two hormones, called epinephrine and norepinephrine, which are responsible for the fight or flight response. The outer adrenal cortex comprises 80 percent of the adrenal gland and is responsible for producing over 50 different types of hormones in three major classes - glucocorticoids, mineralcorticoids and androgens.

The most important glucocorticoid is cortisol. When this is lowered, the body will be unable to deal with stress. This happens in Adrenal Fatigue.

Mineralcorticoids, such as aldosterone, modulate the delicate balance of minerals in the cell, especially sodium and potassium. It therefore regulates our blood pressure and the fluid in the body. Stress increases the release of aldosterone, causing sodium retention (leading to water retention and high blood pressure) and the loss of potassium and magnesium in the early stages of Adrenal Fatigue. Magnesium is involved in over 300 enzymatic reactions in the body. When the body lacks magnesium, it will suffer from a variety of pathological conditions such as cardiac arrhythmias.

The adrenal cortex is also responsible for producing all of the sex hormones, although in small amounts. One exception is DHEA, a weak androgenic hormone that is made in large amounts in both sexes. DHEA, together with testosterone and estrogen, are made from pregnenolone.

Pregnenolone also leads to the production of progesterone and is one of the intermediary steps in the making of cortisol. Pregnenolone is therefore one of the most important intermediate hormones being produced in the hormonal cascade. Prolonged deficiencies in pregnenolone, which are found in Adrenal Fatigue, will lead to the reduction of both glucocorticosteroids and mineralcorticoids such as cortisol and aldosterone respectively.

Cortisol (The Hormone of Death)

The most important anti-stress hormone in the body is cortisol. Cortisol protects the body from excessive Adrenal Fatigue by:

In summary, cortisol sustains life via two opposite, but related, kinds of regulatory actions: releasing and activating the existing defense mechanisms of the body, while shutting down and modifying the same mechanisms to prevent them.

Cortisol Regulation

The adrenal glands are controlled via the hypothalamus-pituitary-adrenal (HPA) axis. There is an existing negative feedback loop that governs the amount of adrenal hormones secreted under normal circumstances in people with Adrenal Fatigue. For example, the HPA axis adjusts cortisol levels according to the body's need via a hormone called Adrenal Corticotrophic Hormone (ACTH) that is secreted from the pituitary gland in response to signals from the hypothalamus. When the ACTH binds to the walls of the adrenal cells, a chain reaction occurs within the cell. This leads to the release of cholesterol where it is manufactured into pregnenolone, the first hormone in the adrenal cascade. After this, cortisol is released into the blood stream where it travels in the circulatory system to all parts of the body and back to the hypothalamus.

Cortisol and ACTH are not secreted uniformly throughout the day. They follow a diurnal pattern, with the highest level secreted at around 8:00 a.m. in the morning after which there is a gradual decline throughout the day. Episodic spikes during the day can also occur when the body is stressed or when certain foods are taken. The cortisol level is at its lowest between midnight and 4:00 a.m.

Common Causes of Adrenal Fatigue

Chronic stress is very common in western society. The most common causes of stress are work pressure, changing jobs, death of a loved one, moving homes, illness, and marital disruption. Adrenal Fatigue occurs when the amount of stress overextends the capacity of the body to compensate and recover.

Stressors that can lead to Adrenal Fatigue include:

One of the most commonly overlooked causes of Adrenal Fatigue is chronic or severe infection that gives rise to an inflammatory response. Such infection can occur sub-clinically with no obvious signs at all. Parasitic and bacterial infections including Giardia and H. pylori are often the main causes.

How Stressors Affect the Body

When a person is stressed, the body reacts by mounting a stress response through the stimulation of the sympathetic nervous system. This is also called the "fight or flight" response as the body arms itself to face what it perceives as a danger. When this happens, epinephrine is secreted from the adrenal medulla, and the hypothalamus-pituitary axis is stimulated to release ACTH, which in turn causes the adrenal cortex to increase production of the anti-stress hormone cortisol.

When a person experiences chronic stress, the cortisol level may rise to such a high level that it's production reduces as the adrenal becomes exhausted. At the same time, DHEA, a hormone normally produced in the adrenal glands, will start to decrease from stress without hitting a peak first (as in the case of cortisol). With chronic stress, there is decompensation of DHEA with a concurrent rise of cortisol. As a result, the ratio of cortisol to DHEA increases.

As with most hormonal systems, there is a negative feedback system in the body to limit the production of each hormone. The same occurs in the case of cortisol, with one exception. During prolonged or acute stress, when the body perceives that its survival is at stake, the excessive cortisol output actually blunts the negative feedback response. In other words, instead of a negative feedback system to shut down cortisol production when the total cortisol is high, the body reacts in the opposite way. As cortisol is the anti-stress hormone, the body will interpret a very high cortisol level and impending danger. When this happens, the high cortisol level exerts a dampening effect on the negative feedback system instead, saying that we can survive this threat. More cortisol will therefore be produced. This is the body's way of coping with the ongoing stress.

