Electrolyte Imbalance and Adrenal Fatigue Syndrome – Part 1

By: Michael Lam, MD, MPH; Justin Lam, ABAAHP, FMNM; Dorine Lam, RDN, MS, MPH


Electrolyte imbalance issues need to be taken seriously, especially when adrenal fatigue is present.The average adult human body is fifty to sixty-five percent water. Those who are overweight will have more water compared to those who are lean. While one can survive fifty days or more without food, the body can only be depleted of water for a few days before survival is at risk. Maintaining optimum fluid balance, and not having an electrolyte imbalance, is important in achieving general good health. This is especially critical in Adrenal Fatigue Syndrome (AFS), where fluid dysregulation and electrolyte imbalance are common occurrences, especially in the advanced stages.

Fluid or electrolyte imbalance presents in a continuum. Conventional medicine, unfortunately, is versed mostly when fluid or electrolyte imbalance reaches extreme opposites, with severe dehydration on one extreme and a massive fluid overload at the opposite pole. Fluid overload clinically results in pulmonary edema, peripheral edema, and congestive heart failure. They are quickly resolved with administration of medications called diuretics that increase urine output to reduce body fluid load. Deficiency in fluid, or clinical dehydration, is clinically treated with fluid replacement.

Little attention is paid when fluid or electrolyte imbalance lies between the two extremes, when symptoms can be evident but laboratory tests are normal. This is especially evident for those in the fluid depletion side of the spectrum. In this subclinical state of dehydration, signs and symptoms are mild and subtle at best. It is often missed and ignored as important contributing factors to ailing health.

For the healthy person, thirst is the first compensatory response to low fluid levels or an electrolyte imbalance. This is usually felt when the body has lost around two to three percent of its water. At the cellular level, however, damage begins to occur with as little as one percent loss of body water. Those with AFS fare worse. They can exhibit signs and symptoms of fluid and electrolyte imbalance and subclinical dehydration at a lower threshold and well before laboratory tests become positive.

Fluid Regulation and Electrolyte Imbalance

We begin our discussion on electrolyte imbalance with first understanding how the body handles fluid or water as a whole.

Body fluids are comprised of intracellular and extracellular fluid. The intracellular fluid makes up about two-thirds of body water. The extracellular fluid makes up the remainder and consists of mainly interstitial fluids between the cells, plasma and lymph, spinal fluid, and in the GI track.

Water moves from one compartment freely to another due to osmosis. Osmosis is influenced by dissolved solutes in fluids such as minerals and electrolytes. When each compartment of the body contains the appropriate concentration of water and electrolytes, the body is said to be in fluid balance. This is the way nature intended it to be. Problems begin to occur when one compartment has more fluid than others do.

The bulk of our daily body water needs come from food and drink that averages 2,300 ml per day. Another 200 ml is produced from our internal metabolic breakdown of nutrients. Together, the average total daily intake of 2,500 ml should equial the total output through the skin, lungs, kidneys and GI track for the body to be in balance.

When our body is depleted of fluid, the brain initiates a chemical chain reaction that leads to a sensation of thirst by increasing the osmotic pressure of blood passing through the hypothalamus. We respond to thirst by taking in more fluid orally. When the body has too much fluid on board, output is automatically increased, usually by way of the kidneys in those who are healthy.

Aldosterone and Adrenal fatigue are crucial in electrolyte imbalanceWater output is regulated by antidiuretic hormone (ADH) and aldosterone. Both hormones cause the kidneys to reabsorb more water from the urine for the body.

Antidiuretic Hormone

Antidiuretic hormone (ADH), also known as arginine vasopressin, is secreted from the posterior pituitary gland. After travelling to the kidneys, antidiuretic hormone binds to receptors on cells in the collecting ducts. It promotes reabsorption of water back into the circulation, reducing water output. Without ADH, water flows freely out in urine, as the collecting ducts are virtually impermeable to water. The most common disease of man and animal related to ADH is diabetes insipidus. This clinical condition arises from either dysfunction in the hypothalamus or in the kidneys. The major sign of either type of diabetes insipidus is excessive urine production, and thus accompanied by dry mouth and thirst. Fortunately, ADH dysregulation is seldom a problem encountered as the root cause of thirst and fluid imbalance in adrenal fatigue.

Aldosterone 101

On top of our kidneys, sit the walnut sized endocrine glands called the adrenal glands. These glands secrete over fifty different types of hormones, regulating our ability to deal with stress, libido, inflammation response, fight-or-flight response, and fluid balance. Each gland contains two layers. The outer layer is called the adrenal cortex. Three different types of steroid hormones are secreted here: mineralocorticoids, glucocorticoids and sex hormones. The main mineralocorticoid is called aldosterone. Mineralocorticoids are hormones that the body secretes to maintain an adequate fluid and salt balance. Salts are composed of electrolytes like sodium and potassium; these electrolytes affect the body’s fluid content. Cortisol is the body’s main anti-stress hormone. It also has a weak mineralocorticoid effect and in high, enough doses can work like aldosterone.

Basic biochemistry dictates that where sodium goes, water follows. They are like twins. Aldosterone signals the kidneys to reabsorb, or hold onto, sodium so it does not leave the body by way of urine. As sodium is retained, so is water. The more aldosterone is released by the adrenal glands, the more water is retained in the body. Because the cardiovascular system is a closed system, more water in the body will lead to a higher blood volume. This added volume increases the pressure within your blood vessels, and translates into higher blood pressure if all else is equal.

The release of the proper amount of aldosterone and cortisol by the adrenal glands is a continuous and automatic process. As the body senses blood pressure being low, more aldosterone will be released. The normal body therefore has an automatic process of internal fluid balance without us knowing.

