Connecting Adrenal Fatigue and Low Thyroid Gland Function

By: Michael Lam, MD, MPH

Fatigue and thyroid gland function and AFSEven in the best of hands, many find thyroid replacement a challenging exercise that often ends with stagnant or worsening thyroid gland function and symptoms over time. When this happens, one needs to look outside the box. Various other conditions can present with symptoms very similar to low thyroid gland function or hypothyroidism. The most common of which is Adrenal Fatigue Syndrome (AFS).

Let us look at this in more detail.

Primary vs. Secondary Hypothyroidism

Hypothyroidism, or low thyroid gland function, can be primary, which means first in order of development, or secondary, which develops as a result of changing conditions in other parts of the body.

Primary hypothyroidism means that the thyroid cannot make the hormones T3 and T4 because of a problem with the gland itself. One of the most common causes is the destruction of the thyroid gland by the immune system. This condition is called Hashimoto’s thyroiditis and is by far the most common diagnosis given for people with low thyroid gland function. Treatment usually involves thyroid replacement therapy. Primary hypothyroidism can also be caused by surgical removal of the thyroid gland, which is then followed by inadequate thyroid replacement therapy. In primary hypothyroidism, TSH is usually high. However, if hypothyroid symptoms, such as low body temperature, fatigue, dry skin, and weight gain persist, despite thyroid replacement therapy and regardless of laboratory test results, we must look elsewhere for the cause of low thyroid gland function.

Secondary hypothyroidism is commonly thought to be linked with issues involving the pituitary gland, hypothalamus, and/or medications such as dopamine and lithium. In recent decades, we also include what is known as non-thyroid illness syndrome (NTIS). In this situation, patients have physical signs of hypothyroidism but do not have structural problems with the thyroid gland function, and the TSH is normal.

For example, in those suffering from anorexia nervosa (an eating disorder), low thyroid gland function has metabolic causes that do not fit the criteria for classic hypothyroidism as defined by endocrinologists. Treatment is usually directed toward the underlying cause, and steroid replacement is usually employed in addition to surgery, as needed.

Adrenal Fatigue Syndrome (AFS)

Adrenal Fatigue Syndrome is a common but frequently overlooked condition, closely associated with and possibly a cause of secondary clinical and subclinical hypothyroidism.

We can see the everyday consequences of Adrenal Fatigue Syndrome in the following statements:

  • I’m tired all the time – I manage to keep going on my job, but I drink coffee every few hours to get through the day.
  • I used to merely gripe and complain about feeling tired, but now the fatigue is so overwhelming and debilitating, I’m underperforming on my job.
  • I’m anxious and fearful much of the time.
  • I seem to catch every cold or flu that comes around.
  • My joints ache, and my doctor said I probably have arthritis, even though I just turned forty.
  • I’m depressed and can’t think straight—I feel like I walk around with brain fog.
  • I’ve tried every diet in the book, but I can’t lose weight.
  • Last year I lost my job, and shortly after those emotional and financial blows, I became chronically tired and depressed.
  • I wake up at 3:00 AM and toss and turn for hours and cannot fall asleep again.
  • I used to have great energy, but now a short walk wears me out.

If the adrenals are dysfunctional it can cause low thyroid gland functionThese statements personalize some of the typical — and persistent — signs and symptoms of Adrenal Fatigue Syndrome. You might have described these same things to your doctor, or you may have noted these changes in your health or know someone who has these complaints, but you don’t know what to make of them. If you’re over age forty-five or fifty, you might even be told to attribute your symptoms to “normal” aging!

Below, you’ll find an expanded list of the signs and symptoms of AFS. As you can see, many of these symptoms are also related to other conditions including thyroid gland function like primary hypothyroidism, and they match the statements listed above:

  • Progressively increasing lethargy and lack of energy.
  • Increased effort needed just to perform daily tasks.
  • Decreased ability to handle stress.
  • Tendency to gain weight, coupled with an inability to lose it, especially settling around the waist.
  • Frequent bouts of influenza and other respiratory diseases, with symptoms lasting longer than usual.
  • Trembling under pressure.
  • Reduced sex drive.
  • Tendency to feel light-headed especially when rising from a horizontal position.
  • Inability to remember things.
  • Lack of energy in the morning and in the afternoon between 3:00 and 5:00 PM.
  • Tendency to feel better suddenly for a brief period after a meal.
  • Often feels tired between 9:00 and 10:00 PM, but resists going to bed.
  • Difficulty getting out of bed in the morning.
  • Once out of bed, has a need for coffee or other stimulants to get going.
  • Cravings for salty, fatty, and high protein food such as meat or cheese.
  • For women, increased symptoms of PMS and irregular menstrual bleeding, with days of heavy flow that stops (or nearly stops) on day 4, only to resume on days 5 or 6 of the menstrual cycle.
  • Pain in the upper back or neck for no apparent reason.
  • Tendency to feel better on vacation and when stress is relieved.
  • Mild depression.
  • Food and or inhalant (airborne) allergies.
  • Dry and thin skin.
  • Hypoglycemia.
  • Low body temperature.
  • Nervousness.
  • Heart palpitations.
  • Unexplained hair loss.
  • Alternating constipation and diarrhea.
  • Dyspepsia (indigestion).

Addison’s Disease and Adrenal Fatigue Syndrome

Addison’s disease, also called adrenal insufficiency, is a rare but recognized disease in which the adrenal hormonal output falls below a level that meets established clinical parameters. It affects about four out of 100,000 people and is diagnosed with blood testing. In this case, if blood tests results are abnormal we know the adrenal glands are structurally dysfunctional and the patient needs lifelong steroid replacement.

Addison’s disease is often caused by an autoimmune dysfunction, whereas stress, either physical or emotional, is the primary culprits of Adrenal Fatigue Syndrome. The symptoms of Addison’s disease include low energy, joint and abdominal pain, weight loss, diarrhea, fever, and electrolyte imbalances. Some Adrenal Fatigue Syndrome sufferers report these symptoms too, but they are usually much less intense unless in advance stages.