When our body is stressed, our cortisol level rises in an environment where the negative feedback system is dampened. While this is happening, our DHEA level continues to drop. The result is a high cortisol to DHEA ratio and:

Stress Response from a Hormonal Perspective

At work, what happens if your boss screams at you? Let us now examine some of the effects within our body from a hormonal perspective:

When the above physiological response occurs over a long duration, or in certain cases when there is acute stress, then Adrenal Fatigue is the result as the adrenal glands become worn out.

Adrenal Fatigue Progression

Adrenal weakness typically progresses through stages as the body de-compensates. It is the body's strategy to return to a state of simplicity from a life that is too complex for the body to handle. Let us take a closer look.

Stage 1: Alarm Reaction

In this stage, the body is alarmed by the stressors and mounts an aggressive anti-stress response to reduce stress levels. Some doctors call 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 usually, but not always, 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 No symptoms are reported at this stage. There may be a sense of being tired. Daily activities continue unaffected.

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 are also frequent awakenings as well. Infections can become recurrent, and PMS and menstrual irregularities surface, symptoms suggestive of hypothyroidism (such as a sensation of feeling cold along with a 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.

There is occasional mild fatigue. A nap or some time off work usually can help the recovery process greatly.

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 (Phase A). As the condition gets worse, multiple endocrine axis imbalances tend to occur (Phase B). This is commonly manifested in the form of ovarian-adrenal-thyroid (OAT) axis imbalance in females and adrenal-thyroid axis imbalance in males. The body is in a constant state of mild to moderate fatigue in phase A and B.

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 (Phase C). Severe fatigue is the norm for those with Phase C.

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, fall 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 (Phase D) is quite serious and requires professional attention. This is a state of extreme low energy as the body tries to conserve to survive. Normally helpful nutrients may be blunted in their action and may backfire with paradoxical responses being the hallmark. Those in Phase D are usually bed-ridden most of the time. Ambulatory help for normal daily chores is required. Traditional macro-nutritional approaches may be helpful, but clinical outcome over time is often blunted and may fail if the body continues to de-compensate. In such a case, a carefully titrated micro-nutritional 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 following diagram shows how typically Adrenal Fatigue progresses with time through the stages. This is not to be used for diagnosis purposes because Adrenal Fatigue is not a recognized medical condition by mainstream institutions. This diagram merely helps to paint a broad picture of what is commonly seen clinically based on a typical history. Each person's progression varies tremendously and is dependent on a wide variety of factors.

Why Conventional Medicine Missed Adrenal Fatigue

Despite sub-clinical adrenia, with its various stages, recognized as a distinct clinical syndrome since the turn of the 20th century, most doctors are unfamiliar with this condition for the simple reason that it is difficult to diagnose effectively by traditional blood tests. Normal blood tests are designed to detect severe, absolute deficiencies of adrenal hormones known as Addison's disease. This disease afflicts only 4 out of 100,000 and is often the result of an autoimmune disease or infectious origin. Blood tests are also useful to detect extreme, excessive levels of adrenal hormones, a condition known as Cushing's disease.

Let's examine this in more detail. The conventional test used is called, the ACTH (adrenocorticotropic hormone) challenge test. This test recognizes extreme underproduction or overproduction of hormone levels, as shown by the top and bottom 2 percent of a bell curve. In other words, adrenal function has to be extremely low (the bottom 2 percent) before a diagnosis is made.

Symptoms of non-Addison adrenal malfunction, meanwhile, can start to present itself symptomatically after a 15 percent deviation from the mean on the bell curve. Therefore, the adrenal glands could be functioning anywhere from 15 to 48 percent below the norm and not be detected by the ACTH test.

To sum it up, adrenal hormones are low in the case of Adrenal Fatigue, but still within the "normal" range and not low enough to warrant the diagnosis of Addison's disease by regular blood tests. Such "normal" levels of adrenal hormones do not mean that the patient is free from adrenal malfunction. Conventional doctors are not taught the significance of sub-clinical Addison's disease, or Non-Addison's Hypoadrenia (commonly referred to as Adrenal Fatigue). They are misguided by the blood tests. As a result, patients tested for adrenal functions are told they are "normal" but in reality, their adrenal glands are performing sub-optimally, with clear signs and symptoms as the body cries out for help and attention.

Laboratory Tests

There are many routine laboratory tests for fatigue. Unfortunately, they are not diagnostic. Normal values do not necessarily mean the body is free of illness. Similarly, abnormal values are not necessarily diagnostic. Numerous advanced functional tests are additionally available. They also pose similar problems with regards to accuracy, and can often be misleading if not properly correlated with the overall clinical picture.

Adrenal Fatigue can be screened easily and demonstrated in laboratory studies of surrogate markers of adrenal function. Two such markers used are cortisol and DHEA by serum. These two markers by blood give a general picture of the body as to whether it is in anabolic (build up) or catabolic state (breakdown). It is not diagnostic. Another way to test your adrenal health is to measure your level of free key adrenal hormones such as cortisol and DHEA. Saliva but again, this is not diagnostic. Relying on a single snapshot to draw clinical conclusions can be misleading. Serial studies are needed for best correlation.

