Laboratory Testing For Adrenal Fatigue Syndrome

By: Michael Lam, MD, MPH; Dorine Lam, RDN, MS, MPH

Adrenal Fatigue Syndrome (AFS)

Any time stress afflicts the body, the response is the same. The hypothalamic-pituitary-adrenal (HPA) axis is activated, ending in the adrenal glands secreting cortisol, the stress-fighting hormone. As stress continues, the adrenals become less and less able to produce this hormone. Eventually, adrenal fatigue sets in and the vague symptoms of AFS begin. Due to the vagueness of the symptoms, they prove hard to evaluate clinically. If not assessed and addressed adequately, these symptoms will grow to the point of rendering the person suffering from them bedridden. Routine laboratory tests are not designed to pick up these vague symptoms.

Routine Laboratory Testing

Laboratory testing is common when diagnosing Adrenal FatigueThe most common presenting complaints of Adrenal Fatigue are lack of energy, lethargy, dizziness, insomnia, hypoglycemia, low blood pressure, and anxiety. Routine conventional medicine laboratory testing for these in an otherwise healthy person commonly include:

  • Hematology (full blood count (CBC) – red cells, white cells and platelets to make sure patient is not anemic.
  • Biochemistry (liver and kidney function) to rule out systemic organ damage.
  • Inflammation in the blood – ESR, C reactive protein, plasma viscosity to rule out autoimmune diseases, among others.
  • Cancer markers for early detection of cancer.
  • Blood Sugar level to rule out diabetes mellitus.
  • Urine testing to rule out infection or kidney damage.
  • Fecal occult blood to rule out bleeding from the gut and cancer screen.
  • Electrolyte panel to assess kidney function.
  • Thyroid stimulating hormone to rule out primary thyroid failure.

These tests are good in detecting macroscopic pathology such as major organ failure including anemia, heart disease, metabolic dysfunction, cancer, liver failure, kidney failure, thyroid diseases.

Unfortunately, these routine laboratory testing procedures do not detect organ dysfunction at the sub-clinical level such as those afflicted with sub-clinical hypothyroidism, Adrenal Fatigue, mild liver dysfunction, imbalanced electrolyte function, minor hormonal imbalance, estrogen dominance, and suboptimal detoxification capacity.

In addition, little if any attention is paid to laboratory values that lie close to or just outside of normal range. Low normal or high normal values are generally passed over as insignificant until the result is much higher or much lower than normal range.

Modern medicine has also ushered in a wide array of standardized protocols of testing in addition to the number of tests. These well-intended tracks are meant to efficiently and effectively handle most common medical problems with accuracy and speed. They are by definition fitting for the masses. Those whose response falls within the statistical norm but physically symptomatic will be inadvertently ignored as they will be considered normal when they are not. In these cases, conventional medicine has little to offer. Instead, normal laboratory values are used to justify why patients are sent home to self-navigate, and that nothing is wrong when the body continues to suffer.

Unusual and convoluted clinical states such as those suffering from chronic fatigue syndrome, Adrenal Fatigue Syndrome, tension myositis syndrome, and estrogen dominance are difficult to diagnose to start. Conventional physicians usually dismiss these conditions because routine test values are invariably within the standard laboratory reference range. This is why it is most frustrating to the patient—when they are told there is nothing wrong while they feel physically tired and lethargic.

Doctors rely on detailed medical history and laboratory testing for diagnosisPrior to the advent of modern medical laboratory tests, the astute physician had to rely on a detailed history and physical examination to assess the clinical state. Laboratory values are used only in case of doubt, or as a confirmatory tool. Unfortunately, this is fast becoming a lost art in the clinical practice of medicine. The failure of conventional medicine to be on alert and to recognize that a person can be ill but have normal laboratory blood test results is alarming. Many sufferers are sent home to self-navigate and are abandoned by the very health professionals who are supposed to help them recover.

To make matters worse, most conventional physicians are not nutritionally oriented or trained. Even if laboratory tests come back abnormal, they are at a loss on how to correlate it with clinical findings when the presentation is overwhelmingly convoluted as one sees commonly in Adrenal Fatigue.

NeuroEndoMetabolic (NEM) Model

In order to comprehensively understand and assess conditions like AFS, a different approach must be undertaken by healthcare professionals. Two major factors of the body’s response to stress must be combined: the typical neuroendocrine factor and the functional metabolic factor. Incorporating the systemic metabolic component with the organ specific neuroendocrine component allows the healthcare professional to get to the root cause of symptoms and develop adequate remediation efforts. In this model, there are six circuits that all work interdependently in dealing with stress. These six circuits include the metabolic, detoxification, inflammation, cardionomic, neuroaffective, and hormone response circuits.