Adrenal Fatigue symptoms can cause low thyroid gland functionAt its core, symptoms of AFS represent the body’s internal neuro-endocrinological response when overwhelmed by stress. To survive, the body starts to down-regulate all organs in order to maintain homeostasis. This is one of the most effective way to conserve valuable energy, the currency of life. Low thyroid gland function is a result of such effort. The thyroid gland function itself is working properly from a pathological perspective. Under the command of the adrenal system telling us to slow down, a clinical state of hypothyroidism is the result. If you are under a stress, either physically or emotionally, be on the alert for Adrenal Fatigue Syndrome.

Adrenal Fatigue Syndrome and You

Many adults are puzzled when they first hear about Adrenal Fatigue Syndrome because they generally have little knowledge of the adrenal glands and their function. They’ve simply never considered that their adrenal glands could be linked to a cascade of symptoms, such as mild to extreme fatigue, lowered immunity, thyroid disease, low libido, menstrual disorders, metabolic disorders, mild to moderate depression, and so on. Yet, AFS is neither rare nor mysterious. Research suggests 11.9 percent of adult population in the United States suffer from severe fatigue, extreme tiredness, or exhaustion lasting more than one month. Many times more of the population suffers mild to moderate fatigue, with less debilitating symptoms. This number is growing exponentially as stress of living in the modern world takes its toll on our body. AFS is therefore one of the most prevalent health conditions, afflicting most adults at one time or another at varying degrees. It is a silent epidemic. Who hasn’t experienced stressful events or even periods of prolonged stress? However, the situation is seldom seen as a serious threat to health and is therefore seldom identified.

Even when identified, many healthcare professionals believe that no recovery protocols exist and perhaps tell their patients to relax and manage their stress. Often, AFS is thought of as a condition of the mind only and doctors prescribe antidepressants. AFS also is commonly tied to thyroid gland function diseases and many doctors order thyroid replacement drugs. Unfortunately, these treatments often leave the root causes unresolved. As a result, the condition worsens over time, sometimes for months but often over years and even decades. With the complex and often convoluted progression of AFS, which admittedly defies conventional medical logic, it’s no wonder that AFS is so often the “victim” of misidentification. Because AFS is not a recognized medical condition, do not be surprised if your physician is not familiar with or rejects the notion.

When considering Adrenal Fatigue Syndrome, it’s important to keep in mind the following principles:

  • AFS exists on a continuum of severity, with individually defined stages and phases. The more advanced the stage, the more severe the condition. Stages 1 and 2 are considered mild, and Stages 3 and 4 are considered advanced and increasingly severe in terms of symptoms.

Hypothyroidism and low thyroid gland function

  • Adrenal Fatigue Syndrome, particularly in Stage 3 (Adrenal Exhaustion), is related to many recognized diseases, such as hypothyroidism, polycystic ovary syndrome (PCOS), fibroids, hypoglycemia, depression, Lyme disease, irritable bowel syndrome (IBS), autoimmune diseases, and many other defined and regularly diagnosed and treated medical conditions.

AFS and Primary Hypothyroidism – Similarities and Differences

The following table outlines the key differences in the signs and symptoms between Adrenal Fatigue and hypothyroidism.

Characteristics Adrenal Fatigue Hypothyroidism
Body Measurements
Weight Early: gain weight;
Severe: cannot gain weight
Generalized weight gain
Body temperature 97.8 or lower Low 90s to 98.6
Temp regulation Fluctuating and exaggerated Steady
Mental Function
Mental function Brain fog Slow thinking
Depression Sometimes Frequent
Physical Looks
Eyebrows Full Sparse outer 1/3
Hair Thin, sparse on extremities Coarse and sparse
Hair loss Sometimes Common
Nails Thin, brittle Normal to thick
Peri-orbital tissue Sunken Puffy
Skin Thin Normal
Skin tone Dry Oily or moist
Internal Feeling
Ligament flexibility Good Poor
Fluid retention No Yes
Pain Headache, muscular, migraines Joints, muscles
Reactivity Heightened and hyper-reactive Hypo-reactive
Medical Condition
History of infections Common Occasional
Chronic fatigue Yes Yes
Orthostatic hypotension Frequent No

It is not unusual to have concurrent presenting symptoms of both low adrenal and low thyroid gland function. Conventional medicine tends to miss this due to ignorance about Adrenal Fatigue Syndrome. Those who were diagnosed as hypothyroid after a traumatic and stressful event such as pregnancy, accident, infection or an emotional trauma including divorce or death of a loved one, should be especially on the alert if thyroid replacement alone is not helping.

Individuals with poor body temperature regulation are more prone to have mixed presentation as well. They may present a steady low body temperature from the low 90s to a little below 98.6F. They may also present a slight exaggerated response in body temperature as compared to the environmental temperature as characterized by a sensation of feeling hot when it is warm and cold when it is cool outside.

Thyroid test results in AFS sufferers usually show normal or low free T4 and free T3. TSH can be normal or high, but body temperature is generally consistently low. Fortunately, such secondary hypothyroidism can be reversed if indeed AFS is the cause. We see many with Adrenal Fatigue Syndrome who are on thyroid medication reduce their thyroid medicine as their adrenal health improves.

Low Thyroid Gland Function – A Normal Survival Mechanism

When the body is exhausted, its ability to handle the stress associated with normal bodily functions and energy requirements is often compromised. As mentioned before, to enhance survival, the adrenals force a down-regulation of energy production and thyroid gland function.. In other words, the body is being metabolically down-regulated to slow down in order to conserve energy as the body needs to rest. Lower energy output reduces the workload of the body.

Low thyroid gland function can be a result of adrenal problemsIn times of stress, this is exactly what the body wants. As the thyroid down-regulates, production of thyroid hormones T4 and T3 is reduced. The down-regulation in thyroid gland function also leads to an increase in thyroid binding globulin (TBG) level. As a result of increased TBG, more thyroid hormones are bounded on a relative basis and less is released to the body cells where they work. The result – reduced free T4 and free T3 levels in the blood when measured, while total T3 and T4 levels may be normal.