DHEA can be measured anytime during the day. Cortisol, on the other hand, is the highest in the morning and lowest in the evening before bedtime. Taking 4 samples of cortisol (at 8 am, noon, 5 pm, and before bedtime) is desirable if saliva test is undertaken. With multiple samples taken throughout the day, we are able to map the daily diurnal curve of free cortisol in the body relative to DHEA level. This will give us a much clearer picture of adrenal function.

Saliva cortisol level also needs to be interpreted properly. Morning free cortisol level is indicative of peak cortisol output. Lunch cortisol level points more towards cortisol adaptability. Mid-afternoon cortisol is highly associated with metabolic issues such as blood sugar imbalances. Evening cortisol level refers to baseline adrenal cortisol function. Without matching the different cortisol values with the body's symptoms throughout the day, saliva test is of limited value and can in fact be misleading.

If you are taking oral or applying topical supplemental hormone creams such as DHEA or pregnenolone, the saliva test results may be elevated immediately. Blood test results will also increase, but this will take about 3 months to show.

Stress can also affect the levels of adrenal hormones. Your cortisol level tested after a quiet and relaxing morning will be very different from that taken when you are under tremendous stress.

To rule out sub-clinical infection as a cause of Adrenal Fatigue, specialized test measuring the immunoglobulin response may be necessary as normal culture for bacteria and parasites will often be negative.

WARNING: Due to tremendous individual variance and the body's constant changing state, laboratory tests should be undertaken judiciously under the right setting and only when needed in order to be cost-effective and relevant. It is not uncommon to have Adrenal Fatigue symptoms with "normal" laboratory results, and vice versa. Furthermore, in advance Adrenal Fatigue, the 24 hour saliva cortisol curve invariably becomes flattened most of the time and can stay that way for an extended period of time, even during recovery. Sometimes there is a delay response, resulting in testing results that may be confusing. Therefore, one can be easily confused as test results can be misleading. Over-reliance on tests is a common adrenal fatigue treatment mistake.

A good history by an astute and experienced clinician is by far the best and most accurate way to ascertain Adrenal Fatigue status and is far better than any laboratory testing.

Laboratory tests are best used as supporting tools under the guidance of the right health professional and should not be relied on as a sole gauge of adrenal function and therapeutic options. The best use of saliva testing is serial studies performed regularly overtime for comparative purposes. Relying on a single snapshot of the hormonal picture at one time to determine your adrenal fatigue treatment strategy is a common mistake. Consumers often make the mistake of embarking on a self-guided nutritional recovery program that relies on laboratory test without understanding their limitations. Over time, this approach often leads to improper use of nutrients which makes the condition worse.

Paradoxical Reactions

In Adrenal Fatigue, the body can often exhibit multiple paradoxical reactions that one does not normally expect. These include:

One can have any combination of the above. The exact pathophysiology of each of these symptoms is not fully known. The more advanced the Adrenal Fatigue, the more prevalent these are. Collectively, they point to an adrenal that has lost its ability to maintain the fine control necessary of a stable internal homeostasis environment along with low clearance of metabolites. Self-directed adrenal fatigue treatment programs normally fail in such cases because normal healing tools do not apply. It is best to consult a professional for help if you have a significant number of these paradoxical reactions.

Paradoxical reactions can be the result of various concurrent conditions that mimic Adrenal Fatigue or exacerbated disruption of internal body function with collateral damage to the adrenal glands. They include:

Women and Adrenals

Ovarian Adrenal Thyroid (OAT) Axis Imbalance. There are very strong interlinked relationships between the ovarian, adrenal, and thyroid systems in the women. These three organs are intimately co-dependent on each other for optimal function. This axis, also called the Ovarian Adrenal and Thyroid axis (OAT), must be balanced if a woman wants to feel good. When medication alters one of the organ's functions, it will invariably lead to an often unrecognized change in the other two organs. For example, if thyroid medication is administered, it is not uncommon to see concurrent menstrual irregularities, a function of ovarian hormones, and reduced ability to deal with stress, a function of the adrenals.

Let us look more closely at the reason. In Adrenal Fatigue, internal cortisol often creates a condition of multiple organ resistance, including the thyroid and ovaries. Thyroid tissues fail to respond as efficiently to the hormonal signal. Adrenal Fatigue is often accompanied by clinical or sub-clinical hypothyroidism. Laboratory values can be normal but classical signs of hypothyroidism may be present. Physicians and patients alike are often confused. Anti-depressants are often prescribed as a solution. However, this seldom works but will instead often make the condition worse.

A cortisol induced organ resistance applies to nearly all other hormone regulated organs including the ovaries and the pancreas. Few hormones are allowed to work at optimal levels in the presence of Adrenal Fatigue. A multitude of hormones including insulin, progesterone, estrogen, and testosterone become affected. The normal negative feedback loop in place can be disrupted. The ability of each hormone to regulate and fine tune its target organ to achieve homeostasis is often compromised. Blood pressure can becomes erratic, blood sugar levels may experience wide swings, bipolar and anxiety states come at will, and menstrual flow can become irregular. Even the brain may become less sensitive to estrogen.