When Normal is Not Normal with Laboratory Testing

To illustrate how a normal laboratory test can be present in a body that is not well, let us consider the following:

  • Most Adrenal Fatigue sufferers have low immune function present with frequent infections but normal white cell count. Low or low normal white cell count can be a sign of poor immune function. Nutritional deficiencies, such as low zinc, low magnesium,low B vitamins, and low essential fatty acids can contribute to this. Normal white cell count does not rule out these problems at the sub-clinical level.
  • Normal platelet count does not rule out stealth viruses or a residual bacterial infection, such as that seen in post-acute Epstein-Barr virus infection. Low or low normal platelet count can be a sign of toxic stress from viral or emotional forces.
  • Borderline or high mean cell volume (MCV) suggests B12 deficiency, folic acid deficiency, or hypothyroidism. Normal MCV can occur with sub-clinical B12 deficiency in those who are constitutionally weak or sensitive.
  • Low white blood cell count is common in laboratory testing for Adrenal FatigueA normal fasting blood sugar in absolute terms associated with clinical hypoglycemia is common in advanced stages of Adrenal Fatigue.
  • Normal electrolyte levels do not rule out the presence of debilitating sub-clinical dilutional hyponatremia seen in advanced Adrenal Fatigue.
  • A normal thyroid Free T3 and Free T4 do not rule out secondary subclinical hypothyroidism due to pituitary or adrenal dysfunction.
  • Normal aldosterone level with salt craving and low blood pressure is commonly found in Adrenal Fatigue. Both serum aldosterone and sodium levels are usually within normal range.
  • Normal potassium level does not rule out the need to reduce internal potassium load. In Adrenal Fatigue, sodium depletion is common, leading to a relative (and not absolute) potassium overload that is still within normal laboratory range on testing.
  • High normal liver enzymes usually suggest liver dysfunction, typically from chemicals such as medications, or poor nutritional status. Normal liver enzymes are commonly associated with poor clearance of metabolites in Adrenal Fatigue as the body slows down to conserve energy.
  • High normal or high total cholesterol could mean low levels of vitamin D or hypothyroidism commonly seen in Adrenal Fatigue and does not necessitate the administration of statin medications to normalize lipid level.
  • A normal TSH can be present in those with clinical hypothyroidism. In other words, you can be suffering from hypothyroidism but have normal TSH levels.

Laboratory testing plays an important and significant part of assessing bodily function. It should not be disregarded. However, as you can see from the above, just because laboratory testing results are within normal range does not necessarily mean a person is free of illness. Many chronic illnesses, including Adrenal Fatigue, progress over time slowly. Sole reliance on routine blood serum laboratory tests for definitive assessment is a grossly incomplete approach to start in the case of Adrenal Fatigue.

Read Part 2 Now!

© Copyright 2016 Michael Lam, M.D. All Rights Reserved.

Laboratory testing is common when diagnosing Adrenal Fatigue
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Thank you very much, Dr. Lam, for your reply to my question. Just wanted to say that I’ve been following your guideline diet completely, word by word, and I have lost rapidly weight, from 85 kg to 68 kg. I feel much better since I stopped eating meat. I occasionally eat some chicken breast, but most times fish and soy products. Definitely, there is a health improvement.


  • Jean says:

    I did the Saliva Adrenal Fatigue test and it says the DHEAS is lower that the expected age range (age 60 – female). Cortisol is within expected range throughout most of the day, but rises to a high level at night. Also, it says Metabolic Syndrome is 51.1, High Cortisol 41.7, Low Cortisol 57.5. What does this mean?

  • Selven Sadhasivam says:

    I am 47 years old and had a kidney transplant when I was 14 years old and it lasted till 2008. Now I am on PD dialysis. My Blood Pressure was high and I was on BP medication till about two years ago. My blood pressure went down slowly starting in 2015. I was also on prednisone for a long time for 27 years. Doctor discontinued Prednisone 4 years ago. Is it possible that since I am on dialysis and no kidney function at all, is it possible that my aldrenal glands are producing less aldersterone and coristal levels to cause the low blood pressure. Can a blood can determine my aldosterone and coristol level. Thanks

    • Dr.Lam says:

      Your situation is very complex and there is no simple answer because there is a strong interplay between the adrenals and the kidney. A much more detailed over the phone discussion is needed for me to give you an accurate assessment in real time.