In this well-orchestrated systemic down-regulation to enhance survival, the body also shunts some of the available T4 towards the production of the inactive reverse T3 (rT3) which acts as a braking system and opposes the function of T3. This reduction in T3, combined with an increase in rT3, may persist even after the stress has passed and cortisol levels have returned to normal. Furthermore, rT3 itself may also inhibit the conversion of T4 to T3 and may perpetuate the production of the inactive rT3.

If the proportion of rT3 dominates, then it will antagonize T3, possibly leading to a state called rT3 dominance. This results in hypothyroid symptoms despite sufficient circulating levels of T4 and T3. The body therefore, has multiple pathways to down-regulate energy production to enhance survival under the direction of the adrenal glands.

In such cases, laboratory test results of T4 and T3 may be normal and classic symptoms of Hypothyroid are evident with persistent low body temperature and slow ankle reflex. Alternatively, laboratory test results of free T4 and free T3 may be low while the TSH level is normal or high. In both scenarios, thyroid replacement with T4 and T3 without first considering adrenal fortification is a common mistake and often leads to a worsening state of Adrenal Fatigue over time.

The reason is simple. Thyroid replacements tend to increase metabolic function and energy output. Raising the basal metabolic rate is akin to putting all systems of the body, including thyroid gland function, into overdrive at a time when the body is trying to rest by down-regulation through the many mechanisms described above. The body’s survival mechanism is designed to achieve a reduction of and not the increase in the levels of T4 and T3. What the body wants (to slow down) and what the medications are designed to do (to speed up) are diametrically opposed to one another.

The Hidden Culprit

Administering thyroid medication to a stressed out body without concurrent attention to optimizing adrenal health and thyroid gland function will often fail over time. In many cases, it is like to pouring oil onto a fire. An already weak adrenal system in a low energy state may not be able to carry the burden of extra energy output bought on by thyroid replacement medication. What the adrenals need is rest, not extra work.

Thyroid gland function medicationThyroid medication administered under circumstances of weak adrenals may lead to a temporary relief of symptoms and a slight boost in energy at first. However, this is often short lived. Ultimately, fatigue returns as the thyroid medication further weakens the pre-existing Adrenal Fatigue condition and often precipitates an adrenal crisis. The overall fatigue level continues to increase well beyond what the medication is trying to combat. Only by increasing the thyroid medication dosage or switching to more powerful thyroid drugs can the worsening fatigue be avoided.

Let us look at this in more detail clinically. Remember that one of the most common presenting complaints to a physician is fatigue. Routine laboratory tests often show higher than normal TSH level. Physicians are more apt to make the diagnosis of Hypothyroidism and start the administration of thyroid medications. While laboratory levels of T4, T3 and TSH may appear improved once the thyroid replacement medication has been administered, the patient clinically continues to show lack of significant improvement and often clinically his condition will get worse over time.

As indicated earlier, many who are diagnosed with Hypothyroidism and are treated, continue to complain of unresolved symptoms with repeat visits to a physician’s office. These well-intentioned physicians can be misled by the “improving” laboratory test results as being “on the right track” and not attuned to possible concurrent underlying adrenal dysfunction that remains to be the main culprit.

Unless FT4, FT3, and rT3 values are factored into the clinical picture, the true cellular delivery of thyroid medication is not known. The body’s cry for help by forcing a persistent low body temperature is often not attended to. The unsuspecting physician may continue to increase thyroid medication dosage in an attempt to relieve the unpleasant and unresolved hypothyroid symptoms such as fatigue. This approach seldom works long term as it unknowingly subjects the patient to the worsening of his overall symptoms which are triggered by the thyroid medication’s un-intended negative effects on the adrenal glands and thyroid gland function. This overshadows the benefit such medication may have on the thyroid gland function. As long as the adrenals are still functioning, the body will continue to down-regulate as much as it can, blunting the body’s response to the thyroid medication.

Over time, despite improving or stabilizing T4, T3, and TSH levels that may be considered within normal range, the patient still needs an ever larger dose of medication clinically in order to keep his symptoms at bay. He continues with complaints of unresolved symptoms with low body temperature that refuses to normalize while the classic signs of hypothyroidism persist despite medication.

The Hidden Gem

Those who have hypothyroidism but fail to improve with thyroid replacement medication should therefore always investigate Adrenal Fatigue Syndrome as a possible etiology for their thyroid problem. Normalization of the adrenal and thyroid gland function in such cases is the key and it often leads to spontaneous resolution of the hypothyroid symptoms.

Investigating Adrenal Fatigue and Low Thyroid Gland FunctionThe faster the sufferer of Adrenal Fatigue recovers, the faster the symptoms of hypothyroidism will be resolved. Those who are on thyroid replacement will invariably find that less medication is needed as their adrenal and thyroid gland function normalizes. In fact, the patient can become over medicated and thus run the risk of hyperthyroidism if the thyroid medication is not reduced as the Adrenal Fatigue condition improves.

This is an important yardstick and gauge of improvement of one’s adrenal function. The credit goes to the adrenal glands and not the thyroid gland. As the adrenals improve, the need for down-regulation subsides and thyroid function suppression is lifted, leading to normalization of the thyroid function. For those who pursue thyroid recovery by way of first fortifying the adrenals, it comes as no surprise to see the body frequently regaining energy without an increase in thyroid medication after years of relying on such replacement. In fact, thyroid replacement may not be necessary and can be tapered off totally over time as the adrenal function normalizes.

It is important to note that laboratory test results of thyroid function during this adrenal focused thyroid recovery strategy will continue to show low thyroid gland function for some time due to a lagging effect. TSH level may continue to be high and out of normal range, while free T3 and free T4 levels will continue to be low. This lagging effect can last for months.