Let us look more closely at how the ovarian system is affected in particular. Today, women often have exhausted adrenal glands by the time they reach their mid-thirties or early forties due to a stressful lifestyle. Stress is primarily regulated by our adrenal glands. In early stages of Adrenal Fatigue, cortisol output is high as the body attempts to neutralize the stress by producing more of it. However, when too much cortisol is produced, it will have multiple undesirable effects. For example, cortisol blocks progesterone receptors, making them less responsive to progesterone. Progesterone normally produced by the adrenals comes to a halt in favor of cortisol. Insufficient progesterone production leads to an imbalance of estrogen to progesterone. With reduced progesterone to offset estrogen, the body may experience a host of undesirable side effects associated with excessive estrogen. This leads to a condition known as estrogen dominance. It is no coincidence that we see a proliferation of conditions associated with excessive estrogen such as PMS, fibroids, and pre-menopausal syndrome when women reach their mid thirties and early forties.

It is interesting to note that most post- menopausal women who are experiencing hair loss have an adrenal function problem. Hair loss is a sign of excessive androgen. Some women tend to produce too much androstenedione, which then gets converted into estrone and testosterone. Testosterone in turn is converted into DHT, the more potent form of testostorone largely responsible for excessive hair loss. Estriol can be given to offset the testosterone effects as estrogen balances testosterone in the body. Cortisol can be considered when closely supervised and used for a short period of time. It keeps the adrenal glands from getting stuck in the androgen part of the stress cycle if indeed it is in that state. Cortisol also complements the use of progesterone as well. The effective cocktail therefore consists of estriol, cortisol and progesterone. Each of these hormones, especially cortisol, has their own side-effects. Knowing what to use and when to use is critical, or hair loss could worsen.

Any serious attempt to normalize this axis should consider adrenal fatigue treatment as the first step. Adrenal normalization should precede hormone modulation. The adrenal glands deal with the daily stresses of life. A woman must normalize her adrenal glands in order to have a total body hormonal balance. In fact, replacement of deficient hormones alone without addressing the overall health of the adrenal gland is a band-aid approach and is often ineffective in the long run. The normalization process can begin with investigating and eliminating stressors. Stressors are often chronic in nature, and can be related to lifestyle, dietary, mental, and inflammatory causes. Women with heavy menstrual bleeding and adrenal exhaustion can normalize their adrenal functions with natural compounds to boost internal cortisol production, adequate sleep, proper diet, and nutritional supplementation before considering progesterone therapy. Exogenous cortisol replacement should only be considered as a last resort due to its long term negative effects.

Often times, the use of anti-depressants, thyroid replacements, and ovarian hormones often make women with OAT axis imbalance worse. Estrogen replacement often becomes ineffective, and symptoms of estrogen dominance like hot flashes, weight gain at the hips, water retention, and moodiness are commonly observed despite normal estrogen levels. Patients become frustrated as it seems that nothing can help when a downward spiral of multiple symptoms commonly surface: depression, insomnia, fatigue, metabolic and hormonal imbalances. Failing conventional therapy, many turn to natural compounds. It is not unusual to see many people take a full battery of these nutrients. For example, Vitamin C, DHEA, pregnenolone, natural progesterone, and natural thyroid replacement, just to name a few. In the beginning, this might be helpful. Unfortunately, a shot-gun approach by taking many nutrients seldom works and often backfires with time. The higher the dose the worse the patient can become. That is why chronic stress and Adrenal Fatigue can make one feel so rotten, like a slow-motion train wreck in progress. In severe cases, the patient often feels like the "walking dead" caught in a vicious downward cycle of deteriorating physical and emotional functions.

Adrenal Fatigue Treatment

Adrenal Fatigue can be reversed. You may need to allow 6 months to 2 years for the recovery process to take place. These are some of the important steps:

From our Readers:

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Nutritional Supplementation

In an adrenal fatigue treatment program, it is prudent to consider optimizing the adrenal gland functions gently when they are indicated along with lifestyle and dietary changes.

An optimal balance of vitamins and minerals for optimum adrenal function can include:

It should be noted that while many practitioners use synthetic or bio-identical hormones (estrogen, progesterone, and testosterone) to modulate symptoms of fatigue and hormonal imbalance, this approach should be taken with care as it may mask the underlying root cause and worsen the overall condition over time.

The complete toolbox of natural compounds for adrenal recovery is therefore very big. Each tool serves a specific purpose. A systematic and comprehensive approach is necessary to avoid over stimulating or inadequate dosing. Proper timing is critical because each should be given only when the body is ready to assimilate, process and excrete. Knowing when and how much of each compound to use and to avoid requires extensive clinical experience if a fast-track recovery is the goal and minimization of mistakes a top priority.