The problem comes when this regulation is dysfunctional or imbalanced, as in the case with Adrenal Fatigue Syndrome.

Frequent Urination and Adrenal Fatigue Syndrome

Many AFS sufferers have increased and frequent urination, no matter their amount of hydration. Here are three reasons why:

  • In the early stages of Adrenal Fatigue Syndrome, aldosterone levels first rise as the body tries to conserve water. As AFS progresses to advanced stages, aldosterone level tends to fall, resulting in low body fluid level. Next, low blood volume results and blood pressure falls. With reduced aldosterone, sodium retention is reduced, and fluid loss increases, leading to increased urine flow.

Frequent urination and electrolyte imbalance

  • Severe short term stress increases adrenaline release as the body begins the “fight-or-flight” alarm response, which in turn increases the rate of urine flow.
  • Chronic stress increases HPA (Hypothalamic-pituitary-adrenal) axis stimulation to the adrenal glands, resulting in increased cortisol output from the adrenal cortex. Cortisol causes reduction in Anti-Diuretic Hormone (ADH), which increases urine flow as the production of urine is not held back by ADH in the body. To put it simply, high cortisol leads to low ADH.

It comes as no surprise that most sufferers of AFS are in a chronic stage of fluid depletion, either clinically or sub-clinically, with increased urination.

Adrenal Fatigue and Aldosterone

The adrenal glands are the key stress control center of the body. Stress can be physical, such as over-exercise, or emotional. Under chronic stress, its function may be overly burdened beyond what it is capable of handling, resulting in AFS. When adrenal gland function is compromised, the body experiences fatigue and other symptoms.

There are four progressive stages of AFS. Stages 1 and 2 are considered mild. Typical symptoms include lack of energy, insomnia, anxiety, salt craving, afternoon slump, and waking up unrefreshed. Coffee and sugary snacks are common socially acceptable ways to boost adrenal function and to temporarily increase energy. The adrenal glands are working extra hard to help the body handle stress. This can go on for a long time. The adrenal function will gradually decline as it becomes overworked and exhausted if the stressors are not removed or worsen. This is when AFS enters stages three and four. More severe symptoms include reactive hypoglycemia, low blood pressure, postural hypotension, dizziness, faster than normal resting heart rate, tachycardia on slight exercise, irregular menses, low libido, PMS, low thyroid function, heart palpitations, depression and adrenaline rushes. In severe cases, one could be house bound and bedridden, unable to perform the basic tasks of normal daily living without assistance.

Out of the myriad signs and symptoms, two specifically reflect the dysregulation of aldosterone as AFS progresses—salt craving and low blood pressure.

When under stress, the adrenals are put in overdrive to secrete more compensatory hormones, such as cortisol and aldosterone. Typically, both rise in early AFS stages. Because of increased aldosterone, blood volume increases and thus blood pressure rises for those who are low. It is common to hear of people under stress having a higher blood pressure than normal. This, is part, is due to higher aldosterone. If stress is unrelenting and becomes chronic, adrenal burnout and fatigue progresses to its more advanced stages. Aldosterone output, along with cortisol, after reaching its maximum output in early stages, start to fall as the adrenal glands become exhausted. The more advanced the stage of AFS, the lower the aldosterone output. As aldosterone output falls, the body’s ability to retain fluid is compromised. Salt craving becomes more severe and is a warning sign of underlying problems. A girl who is stressed and may be suffering Adrenal fatigue and electrolyte imbalanceMany under stress automatically reach for salty foods such as potato chips for this reason. They also tend to salt their food more. This represents the automatic response to low internal aldosterone level in an AFS setting.If unresolved, the aldosterone level will continue to drop, contributing to a chronic state of low blood pressure. One can feel dizzy, lightheaded, and reduce urine output. Efforts to increase blood pressure fail with increased water intake.

Multiple visits to conventional medical doctors are usually made. Under these circumstances, unless a physician is alert and on the lookout for underlying adrenal dysfunction, the focus of investigation is usually placed on the cardiovascular system and kidneys. A thorough work up is usually conducted and unremarkable.

The key lies in the history. Classically, those under chronic stress report increased salt cravings and low blood pressure that remains chronically low despite taking in more salt in their diet. They often do well with drinking a glass of water with salt in the morning and in the afternoon. Taking food and snacks high in salt and fat also helps. Unfortunately; few are asked these key questions to rule out adrenal fatigue as the possible root cause. As long as laboratory tests are unremarkable, another classic sign, patients are discharged and told all is normal. Even for those astute physicians that do blood tests to rule out aldosterone deficiency, sub clinical low aldosterone is seldom recognized because tests invariably come back normal or borderline low. Few recognize that this is also a classical sign of adrenal fatigue where low aldosterone level is not expected. Instead of focusing on the history for more clues, patients are abandoned. There is seldom if any recognition that the symptoms are the consequence of subclinical fluid depletion caused by aldosterone dysregulation when AFS is present.

Read Part 2 Now!

© Copyright 2015 Michael Lam, M.D. All Rights Reserved.


Dr. Lam’s Key Question

Potassium and sodium are opposing forces. They balance each other. If you have an imbalance in potassium, you need to see your doctor and find out why because that is not normal. In AFS, both potassium and sodium level in serum is normal unless in advances stages.

Electrolyte imbalance issues need to be taken seriously, especially when adrenal fatigue is present.

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I really enjoy reading the articles on the website to further my understanding of this difficult diagnosis. Always written in language anyone can understand. Dr Lams writing style is gentle and supportive whilst remaining informative and genuine. It is really a difficult problem to live with and the do it yourself management information is life changing, putting me back in control. Thanks Dr Lam.