As the adrenals recover, the patient clinically will improve, with rising body temperature back to normal, increased energy, reduced need for thyroid medications and improved weight management. Conventional physicians who are not trained to recognize this adrenal-thyroid connection are pleasantly surprised clinically to see the patient improving despite “abnormal” laboratory studies, but not knowing why. The key, of course, lies in the improved adrenal function.

Wired and Tired

Weak adrenals and thyroid gland function, when present concurrently and not attended to properly, start an adversely reinforcing vicious downward spiral of adrenal dysfunction. Individuals requiring an ever increasing dose of thyroid medication to keep fatigue away may end up becoming dependent not only on the heavy dose of strong thyroid medication, but have to suffer the side-effect symptoms of toxic thyroid (such as heart palpitation) as medication dosage is being increased.

The result is that they feel “wired and tired” as mentioned earlier, with constant fatigue, unable to fall asleep and feeling anxious throughout the day. Internally, their adrenals continue to weaken as the stimulatory properties of thyroid medication are negated by the continued overwhelming rejection of the adrenal glands, resulting in a body that continues to be down-regulated to conserve energy.

Thyroid gland function and feeling wired and tiredThis is the worst of both worlds and it happens too frequently and often goes unnoticed. Clinicians and patients alike are baffled by what appears to be clinical contradictions—improving laboratory TSH levels (as a result of increased medications) or high TSH levels that refuse to come down, rising need of thyroid medication to maintain energy and worsening symptoms of Adrenal Fatigue with continued low basal body temperature, metabolic imbalances, weight gain and increased sluggishness.

Laboratory Tests Specific for Adrenal Fatigue

Routine serum-based laboratory tests can be useful in the setting of confirming disease, measuring disease burden, and explaining unusual findings in a particular patient. Its use in Adrenal Fatigue Syndrome is severely limited though due to the lack of sensitivity to detect subtle adrenal dysfunction.

Adrenal Fatigue Syndrome is therefore difficult to evaluate with traditional blood tests; those available are designed to detect the severe, absolute deficiencies of adrenal hormones that characterizes Addison’s disease. Blood testing also is useful to detect extreme, excessive levels of adrenal hormones associated with Cushing’s disease. In other words, available blood tests measure adrenal hormones only at the extremes.

What this tells us is that a test result showing so-called normal levels of adrenal hormones does not mean that the patient is free from adrenal imbalance. As long as conventional doctors are not taught the significance of this sub-clinical state of Non-Addison’s Hypoadrenia that is characteristic of Adrenal Fatigue Syndrome, these blood tests lead to misguided interpretations. Patients tested for adrenal function are told the results are well within the normal range, but in reality, their adrenal glands are performing sub-optimally. Meanwhile, clear signs and symptoms continue as the body cries out for help and attention.

Serum laboratory studies of two surrogate markers of adrenal function, cortisol and DHEA (measured in the blood by way of DHEA-S) can, however, reveal a general picture that tells us if the body is in an anabolic state (build up) or catabolic state (breakdown). These blood levels alone do not provide clear evidence that leads to a diagnosis of Adrenal Fatigue Syndrome.

Saliva Cortisol and DHEA

We can also test adrenal health by measuring levels of key adrenal hormones such as cortisol and DHEA in the saliva. A saliva test is far more accurate than serum for cortisol and DHEA as it measures the free and circulating amount of each of these, not the total bounded amount as measured by serum.

DHEA can be measured at any time during the day. Cortisol is different; cortisol levels vary throughout the day—with the highest being in the morning and lowest in the evening before bedtime.

The following are general correlations on how saliva cortisol and DHEA levels relate to Adrenal Fatigue.
Adrenal Fatigue, low thyroid gland function and testing Cortisol and DHEA

  • Normal cortisol, normal DHEA does not rule out Adrenal Fatigue.
  • Normal cortisol, high DHEA points to early Adrenal Fatigue or excessive DHEA intake.
  • High cortisol, normal DHEA points to early Adrenal Fatigue as the body puts out more cortisol relative to DHEA as part of the stress response.
  • High cortisol, high DHEA is commonly associated with chronic stress.
  • High cortisol, low DHEA usually points to early phases of Adrenal Exhaustion.
  • Low cortisol, low DHEA usually is associated with late phases of Adrenal Exhaustion.

The above correlations are very general. There are many exceptions, each requiring paradoxical values are common especially in those who have a sensitive body or in advanced Adrenal Fatigue. Delayed response needs to be factored in as well.

How to Properly Interpret Saliva Cortisol Test?

The recommended tests require four saliva samples: 8 am, Noon, 5 pm, and before bedtime. The multiple samples allow for the ability to map the daily diurnal curve of free cortisol in the body relative to DHEA levels, allowing us to have a much clearer picture of adrenal function.

Like many other tests, the saliva cortisol test has limitations. Results can be confusing and oftentimes defy conventional medical logic. To be useful, saliva cortisol levels must be viewed in the proper context. Keep in mind the following:

  • Morning free cortisol level is indicative of peak cortisol output modulated by the HPA axis.
  • Lunch cortisol level points more toward 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. As AFS advances, the daily cortisol diurnal curve changes, as shown in Figure 1.

Remember that AFS consists of a continuum of 4 stages, from mild to severe. As the condition worsens, the cortisol curve will change accordingly. Typically, normal people have a rise in cortisol while we are in deep sleep, reaching peak in morning followed by a gradual decline throughout the day. The low point is at bedtime. Those in mild AFS (Stage 1 and 2) generally see a rise in total cortisol output, especially in the morning, which can linger well into the afternoon as the adrenal cortex is put on overdrive. Those in early phases of advance AFS (Stage 3) will see morning cortisol declining from a high level back to normal, and then as Stage 3 progresses further towards Stage 4, the morning cortisol level becomes quite low. Most in late Stage 3 experience flat cortisol output throughout the day. In other words, the entire 24 hour cortisol curve resembles a flat line.

The following diagram shows the general cortisol curve as AFS progresses from mild to severe.