  • Riudy Lopez says:

    i am greatly concerned for my 28 year old daughter. She was diagnosed by our chiropractor with Adrenal Syndrome. His knowledge in applied kinesiology helped to determine this. She had several blood test from MD and everything test ok, including CT scan and heart test. She has been like this for 7 weeks and is always tired. She just had a fire in her aprtment and now lives with us. Her mom has her on a strict diet of all organic foods for the past month which includes chicken, fish and hard boiled eggs for protein. She gets dizzy often and gets stressed often. Her boss has been very supportive. Doctor’s say she doesn’t have this and want to give her stress meds. We are in the east bay of San Francisco bay area. The doctor says the stress meds will make the dizziness go away and the stress and she will get her energy back and that’s all she needs. She had been progressing but after the fire, she went down hill again. If she doesn’t eat every 2 hours, she feels dizzy and sick. Could we have several problems going on. The doctors checked her ears and found nothing wrong. What do we do.

    • Dr.Lam says:

      AFS is a condition that requires detailed history to put the pieces together. Lab are usually normal.
      Her signs are classic of adrenal exhaustion.
      Click Adrenal Exhaustion for more information.

      Dr Lam

  • Rahul says:

    hi dr lam… i have had my liver function test done…everything is normal except sgpt..149 (range is 21-72)… and slightly high albumin..5.3 (range is 3.5-5)…. also i have grade 1 fatty liver. my endocrinologist doctor also adviced for serum calcium and phosphorus…results came to be …calcium 10.3 mg/dl(range is 8.4-10.2) … phosphorus is 4.8 mg/dl (range is 2.5-4.5).
    Also my TSH has been increased from 0.9 to 1.7 to 2.1 uIU/ml (range is 0.35-4.94).
    my serum cortisol at 8 am came to 10.1 mg/dl(range is 3.7-19.4)
    I have symptoms of adrenal exhaustion..hypoglycemia, heart palpitation,bp problem..shortness of breath..difficulty speaking when energy is low..
    i want to know why my sgpt and some other parameters are elevated

    • Dr.Lam says:

      There may be multiple issues going. Your doctor will go through the numbers with you. We do see type of pictures in AFS cases sometimes when the body’s metabolism is deranged. It is far too complex to be able to be dealt with in this forum as will require extensive history to sort it out.

      Dr Lam

      • Rahul says:

        Will my calcium and phosphorus levels create any problem?..i am consuming cod liver oil since last 4 months as my vitamin D level was low…what should I have to do dr lam..

        • Dr.Lam says:

          Calcium is highly and tightly regulated by the body. Any deviation can be problematic and needs to be further investigated.

          Dr Lam

          • rahul says:

            my triglycerides levels are high..245 (upper range is 150)… but my cholesterol level is within limit …170 (upper limit is 200)…what does is mean doctor lam…sometimes I also feel heaviness of chest and slight difficulty in breathing…….kindly interpret it for me dr. lam…thanks

          • Dr.Lam says:

            Unless there is an hereditary issues, triglyceride level is directly tied to your intake of carbohydrates. It is also a risk factor for cardiac disease which you need to see your doctor.

            Dr Lam

  • Mary Kay Gould says:

    Dr. LAM-THANK YOU for this interesting article. I have been on a very long journey since 2006 post donor nephrectomy, husband’s job loss, move, etc. I have tried to not lose faith in the medical profession, but tired of hearing “your labs are normal” when I feel horrible. I have been told by a digestive health doctor and gyn, that my abdominal pain is psychological. Finally, a begged my NINTENDO a full panel thyroid which cost me $700 thru the hospital, but can get on line for $200. Anyway, it in my opinion clearly showed a T3 issue, pointing to adrenal fatigue. I would like your opinion. If so, aside from eliminating stressor which is impossible, (but I am good at categorizing them), is there a good supplement to take? I have looked at a few but it’s hard to know for sure. I don’t fully understand the high/low cortisol or T3/T4 issue though I am learning. I have been to 3 naturopath doctors since 2006 and after a year feel no difference. I am really concerned that the medical field doesn’t study the intricacies of the Thyroid, parathyroid, adrenal glands more. I am firmly convinced it is the basis for my stomach issues as well as I have a clean diet. Thanks for your help.

    • Mary Kay Gould says:

      Darn spell correct: not NINTENDO, my NP. Also, my labs were: T3 Reverse 2.8, T3 Free 2.5, TSH, 1.35, T4F 1.03, TPO 40.