Improper selection, dosage and timing of nutritional supplementation is the number one cause of adrenal fatigue treatment failure. Unless Adrenal Fatigue is in its mildest form, selecting the right compound, dosage, delivery system to match the stage of Adrenal Fatigue is best left to the experienced clinician.


It is very important to understand that a shot-gun approach by taking many nutrients at the same time seldom works and often backfires over time. The use of nutritional supplementation in overcoming Adrenal Fatigue needs to be individualized, base on each person's history, background, and body metabolic and clearance system. One person's nutrient may be another person's toxin. Each nutrient is like one bullet in the arsenal. Using the right bullet at the right time is critical. Misguided by marketing and often misinformed, many sufferers make the mistake of take a whole battery of nutrients without careful consideration and that approach seldom works long term in the case of Adrenal Fatigue. The more advance the condition, the more dangerous this approach. Even if some nutrients appear to work well at first, they may subsequently fail as the body developed tolerance and resistance. More is not necessarily better and may actually worsen the condition because improper administration may mask the underlying condition, creating a sense of temporary which eventually fails. Most only need a few natural compounds to get significantly better. The key is selecting the right ones.

In Adrenal Fatigue, the body's ability to process and assimilate nutrient is invariably compromised. Proper clearance of metabolites is a major concern. The more advanced the fatigue, the less the body is able to properly clear breakdown metabolites out of the body after nutrients have served their function. This is called the low clearance state. Without proper clearance, the best nutrient can accumulate in the body and become toxic. There is no laboratory test available to measure this. Experienced clinicians use various qualitative challenges to determine the amount of reserve capacity and clearance the adrenal has as a guide before initiating any comprehensive nutritional program. Failure to do so is a common mistake and a major reason why many self-guided program fails. Nutrients in the right dose should be administrated in a graded and step-wise approach, with follow up evaluation by a qualified health care professional.


Glucose is a simple sugar found in food. It is an essential nutrient that provides energy for the proper functioning of the body's cells. After meals, food is digested in the stomach and is broken down into glucose and other nutrients. The glucose is absorbed by the intestinal cells and carried by the bloodstream to cells throughout the body. However, glucose cannot enter the cells alone. It needs assistance from insulin in order to penetrate the cell walls. Insulin therefore acts as a regulator of glucose transport and metabolism in the body.

Insulin is called the "hunger hormone." As the blood sugar level increases after a meal, the corresponding insulin level rises with the eventual lowering of the blood sugar level and glucose is transported from the blood into the cell for energy. As energy is produced by the cell, the blood glucose level is slowly lowered; the insulin released from the pancreas is turned off. As energy continues to be generated, the blood sugar level continues to drop. When it drops below a certain level, hunger is felt. This often occurs a few hours after a meal. This drop in blood sugar triggers the adrenals to make more cortisol. The cortisol increases the blood sugar by converting protein and fat into its component parts. With this, the blood sugar rises to provide a continuous supply of energy for our use between meals. Cortisol therefore works hand in hand with insulin to provide a steady blood sugar level twenty-four hours a day and keeps blood glucose levels in a tightly controlled range.

When the adrenal gland is in a state, the amount of cortisol production drops below the normal level, and the amount of sugar available to the cells is reduced. With less sugar, less energy is available to the body, and fatigue is experienced. As the sugar level drops below a critical point, dizziness and lightheadedness can be experienced. These are common symptoms of low blood sugar (also called hypoglycemia). Low blood sugar is most likely experienced between meals at 10 12 p.m., as well as 3 p.m. to 4 p.m.

To make matters worse, the body's automatic response when more sugar is needed during a stress response is to make more insulin in an attempt to move the sugar into the cell from the blood stream to create more energy. Insulin opens up the cell membrane to push the glucose in, resulting in further reduction in blood glucose. This worsens the already existing hypoglycemic state.

Those with Adrenal Fatigue often report symptoms such as dizziness and weakness, as the blood sugar level drops below a comfortable level for the body to function normally. To overcome this, the quick fix solution is to take food that is high in refined sugar such as a donut or sweets, or drinks such as coffee or cola's that are stimulatory. This causes the adrenal to put out more cortisol and gives the person a boost of energy. However, this hypoglycemic symptom relief only lasts for about one to two hours. Inevitably, it is followed by a crash to an even lower blood level. Those suffering from Adrenal Fatigue are constantly on a roller coaster ride in terms of their blood sugar level throughout the day. The sugar level tends to increase after each quick fix, but drops after a few hours. By the end of the day, the body is totally exhausted.

A diet that maintains a constant sugar level in the blood is a critical consideration in Adrenal Fatigue treatment. This can be done by taking a variety of low-glycemic index food that releases sugar slowly to sustain the body during and between meals. Starchy carbohydrates that are converted quickly into glucose (such as pasta and bread) should be limited. Soda drinks should be totally avoided.