Cortisol irregularities contributing to low thyroid gland function symptoms

Many exceptions exist to the above generalizations, so we can’t rely totally on a test result to make clinical decisions. For example, some people who are in Stage 2 show high evening cortisol but low or normal morning cortisol. These individuals tend to have low energy in the morning but are alert as evening arrives. Then, despite high evening cortisol, they often sleep well and don’t have sleep onset insomnia that commonly plagues those with elevated evening cortisol. Even after a night’s rest, though, they tend to be sluggish in the morning. Others may show both high noon and nighttime cortisol levels, with normal morning and afternoon levels. This may be reflective of the body’s erratic response to increase cortisol output during the day when faced with episodic stressor events.

For reasons not well understood, some clinically in Stage 3 may exhibit the Stage 2 Adrenal Fatigue Syndrome cortisol curve pattern. A small number of people can have a totally normal cortisol curve while in late phases of Stage 3. This should alert us to further investigate whether other conditions are the ultimate root cause. It should be clear that proper clinical correlation is critical. Few test results are straightforward. Over-reliance on cortisol values alone as a yardstick of adrenal function can therefore be misleading.

Clinical Correlation is Key

AFS is a complex condition with many causes. Symptoms can be convoluted and confusing. Multiple systems are involved. In advanced stages, the entire neuroendocrine system is dysregulated, not just the adrenal glands. The body is embroiled in a massive effort to re-stabilize internal hormones that are dysregulated. Low cortisol is but one of many parameters to consider.

A Saliva cortisol test as an absolute and sole diagnostic tool for AFS leaves much to be desired and is far from perfect. Over reliance on saliva cortisol level as key clinical focus in an AFS recovery program is a common clinical mistake. Not only can this approach jeopardize the entire recovery effort, but can backfire and make the condition worse.

Proper clinical correlation is critical. Adrenal Fatigue Syndrome symptoms can be numerous and severe while at the same time, laboratory results are normal. The reverse is also true. The test results could show abnormal levels of cortisol and DHEA, but one might not be experiencing symptoms. Furthermore, in advanced Adrenal Fatigue Syndrome, the twenty-four hour saliva cortisol curve invariably becomes flattened most of the time and can stay that way for an extended period, even during recovery. Sometimes we see a delayed response, which means the test results may be confusing and mis-leading and show no meaningful change while symptoms are improving.

As you can see, proper clinical correlation between lab results and symptoms is the key to recovery success. Experienced clinician will rely far more on the clinical presentation than laboratory results. Computerized laboratory interpretations of laboratory tests have limited value. In fact, it can be misleading if we fail to match the different cortisol values with the body’s symptoms throughout the day along with the clinical state.

Saliva testing is not without its virtue, however. It is best used in serial studies performed only as needed for comparative purposes when clinical results are sub-optimal or blunted. Relying on a single hormonal snapshot to draw clinical conclusions is a common mistake in recovery. This is especially common among those who are not under professional guidance. For example, patients may rely on laboratory tests without understanding their limitations. They then embark on a self guided nutritional recovery program that eventually leads to improper use of nutrients, thus making the condition worse. If you are not sure if you have AFS, need a baseline picture, or if you are not recovering from AFS, the saliva cortisol test can be very helpful, provided that it is always properly interpreted by an experienced practitioner in AFS and one who knows your history.

© Copyright 2014 Michael Lam, M.D. All Rights Reserved.

Dr. Lam’s Key Questions

Organ resistance, metabolic imbalances, and adrenal fatigue are some of the reasons. A detailed history by an experienced provider literate in AFS is needed to decide which is the most probable cause. Unfortunately, labs are not very helpful.

You should start feeling more energetic; your symptoms should slowly improve. Dry skin should improve and a sense of well-being emerges.

T4 is what is called a pro-hormone. It is the chemical mother of T3. T3 is the workhorse of the thyroid gland is considered a true hormone. It is stronger than T4 and made in lesser quantity. The two are balanced by the body as both are needed.

Iodine is an important mineral in the body to make thyroid hormone. Without adequate iodine, thyroid hormone synthesis is affected, and one could be hypothyroid. Eating seaweed would help boost iodine.

Fatigue and thyroid gland function and AFS
5 - "Thank you so much Dr Lam," Thank you so much Dr Lam, you have been a tremendous help to me. Your research is so wonderful, thank you for all the information.

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  • Dante says:

    Can children be affected by this? I think my son may be but he is only 13.

  • liz simmons says:

    Good morning. I have just had my thyroid removed a month ago and still feel physically tired and gaining rapid weight. I just read your articles and am very happy that I feel I have an answer and now some hope. I bought the Ortho-Adapt. Is there anything else you can recommend? I also bought Kelp tablets.
    Kind regards,
    Liz Simmons

    • Dr.Lam says:

      You should see your doctor and have it checked to make sure you are on the right regiment regarding meds if any. Simply taking kelp to increase metabolic function without knowing the root cause is not recommended. Be careful as you can mask the underlying problem.


  • Harriet says:

    How does cortisol affect the adrenals? What is the best way to regulate my cortisol levels?

  • Annabelle says:

    My doctor has been prescribing me thyroid meds for years and I have only just now started to question him. Reading your articles really sheds a whole new light for me on the complexity of our bodies. Thank you for all your research, I will be digging deeper into this thyroid issue and see about trying to heal my body in a more natural way.

  • Landon says:

    Thank you for this article! it’s helping to make sense of my Doctor’s diagnosis.

  • Linda Darnell says:

    Thank you for this wonderful article Dr Lam!! I have hypothyroidism and only have 1/2 thyroid now and have been experiencing some adrenal fatigue as well over the past year or two. Reading your articles has opened my eyes and gives me hope!!! I would love to be able to help and encourage others in some way!! Thank you!! Linda

  • Gabriel says:

    The extent of this article amazes me. The body is such a complex organism. Thank you.