    • Dr.Lam says:

      Conventional medicine is years behind in understanding AFS unforunately. Many sufferers have recovered, but the journey for each is different. Here are some articles for you to read . The more you understand, the better you are able to take steps to recover. Good news is nothing you mentioned so far is unusual. Our telephone based coaching can possibly help you if you qualify. Click Adrenal Fatigue versus Hypothyroidism for more information.

  • Crystal says:


    What in your professional opinion is the most accurate blood work to determine autoimmune diseases , adrenal fatiguel , high estrogen dominance and cancers? Also how do you know if you have sojorgens disease? I have a coated tounge will not scrape off,dry mouth!. Ty

    • Dr.Lam says:

      There are conventional work ups for auto immmune disease that is well established, such as Sjorgens. For adrenal fatigue and estrogen dominance, a detailed history by someone who really knows is key. you can spend a lot of money on lab and be confused and mislead. Click Laboratory Testing for more information. Coated tongue may indicate yeast.

      Dr Lam

  • Judith Deen says:

    Dr. Lam…my saliva labwork under the Cortisol-DHEA-Correlation Spectrum says (#7, Adrenal hypofunction: low cort, DHEA). What does this mean? (I am white, 69, woman, with a negative on Autoimmune blood labwork. I have duodenal ulcer, under care by Gastro MD, prescribed Carafate Suspension.)

  • Pipi says:

    Dear Dr Lam,
    Thanks so much for your wonderfully informative articles.
    My 17 year old son was diagnosed 2 years back with a severe mycoplasma pneumonia infection causing extra pulmonary manifestations affecting, heart, nervous system, and liver. He was given sustained antibiotics. He has severe fatigue still with tachycardia, loss of appetite and cold feet and hands. He struggles to get up in the mornings and has lost muscle mass. In March his saliva cortisol test showed to be low and flat. He also has a low Ig M and natural killer cells and high Ig E. What would you recommend for him?
    Many thanks,

    • Dr.Lam says:

      When a body is as weak as he is, you first need to be very careful and take time to formulate the right plan for long term recovery. Click 7 Adrenal Fatigue Recovery Mistakes for more information. The good news is that their immune system etc do recover fast, provided that the adrenal system is health and well supported.
      Young people have a very unique set of challenges different from adult. Its too much to be on this forum. YOu should find a doctor who is experienced because navigating this for long term recovery is not easy.

      Dr Lam

      • Pipi says:

        Many thanks for your reply Dr Lam. I am grateful.
        Unfortunately it is very common for a lot of endocrinologists to exclusively focus on test results and ignore the holistic clinical picture. They are in denial of adrenal fatigue as a problem and hence won’ t treat. They also are disregarding the cortisol saliva low flat levels which is frustrating.

  • Jane C says:

    I am impressed with your articles. You really “look” at the human body as holistically as possible.
    I am 60 y.o , in good health , running 2 miles 2-3 times/week until jan 4,2016. Out of nowhere, that morning I fainted and lost consciousness, alone at home. Recovered spontaneously, still “groggy” I called 911 , the ambulance came ( probably for another “drunk”- by the way the cost of ambulance was 500 dollars, the insurance company paid 400 dollars-alleluia !).They told me I had “VASOVAGAL” and I will OK. Actually, I was not. For the next 1.5 months after the fall, I was on complete bed rest due to lightheadedness,dizziness,and clinical Hypoglycemia( the fingerstick was not low but I was very symptomatic with perspiration, lightheadedness, relieved with eating)
    I went to 3 endocrinologists, I have known hypothyroidism-had partial thyroidectomy 30 years ago). The first endo almost “threw me out of the office” since I was insisting that I was not well. The second , at least listened to me and gave me blood work, all normal(TSH/T3/T4/cortisol, electrolytes)The third endo listened too, but told me that he did not know what I had and if my sugar is not lower that 65 mg/dl when symptomatic, he can not do anything.
    Fast forward, I learned how to live with my symptoms, I eat small meals every 3 hrs ,just to survive. I am back at work and take one day at a time.
    Best regards from yet, another sad case of undiagnosed Adrenal fatigue by Western medicine!

  • Shasha says:

    Gluten may make antibodies to the intestines and hurt other glands. The pituitary may get hurt and not make TSH due to gluten. Heavy metals may block the thyroid and thyroid hormone. Mitochondria maybe hurt by antibiotics/chemicals/heavy metals and this issues is not seen on thyroid tests. MS people may have a strange TSH so doctors may not help them with thyroid medicine. They may get cooling suits/air conditioning/statin drugs/antidepression medicine/diuretics and more instead of thyroid medicine they need. They may have mitochondria issues/Celiac/heavy metals etc.