The amount of salt in the body is highly dependent and regulated by a chemical called aldosterone. This chemical is manufactured in the adrenal cortex under the direction of another hormone called ACTH (adrenocorticotrophic hormone). ACTH is produced by the anterior pituitary gland. ACTH stimulates the adrenal cortex to secrete a wide variety of hormones including aldosterone as well as cortisol. Like cortisol, aldosterone follows a diurnal pattern of secretion, peaking at 8 a.m., and its at its lowest between 12 a.m. to 4 a.m. Aldosterone is a very specific compound that is responsible for maintaining the concentration of sodium and potassium inside and outside the cell. This in turn has a direct effect on the amount of fluid in the body. Aldosterone therefore plays a significant role in regulation of blood pressure.

It is important to note that in our body, sodium and water goes hand in hand. Where sodium goes, water follows. As the concentration of aldosterone rises in the body, the concentration of sodium and water rises, more fluid is retained in the body, and blood pressure rises. Conversely, when the level of aldosterone lowers, the amount of sodium and water in the body is reduced. The blood pressure goes down.

Unlike cortisol, aldosterone does not have its own negative feedback loop during excessive levels. If the aldosterone level is too high, aldosterone receptor sites will be down regulated and its sensitivity to aldosterone reduced. In the early phases of Adrenal Fatigue, the amount of cortisol and aldosterone increases in our body due to the ACTH stimulatory effect from stress. As a result, sodium and water is retained in the body resulting in a bloated feeling. The baroreceptors (receptors that are sensitive to pressure) of the blood vessels are triggered and blood vessels go into a relaxation mode automatically and this is regulated by the autonomic nervous system. This auto-regulation helps to maintain a stable blood pressure at a time when the total fluid volume increases due to high levels of aldosterone triggered by stress. With stress, the adrenal glands also secrete another hormone called epinephrine. This hormone constricts the blood vessels and increases blood pressure in order to ensure that our brains have adequate blood flow and oxygen to help us deal with impending danger. The sum reaction of aldosterone, epinephrine, and the autonomic relaxation response are some of the key factors that ultimately decide the final blood pressure at any point in time. During the early stages of Adrenal Fatigue, the resulting blood pressure is often normal if all bodily functions are well balanced. If the body is unable to overcome the aldosterone and epinephrine response, then the blood pressure is elevated. It is common to find people under stress experience an increase in blood pressure.

As Adrenal Fatigue progresses to more advanced stages, the amount of aldosterone production reduces. Sodium and water retention is compromised. As the fluid volume is reduced, low blood pressure ensues. Cells become dehydrated and sodium deficient. Hydration of a person in Adrenal Fatigue should take about twenty-four to forty-eight hours or more. Fluid with adequate electrolytes should be administered two to four times a day in intermittent dosages. Coffee, alcohol, and tea (with the exception of herbal tea) should be avoided.

Most with advanced Adrenal Fatigue report low blood pressure as well as a salt craving. The low blood pressure is due to the reduced fluid in the body. Salt craving is due to an absolute deficiency of sodium in the body. Both are due to the lack of aldosterone. In order to compensate for this, potassium is leaked out of the cells so that the sodium to potassium ratio remains constant. The loss of potassium is less than that of sodium, and as a result, the potassium to sodium ratio is increased. This imbalance causes another set of problems.

Those suffering from Adrenal Fatigue often have a low body fluid volume accompanied by a salt craving due to absolute deficiency in sodium as well as a normal to high potassium level. While lost fluids should be replaced, it has to be done carefully and slowly. When the fluid is replaced too quickly without adequate sodium, the amount of sodium in the body may be diluted, resulting in an even lower sodium level. This is called dilutional hyponatremia. Symptoms of low sodium include non-specific symptoms of confusion, lethargy, nausea, headache, seizure, weakness, and restlessness. Adrenal Fatigue along with low sodium leads to a clinical picture that is very challenging to all but the most experienced clinician.

Those in this state may find themselves visiting the Emergency Room for many of these disturbing symptoms only to be told that all is normal after extensive workup. Electrolytes may actually be within normal range still symptoms persist among those who are severely decompensated and in a highly sensitive state consistent with advanced adrenal fatigue. Some may need diuretics to reduce fluid load while sodium load is being replaced. Symptoms may take some time to resolve.

Sufferers of advanced Adrenal Fatigue usually have a low cortisol and sodium level. They should take filtered drinking water with half to one teaspoon of salt on a regular basis, especially in the morning upon awakening. If blood pressure increases, or signs of edema occur and nausea develops, stop the salt and report to a qualified health practitioner.

Only a small number of people with Adrenal Fatigue have concurrent high blood pressure. Those that fall into this category should check their blood pressure carefully during fluid replacement.

Sea salt is better than table salt in that it contains additional trace minerals as well. A good fluid cocktail for Adrenal Fatigue suffers is vegetable juice diluted with water and sprinkled with sea salt and kelp powder. Kelp contains about 90 mg of potassium and over 200 mg of sodium per serving and is easily absorbed.