  • Susan says:

    Hi Dr. Lam,
    This article seems to summarize exactly what I am going through and I would be so happy for some advice. I have Hashimoto’s and have been on Synthroid for 8 yrs. I was found to have low free T3 a year ago and I was put on slow-release T3 (10mcg). I had hyperthyroid symptoms as a result and my liothyronine dose was lowered to 5mcg. I felt ok on 112mg Synthroid and 5 mcg liothyronine during the spring, 2016, maybe partly due to also starting a paleo diet. I started to feel anxious, sluggish again by summer of 2016. My TSH has been low and my free T3/free T4 were both within normal range but on the low end. My doctor increased my Synthroid to 125mg and kept my liothironine at 5mcg. I have been on this dose for 3 months – my TSH is still low, and my free T3 and free T4 have both decreased to below normal range. I have had pretty severe hair loss, poor sleep, constipation but otherwise feel ok. I also had my cortisol tested and it is high. I have made lifestyle modifications (decreasing exercise intensity mainly over the past few months) and just started some adaptogenic supplements. My questions is regarding my medication dose. In your article you state that low free T3 and T4 may be seen for a few months while adrenal health is improving. I’m wondering whether I should return to my previous dose of Synthroid 112mg with 5 mcg liothironine while continuing to work on my adrenals. My doctor was wanting to increase my liothironine but I am nervous to do this since I’ve experienced hyperthyroid symptoms in the past with every increase. Or would it be best to just accept the low free T3, free T4 in the blood work, keep the meds all the same and work on adrenal health. I guess another way to phrase the questions is, at which point can the meds be lowered? Do we have to wait for the blood work to show increase in free T3, T4 or can we go based on symptoms? Thanks so much for your help.

    • Dr.Lam says:

      There are multiple factors at play. First is to listen to your body in stead of only at the blood levels. One of the most common mistakes is over emphasis on lab. Second has to do with how you are healing your adrenals. Try to stay away from glandulars and herbs.
      Click Adrenal Fatigue Glandular & Herbal Therapy for more information.

      Dr Lam

  • Dawn says:

    Recently had Adrenal stress saliva test over 24 hrs. High Cortisol on night and early evening. Normal but normal but low dhea’s. Previous 24hr saliva test 5 years ago, showed stage 3 maladaption? Low dhea’s . Thyroid currently is very low. Always had low tsh anyway but always low t4 too. Currently on 40mcg T3. Have very low IGF1 as well. Pernicous anaemia & I receive injections 8 weekly. Previously had Synacten test 5 yrs ago & didn’t have addisons. Any advice please ?

    • Dr.Lam says:

      A reverse cortisol curve usually is assocaited with taking stimulating compounds such as thryoid within a body that is resisting such effort. I urge you to dig deeper into the underlying root issue if you are not improving. Low IGF1 may or may not be associated. Low tsh is common in such cases as well as low dhea. Be careful with labs, they can be helpful but also can be misleading, depending on the context.
      Talk to your doctor more and fully understand each test to tie it in clinically is important.
      Click Laboratory Testing for more information.

      Dr Lam

  • Ethan says:

    Thank you for another fascinating article! i really feel like i learn so much from every article

  • Alexandra Stafford says:

    Hi Dr Lam,

    Great Info here! I’m having a bit of a dilemma of which specialists seem to be helping with but are unable to get to the root of what is going on. My last D.U.T.C.H test showed I had:
    low range cortisol levels upon waking (9.1ng/mg)
    within range in the morning (49.5 ng/mg)
    below range in the arvo (3.5 ng/mg)
    low range at night (2.9 ng/mg)
    Free 24hr cortisol is below range is 72ug
    Free cortisone which seems to be sitting higher across the board) is sitting at 306 ug.

    I am on Dr Wilsons adrenal Rebuilder for adrenal support which doesn’t really make that much of a difference and Adaptogen R3 that contains Rhodiola which in the past weeks has helped to really level out my moods and I have noticed a slight drop in weight and finally some restful night sleep.

    On my most recent visit to my specialist we started to hone in on my Thyroid regime – which past and recent lab results have displayed hyper/hypo but I am symptomatic of Hypo. (High free T4, low free t3, low tsh, low antibodies). Again I am on glandular support for this of which has helped half the reversed t3 from a whopping 648mg to 320mg and increased my free t3 by 1mg. She has recommended further supplementation with a vitamin complex to focus on feeding the thyroid gland and assisting in the conversion of t4 to t3 however after a couple of days of taking this supplement i’m feeling worse – declined sleep and mood, cold hands.

    My questions are am I forcing my thyroid to work harder with further supplementation. Should I be focusing on getting the adrenals right first before working on the thyroid? Also I haven’t seen online the many people who have high t4 – low t3 – is that common with people who have low adrenal function. I live my life in a very healthy manor – consistent with exercise and healthy eating. It seems very strange for my body not responding to a protocol that you would assume most people with low adrenal and thyroid function would.

    • Dr.Lam says:

      Your situation is not strange at all. Anytime you push your thyroid, you are stimulating it. Whether it is from supplements or medications is a matter of degree. Your body is not responding for good reasons. There are many possibilities. Your doctor should be able to explain to you and correlate with your body and the clinical situation. Modulating stimulants is not a long a long term solution if there are underlying unresolved issues.
      Click Adrenal Fatigue Glandular & Herbal Therapy for more information.

      Dr Lam

  • don says:

    Hello doctor Lam

    I have a question about the Body temperature as it’s looked at the table

    you wrote that the temp body at Adrenal Fatigue is about 97.8 or lower and the temp body in Hypothyroidism is Low 90s to 98.6 and it’s looks very similar exept people with have temp between 97.8 – 98.6.

    How can i know if lets’ say, 93-97 temp is because Adrenal Fatigue or Hypothyroidism .
    Best Regards

    • Dr.Lam says:

      A detailed history is the best way. The temperature in and off itself without any thing else to go with is not conclusive either way.

