The Myth of Adrenal Fatigue

I recently had the good fortune to attend an event at which Dr. Spencer Nadolsky was talking about the popular diagnosis of adrenal fatigue.  I found his explanation enlightening and thought it would be worth sharing.

“The term ‘adrenal fatigue’ is a misnomer because it implies that the adrenal glands ‘burnout’ in a similar fashion to the pancreas in type 2 diabetes. The literature doesn’t support this which is why it isn’t a real diagnosis.

The only time this happens is with a condition called Addison’s disease, which is an autoimmune condition that destroys the adrenal glands, causing adrenal insufficiency. This is a BIG TIME problem and needs to be addressed quickly or people can get very sick and die.  In people that are diagnosed with ‘adrenal fatigue’, you can give them a cosyntropin (ACTH) stimulation test and they will react normally. ACTH (comes from the pituitary gland) is what tells the adrenal glands to eventually make cortisol. So in people with true adrenal insufficiency this won’t work quite well but in people with ‘adrenal fatigue’ it will.

Now here is the deal…

There is a subclinical dysfunction going on and it is really a dysfunction of the communication between the hypothalamus-pituitary-and-adrenal axis.  When you don’t sleep and when you’re constantly stressed, your adrenal glands don’t “burnout” but instead the whole pathway is disrupted, which causes all of the symptoms.  So there is a real phenomenon going on but it isn’t adrenal burnout.”

Upon asking how to repair this issue, this was Dr. Nadolsky’s response:

“For fixing what I term HPA Axis Dysfunction, it comes down to usually fixing your circadian rhythm via a VERY consistent sleep schedule. I am NOT a big fan of sleep medicines as they actually worsen the problem. Sometimes cognitive behavioral therapy needs to be utilized for sleep disorders but it must be fixed. It is essential.

Beyond sleep is the usual stress reduction through which ever modality you want.

Do adaptogens like rhodiola, ashwaghanda, holy basil, etc work? It is POSSIBLE but it really hasn’t been studied to the extent of me being able to really make an argument for it. There are plenty of naturopaths who will give you their anecdotes, which I suppose is fine but they are usually selling you the pills so be careful.

Some people believe using small physiologic doses of hydrocortef helps while doing the lifestyle measures. I would be VERY weary about doing this.

Also regarding the salivary cortisol tests. Here is the deal – salivary cortisol has been validated for the diagnosis of cushing’s disease (too much cortisol) – with a night time salivary cortisol. Many of the alternative docs are ordering what are called diurnal salivary cortisol tests where you spit into four different bottles at four different times during the day. This really hasn’t been validated for anything but could definitely give you some interesting data as a clinician to see how well you respond to exercise or if you are chronically stressed etc.

Here is the problem… who is validating these labs? I personally ordered 1 from 3 different labs and spit into these things all at the same time one day. Each test that came back should have followed the same pattern starting with the highest cortisol in the morning and ending with the lowest at night. Well what happened was one showed I was hypo functioning (low cortisol – signs of “adrenal fatigue”), one showed I was hyper functioning (signs of chronic stress), and one showed I was normal. Maybe one of them were right but how can you trust these things?”