Carbohydrate, Protein and Fats

It is important for Adrenal Fatigue patients to balance the amount of protein and fat, as well as carbohydrates. As compared to a normal person, the Adrenal Fatigue person has an immediate need for sugar when hunger strikes. At the same time, they also need good protein as well as good fat to have sustained energy until the next meal comes.

The primary diet should be high in raw food that is low in glycemic index. Fruit juices should be avoided. Whole fruits should be limited, especially melons, which are high in sugar and cause sugar spikes soon after food enters the body. Good quality protein from meat, fish, and eggs are recommended. These provide a steady source of energy to carry the body through between meals.

Vegetarians who have Adrenal Fatigue have a much bigger challenge. Legumes (beans) must be eaten with whole grains, seeds, or nuts to make a complete protein. It is important for vegetarians to add eggs and miso, as well as combining beans, seeds, and nuts with a small amount of whole grains. About fifty to sixty percent of the diet should consist of raw food. While six to eight servings of a wide variety of vegetables should be included.

Seeds and nuts are critical elements and sources of fatty acids that the adrenal glands need in order to manufacture cholesterol, a precursor to all adrenal steroid hormones. The key is to take nuts and seeds that are raw and free of rancid oils. Rancid oils make symptoms of Adrenal Fatigue worse and should be avoided at all cost. Raw nuts should be taken on a liberal basis and should be soaked overnight in water. Nuts such as cashews, almonds, Brazils, pecans, walnuts, and chestnuts are excellent. Peanuts should be avoided. Olive oil should be used for light cooking. The cooking heat should be low to moderate. Use coconut oil for any high heat or deep-frying.

Vegetables high in sodium include kelp, black olives, red hot peppers, spinach, zucchini, celery, and Swiss chard. Fruits should only be taken in moderation. If you feel worse after food consumption, that is the body's way of telling you that you are on the wrong track. Organic fruits such as papayas, mangos, apples, grapes, and cherries are recommended. Bananas, dates, figs, raisins, and grapefruits are high in potassium and should be limited.

Many people with Adrenal Fatigue also have a lower level of hydrochloric acid (HCl), which is necessary to break down the protein. Symptoms of this problem include gas, bloating, and heaviness in the stomach after eating a meal containing protein. In such case, the use of digestive enzymes, probiotics, as well as HCl replacement is indicated.

It is especially important to avoid wheat. Wheat has been selectively bred to increase larger quantities of protein, a lectin called “wheat germ agglutinin” and glycoprotein. This lectin protein is what is largely responsible for many illnesses and allergies. This wheat germ agglutinin glycoprotein can do direct damage to the majority of tissues in your body, promote inflammation, pass through the blood-brain barrier, interfere with digestive/absorptive activities, shift the balance in bacteria flora, and may disrupt endocrine function. Lectins are extremely small and resistant to a breakdown; even sprouting does not negate some of the harmful anti-nutrient effects. Those with Adrenal Fatigue usually have a dysfunctional food assimilation pattern, with slowed absorption being the norm. Adding wheat to the diet may lead to additional load for the already weak body to process. This can slow down adrenal fatigue treatment or in advanced cases, trigger adrenal crashes.

Dietary Tips:

Sample Dietary Plan of 2000 calories a day:

Adrenal Fatigue DIET
by Michael Lam, MD, MPH, ABAAM, CNC and Dorine Lam, RD, MPH, ABAAHP
1) Eat before 10:00 a.m.
2) Eat frequent, small meals: breakfast 6-8 a.m., lunch 12 noon, snacks- 10a.m., 3p.m. and bedtime
3) Eat 30-40% whole grains, 30-40% vegetables (50% should be raw), 10-15% beans, seeds and nuts, 10-20% animal foods, 5-10% fruit
Banana, dried figs, raisins, dates, oranges, grapefruit High in potassium - makes Adrenal Fatigue worse
Fruit and juice in the morning High in potassium and fructose
Refined flour products: pasta, white rice, bread, pastry, baked goods Drops blood sugar fast, robbed of nutrients
Honey, sugar, syrups, soft drinks Drops blood sugar too fast within one hour
Dried fruit, fruit juice Most detrimental food early in the day - drops blood sugar too fast
Coffee, tea, black tea, hot chocolate, alcohol, colas, chocolates Drops blood sugar too fast within one hour
Avoid foods you are addicted to or allergic or sensitive to These foods cause more stress on your body
Avoid fruit for breakfast Raise and drop blood sugar fast
Avoid rushed and hectic meals Creates more stress for your body.
Avoid deep-frying and browning; hydrogenated oils Transfat
Most Beneficial
Eat before 10 a.m. Replenishes waning glycogen supply
Eat frequent small meals Coast through low energy periods
Bedtime snack (use soaked raw nuts) Helps to have more peaceful sleep
Combine fat, protein and whole grains at every meal and snack. Provides a steady source of energy over a longer period of time
Mix 1-2 Tbs. essential oils into grains, vegetables, and meats daily
Good quality protein (meat, fish, fowl, eggs, dairy and legumes) Provides good protein and fats
Take digestive enzymes and HCL with meals Helps to properly break down protein and high fiber foods in the stomach
Eat 6-8 servings of a wide variety of brightly colored vegetables You will not gain weight; provides vitamins, minerals, phytochemicals, antioxidants which are crucial for optimal health.
Sprouts High quality concentrated nutrients
Sea vegetables Rich in trace minerals, good quality vegetable protein, easily digested.
Monounsaturated fats Used for low heat cooking; put a little water in the pan before the oil to keep the oil from getting too hot
Fresh and Raw nuts and seeds (soaked in water) - store in freezer Good source of essential fatty acids
Acceptable - Take in Moderation
Whole unrefined grains Provides sustained energy and nutrients
Caution: Take it easy as a breakfast food. Some people may need to avoid for breakfast.
Limited intake of fruits: Papaya, mango, plum, pear, kiwi, apple, a few grapes and cherries
Polyunsaturated fats (corn, safflower, sunflower, peanut oil) Never cook with these oils, add after the food is cooked. Provides essential fatty acids