      Dr Lam

  • ofir says:

    Hello Doctor Lam

    I wanted to ask about the difference between body temperature hypothyroidism and adrenal fatigue.
    Write table adrenal fatigue temperature is 97.8 or less and sub hypothyroidism temperature is 90 -98.6.
    It looks almost the same as for example a temperature of 94 to 97.8 is also suitable for adrenal fatigue and hypothyroidism.
    What do you think?
    Thanks in advance

    • Dr.Lam says:

      Adrenal fatigue does not directly lead to low body temperature which is regulated by thyroid. Thryoid can be low in function due to weak adrenals or primary thyroid issues.

      Dr Lam

  • Mollie McEvoy says:

    Firstly, Thank you Dr. Lam for your attention to this very “complex” and somewhat complicated health condition. I have Secondary Adrenal Insufficiency and am completely life-dependent on steroids, and am also hypothyroid, as well as in the thick of perimenopause. So a lot of different (and difficult) things going on. My question to you is regarding thyroid medication, in relation to cortisone replacement. I recently increased both Synthroid and Cytomel, as my lab results showed both to be out-of-range LOW. The doctor I am seeing didn’t mention anything about the need to also increase hydrocortisone along with the increase in steroid meds. I recall that an endo that I saw years ago said something about the need to increase cortisone if you increase thyroid, as glucocorticoids are “eaten up” or cleared quickly by thyroid hormones. I’ve seen 8 endocrinologists over the past 10 years, and haven’t met one who has much knowledge of Adrenal Insufficiency, beyond text book. Everything I know and have learned has either come from my own research or from others around the globe living with this horrid condition. What are your thoughts on the relationship between thyroid meds and cortisone replacement? Thanks again for all you do for those out there who I’m sure are suffering greatly with endocrine problems, and are not getting any help from the Traditional Medical Community… needs to be greater AWARENESS. Sincerely, Mollie

    • Dr.Lam says:

      Low thyroid numbers by lab alone should be combined with clinical picture before deciding on whether or not to adjust the dosage, if you have an adrenal component to your thyroid issues. Otherwise, you can be putting yourself in an ever increasing cycle of not only thyroid but also steroid. There is no rule to say whether or not the increase in one will necessitate the increase in the other. Your doctor has to make that decision. I urge you not to focus too much on the lab numbers alone as that is a common mistake.

      Dr Lam

  • Diane says:

    I greatly appreciate your generous and critical information about adrenal & thyroid disfunction, it can help me to better understand my condition, as I do not have a thyroid , due to thyroid ablation (RAI) and Im experiencing adrenal insufficiency, due to a dr who did not wean me off of hydrocortisone.
    Im slowly getting out of the crashed stage of adrenal insufficiency (as my saliva tests show) I take WP Thyroid full dose in morning and herbs & vitamins morning and night. I do not do this myself, I have the guidance of a naturopath,

    but I wonder if twice dosing NDT will be easier on my adrenals?
    As midday, I am always low in cortisol, maybe it takes a long time to recover my adrenals, after such a shock to my system , when the doctor did not wean me off HC.

    Thank you

    • Dr.Lam says:

      A more stable and consistent dosage is often more desirable but not for all people. You need to talk to your doctor more.

      Dr Lam

  • Brooke says:

    I believe i have Hypothyroidism in conjunction with Adrenal Fatigue Is my condition likely temporary or chronic?

  • Alice Price says:

    My Cortisol and DHEA levels are both a 1 , what does this mean and what further testing do you recommend ??

  • Marinda says:

    What is the treatment for afs?

  • Stephanie mueller says:

    I suffer from all of the symptoms you listed for adrenal fatigue yet my tests have all come back normal. Blood work as well as cortisol saliva test. I’m an athlete that has gain 30 pounds in less than a year without a change in my diet. I eat very lean and clean. Digestive issues are a big problem for me now as well. Is it possible to have adrenal fatigue with normal cortisol and DHEA. Levels? I have spent thousands of dollars trying to find a diagnosis

  • Anna says:

    If I have been diagnosed with Addison’s disease can I still seek treatment for adrenal fatigue?

  • Sarah says:

    Hi Dr Lam

    I believe I have adrenal fatigue but I have never been tested, should I get blood work done before I start with your program. I had a baby 7 weeks ago and I have been exhausted and nauseous all day long even though I sleep at night, I can’t take care of him and family members have been taking care of my baby.

  • Gaby says:

    Thank you for all the information, was very very helpful….again thank you

  • Han says:

    This content is very in depth, thanks for that. I may have some adrenal issues that run side by side with some of the symptoms of hypothyroidism. Should I go get my thyroid checked before I venture into AFS issues ? If my MD suggests for me to start on some thyroid medication, should i start ? How do I know if I truly need it ?

    • Dr.Lam says:

      You should always listen to your doctor, and that is why you need to make sure your doc is literate on AFS. if you start on thryoid and find no help, that is a sign that it may not be the right thing to do. It all comes down on a detailed history if you are concerned with AFS vs thyroid issues. you can have both concurrently , dont forget.

      Dr Lam

  • Jennie thorn says:

    What a fascinating article but I was so disappointed to get to the end without a treatment! I am at my wits end trying to live with low cortisol levels, continual weight gain despite a very physical job and a complete inability to get restful sleep with extreme dreaming thrown into the mix. Is there anything I can actually do to change this… It’s like living through glue.

    • Dr.Lam says:

      Due to the complexity of the issue, the key to understand is if your thyroid program is not working , do look outside the box. Everyone is different, and your key is to find someone who really knows as many tried self navigation and often fails.

      Dr Lam

  • Amy says:

    Thank you so much, Dr Lam. I’ve researched many different sites (that are credible) about anything and everything dealing with the HPA axis and/or auto immune diseases. I’m a young lady that had respiratory pleurisy boughts, weird infections and constant shortness of breath after a trauma and many other symptoms. All blood tests have come back low to low normal. I’ve been doing ICT kits like crazy. When I read your article, it described literally every symptom from both AFS and Hypothyroidism. By far, yours has been the best research, comfort and peace. Thank you.

  • Kyle M. says:

    Wow. This is the best comparison / informative article, I’ve read , since my journey has started. Thank you guys for having it so well written.