  • Christi B says:

    I go in today to retest labs for slightly elevaded red blood cell count. I am magnesium deficient if that matters any. The doc wants to send me to hematology if it isn’t normal this time. I was exhausted for two months and once I started upping my d and magnesium I slowly began feeling better. Hypertension went away, as well as rapid heart beat, panic attacks, severe exhaustion, insomnia, sweating palms and feet, tremors, blood sugar imbalances and many more weird symptoms. I was having to take b12 just to make it to the appointments back then as my energy was non existent. Could taking the b12 right before labs have any affect? Also what are other reasons my rbc count could be high bit everything else look great? My doctor is clueless . She did have me test for an adrenal tumor by doing a 24 hr urine catch test that I completed this morning. Any thoughts on that? I’m feeling batter. Probably ninety percent my normal self. I don’t want to worry if it’s not necessary but the medical community has me either dying, with cancer, or some rare blood disease! Your advice would be greatly appreciated. Thanks again for another great article. It is clear that you not only know what you are talking about,mount that you love what you do.thank you for that.

    • Shasha says:

      Celiac can cause low minerals/Vit B12/energy/Mg and much more. Tests may not work to diagnose Celiac. Cyrex labs may help. No Grain No Pain book/Dangerous Grain book/Wheat Belly book are good and Grain Brain book. Lyme may also lower Mg in addition to gluten.

      Lyme help…Far Infrared Sauna/Celiac help/LDN/ozone/herbs helped me. Best wishes.

      This is what I do for Celiac.:
      No gluten/dairy/soy/sugar/GMO and vitamins/good oils, LDN and detoxing help me. Vit D3 5000IU, zinc 50mg if detoxing, 2000mg fish oil , 20000mg evening primrose oil. 2000 mg lecithin, Phosphatidylserine/DMAE, krill oil, CLA, Coenzyme Q10, Rhodiola, Mg citrate 400mg, Vit C, 5000mcg of biotin, Nature’s Plus- Source of life multiple, HCl and enzymes with meals, dairy free probiotic, Vit B12 methylcobalamin shot/spray/under the tongue kind/intrinsic factor kind, MTHF folate, coenyzme Q10, rhodiola, may help brain/body/thyroid/depression/immune system and more. Gluten is wheat/barley/rye/corn…oats has gluten with avenin. GMO corn/soy/canola oil may hurt. Amour thyroid maybe needed since gluten may made antibodies to the thyroid. Coenzymated B vitamins far from synthetic kind make make me calm.

      Sunlight (helps the immune system and helps to heal the gut lining),exercise, organic food, good water..not tap water, cooking by scratch pure food….. no food in a box/bag/premade/label/restaurant which may help avoid hidden gluten. Certified gluten free food may have 20ppm of gluten…too much. Nuts not sold in the shell/meat basting/some spices may have hidden gluten and lotion/make up etc. One restaurant cooks special for me…rice/veg/tea/extra mushrooms (no meat since the woks may have MSG/gluten in them).

      EDTA/DMPS IV chelations from an Alternative doctor, 600mg of cilantro, organic sulfur, Now brand- Detox support, Far Infrared Sauna and more may help detox. Hair tests show good minerals and heavy metals. Heavy metals can block thyroid and other chemical reactions in the body/brain.

      LDN may help block hidden gluten/heal the gut lining and help the immune system, but the Celiac diet is still needed. 100% no hidden or microscopic gluten may help. Cutting back on gluten or cheating by eating gluten hurts the immune system. It may take 1 1/2 months to heal the gut lining after getting hidden gluten.

      Amour thyroid has some T3 and Calcitonin. Synthroid is only T4..may not convert to T3. Zn/Se/enough iron/strong probiotic may help convert T4 to T3 for thyroid.

      Alternative doctors/chiropractors/acupuncturists and more may help with health/vitamins etc.

    • Dr.Lam says:

      Its good to retest. RBC elevation has many causes. AFS is seldom related to that. Do be careful as far as your assessment of Magnesium unless you get an intracellular magnesium level as serum level does not tell you the real level. Most people can use more magnesium anyway, so it is good for most people as it is relaxing. B12 does not have effect on RBC , but it can increase your energy and you need to be careful as long term may be problematic.

      Dr Lam

  • siobhan says:

    Hi Dr Lam I have adrenal fatigue. My hair mineral analysis shows undetectable potassium levels and low sodium. Is this the opposite of what you would expect? Thanks!

    • Dr.Lam says:

      Hair analysis is not the preferred method of accessing and evaluating electrolyte such as sodium and potassium. Be careful how you try to interpret data.

      Dr Lam