Tips for a Healthy Adrenal Gland

Adrenal Fatigue Recovery

Most Adrenal Fatigue is mild, lasting a few days or weeks, with full recovery. A minority of people will find recovery a challenge. Their conditions last longer than usual. They improve, but never fully recover. Still, a smaller number slowly decompensate and the condition worsens with time.

Normal Adrenal Fatigue treatment usually takes only a few weeks or months. The normal recovery curve when plotted graphically should resemble a series of stair-steps going up, with a pause between each step. Those failing to recover usually have their recovery curve looking like a series of stair-steps going down, or series of waterfalls, with a lower low after each crash.

Frequent onset of Adrenal Fatigue symptoms with ever increasing severity and duration is often a hallmark of Adrenal Fatigue treatment failure. While the body has a built in system of self-repair, this mechanism is often not properly taken advantage of fully in the treatment process. There are multiple reasons for this failure. Here are a few common reasons why:


Adrenal Fatigue is a decrease in the adrenal glands ability to carry out its normal function. The chief symptoms are fatigue, excitability, or depression.

Adrenal Fatigue 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 stress. It is a condition that afflicts children as well as adults. It can be diagnosed by laboratory tests, if only the physician pays greater attention.

Adrenal glands can be restored to optimum health naturally by adhering to healthy living principals. Proper rest, specific nutrition, proper diet and stress reduction are key components to Adrenal Fatigue treatment.

The road to adrenal recovery is not a linear or straightforward path because of the complexity of our internal hormonal and stress-regulation system.

Most people who suffer from Adrenal Fatigue also have multiple endocrine imbalances including sub-clinical hypothyroidism, insulin resistance, and estrogen dominance. These need to be optimized as well. Adrenal fatigue treatment is a process akin to running a marathon. The process is long, but it can be done easily and painlessly, one step at a time. Most will find some improvement in a matter of weeks, depending on the degree of pre-existing damage and the clinical skills of the health professional. Because the amount of hormonal balancing is intricate and is highly sensitive, the process can take anywhere from three months to three years under the best of hands. It is a long marathon, and recovery should not be expected in a matter of weeks. Frustration and disappointment are common and normal. Patience is key. During the recovery process, most, if not all, will go through a roller coaster type ride with advances and setbacks.

The use of the correct amount of nutritional supplement can certainly speed up the recovery process, if done properly. It is critically important to note that while there are many nutrients that can help adrenal fatigue treatment, only a few are normally needed at any point in time. Nutrients, if not dosed properly, can become toxic and make the Adrenal Fatigue worse. A shot gun approach seldom works and can in fact backfire if the adrenal is not able to take in the nutrients at the right rate, time, and dose.

It is best to take it one step at a time under professional guidance to ensure the right step is taken at the proper time. This is especially true for advanced cases. Laboratory tests can be helpful, but are not critical in most cases. The key is a knowledgeable clinician who takes the time to understand your body with its signals and cries for help. A complete nutritional and lifestyle approach that helps the adrenal gland to normalize itself, along with ongoing adjustments in terms of nutritional supplementation to assist the adrenal during this recovery is the key.

Adrenal Fatigue Questions

Some women with AFS actually feel great during pregnancy due to progesterone's calming effect. Others are not so fortunte. They tend to crash and feel sluggish as pregnacy progresses. Worst of all are first trimester miscarriages that tend to be more prevelant with those who are in advanced stages of AFS prior to becoming pregnant.

If you have fatigue before your pregnancy, it could be AFS. And when you are pregnant, the first trimester maybe the time you feel more fatigue while you have no fatigue before your pregnancy.

DrLam's Adrenal Yoga Exercise is good to use, because it progress in intensity and endurance. It consists of 21 sessions that will challenge your fluidity, control, core, and balance.

There are many different kinds of breathing exercises. Deep breathing or holding your breath between inhale and exhale can help to keep the mind clear. My Adrenal Breathing Exercise helps to keep the body calm. If you have stage 1 or 2 AFS, it's good to practice both kinds of breathing.

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