  • Edna says:

    How can you tell the difference and determine whether you have Addison’s disease or simply suffering from adrenal fatigue?

    • Dr.Lam says:

      There are specific test call ACTH challenge test for Addison’s Disease that your doctor will order. For adrenal fatigue , the key is in history. Click Laboratory Testing for more information.

      Dr Lam.

  • Miranda says:

    What age does someone typically see hypothyroidism develop in themselves?

    • Dr.Lam says:

      It span across all age groups, even in teenagers and younger. One must be careful to note that just because there are symptoms of low thyroid function present does not mean that there is hypothyroidism which is a specific diagnosis. Such can be the case in AFS.

      Dr Lam

  • David says:

    If you have an equal balances of symptoms caused by the Adrenals and hypothyroidism, is it more likely that with normal laboratory results it is the Adrenals causing disruption in the thyroid not actually clinical hypothyroidism?

  • Camilla says:

    I’m on sickleave, fourth week now, quite sure it’s because of my adrenals. Been on thyroidmedication since 2010, never been feeling ok since then. From the very beginning I’ve asked the doctors (they’ve been several during the years) for help with my adrenals. None of them has offered me help except for treating my thyroid. Everytime a question of higher dosage, it has worked, but only for a short amount of time, then I’ve felt poorly again. Now this is my second longtime sickleave in 6 months, last time three weeks. It seems it’s getting worse. I now want to lower my dosage thyroidmedication to see if it will help my adrenals at all, at the same time as i started with Adrecomp today. I take 100mcg Levotyroxine a day, with how much should I lower the dosage and how often?

    • Dr.Lam says:

      You have to be careful about any self adjusting of dosage which is not recommended as it can crash the body, especially if you are weak and your body is already used to it. If indeed your doctor were to reduce your thyroid, it is usually done over months and not weeks or days. Developing resistance to thyroid medication may indicate underlying resistance. Adrenals weakness can be associated, and if that is the case, healing the adrenals should be a priority.

      Dr Lam

      • Camilla says:

        Thank you! My doctor does not think it is my adrenals that’s gone down. He thinks I’m now suffering from anxiety and depression. Anxiety yes, but it’s also a part of the symptoms regarding the adrenals , I’ve told him. He wants to treat symptoms, I want to be treated for actual cause. I feel I have to manage this myself, I’m afraid. But I will try to get as much knowledge I can. I want to be able to get back to work again, not worrying about next time this will occur. I don’t want it to happen again, final.

  • Xandis says:

    Tracking the rhythm of my body seems like a ton of work. Can this be simplified at all? Thank you Dr. Lam!

  • rachel berger says:

    Dr Lam, I’m hypothyroid but beginning to wonder how much has to do w/ adrenal? I have low a.m cortisol and high evening cortisol. Low progesterone. I’m doing o.k. on natural thyroid meds both NDT & T3. And despite not gaining weight, I have gained/ retained water weight in a disproportionate amount in my thighs/ bum. It looks as if i’m growing saddlebags. can’t figure out what is responsible for that.

  • Tiana says:

    Can AF cause these symptoms: adrenaline surges that wake me up in the middle of the night out of sleep with my heart racing body feeling numb. My heart rate jumps up from 79-130 just by standing. Craving salt and sweets on and off. Tension headaches. Im constantly feeling on edge. All of these symptoms seem to have come out of nowhere. I had a thyroid test done that showed low total t3-high free t4, normal tsh. Im so confused at what approach to take. Dr’s say blood work is mostly fine besides high cholesterol but I know something is not right

  • Kerri Johnson says:

    I just had the adrenal, index test done. my levels are severely elevated. I have had a pituitary tumor removal in 2014. I have estrogen dominance rt3 low progesterone can you please help me.

    • Dr.Lam says:

      With your history, you have to be very careful on how to interpret test results as without comparative studies, lab results can be misleading. Go to the doctor who ordered the test and put the clinical picture together. Do not rely only on the lab results. Low progesterone and high estrogen along with high rt3 can signify adrenal fatigue as the body slows down to conserve energy. We do have a program to help support AFS sufferers nutritionally by phone, but you have to qualify. If you are interested, you can call my office.

      Dr Lam.

  • mike says:

    Can hashimotos antibodies cause further damage to adrenals? Which should be attended to first, hashimotos or adrenal?

    • Dr.Lam says:

      Each person is different, depending on the most dominant weakness. Generally speaking you should address both concurrently so both gets the proper attention. The more advance the AFS the more careful one has to be in terms of prioritizing. If there is advance AFS, then thyroid only focus can make matters worse. Read O.A.T. Axis Imbalance for more information.

      Dr Lam

  • Ana says:

    If you already have hyperthyroid, would iodine help? If not, what natural sources can be used to help hyperthyroid?

    • Dr.Lam says:

      Iodine can make hyperthyroid worse, so do be very careful. Remember that hyperthyroid is a symptom mostly and you need to figure out what is the underlying problem to fix that and thyroid function will return to normal.

      Most people with adrenal fatigue has low thyroid function unless in early stages where the thyroid may be overactive.
      Read Adrenal Fatigue versus Hypothyroidism for more information.

      Dr Lam

  • Bob says:

    My doctor has me on many thyroid hormones, but I’m worried this can cause a crash. Are there natural resources I can have my doctor read to help me with this concern?

    • Dr.Lam says:

      Educating doctors is a very slow process. Most are too busy and will not be too interested. My book is an excellent resources for those who have an open mind.

      Dr Lam

  • Letty says:

    I have heard that iodine is helpful for the thyroid. What is the mechanism behind how iodine can help the thyroid?

    • Newsletter says:

      Iodine is a key and necessary ingredient in making thyroid hormone. Those will low thyroid function may benefit from iodine supplement. The key is dosage. The RDA by the government is very low, and studies have shown that 30 mg may be needed for optimum thyroid health. Due to its stimulatory effect, you need to be careful as one can get hyperthyroid is not monitored.

      Dr Lam