Medical school teaches nothing about adrenal exhaustion (also known as adrenal fatigue). Most conventionally trained physicians believe this not to be a real medical diagnosis. Instead, it is simply felt to be only in the mind of the patient with no actual pathophysiology. Until very recently, this was exactly what was believed to be the case for other conditions that are also not well understood such as chronic fatigue syndrome, fibromyalgia and irritable bowel syndrome. A more medical sounding name, that the functional medicine physicians have started using instead of “adrenal fatigue/exhaustion,” is “hypothalamic-pituitary-adrenal axis dysfunction” or “HPA axis dysfunction.”
Diseases develop in a continuum:
Conventional medical education is an ‘all or nothing’ science, you either have a certain condition or problem or you don’t. For example, think about the ‘normal’ range on a blood test. If you have any result in the normal range you are considered healthy, and if you have a result outside of the range you are unhealthy. This makes very little sense, as most medical conditions are not truly ‘black or white.’
One example of this is diabetes. Until recently, medical doctors only considered patients with full-blown abnormalities in their blood sugar levels (diagnosed with a high fasting blood sugar) as having a medical condition that required treatment (type 2 diabetes). We now know that type 2 diabetes develops as a continuum from mild-to-severe insulin resistance, as there is no numerical ‘threshold’ blood sugar level that is all of a sudden unhealthy. The more informed and progressive medical doctors now recognize the earliest stages of insulin resistance as “pre-diabetes,” a condition that leads to high blood sugar and high insulin levels when someone eats a meal with too much sugar or carbohydrates.
The same analogy can be made with the diagnosis of high blood pressure (anything above 120/80 mm/Hg)…why is 121/80 all of a sudden an unhealthy blood pressure? Seems quite arbitrary to me. Wouldn’t you want to start making healthful lifestyle changes below 120/80?
Similar to pre-diabetes and pre-high blood pressure (pre-hypertension), adrenal exhaustion represents physiologic dysfunction that occurs through a continuum from stage 1 to stage 3 (as you will read below).
Chronic stress causes adrenal exhaustion:
- The top 4 causes of cortisol imbalances: #1) emotional stress, #2) dietary stress/poor diet, #3) pain, #4) hidden sources of systemic inflammation (i.e. toxins, gut inflammation, free radicals, etc.)
Normally, when the stress goes away, the adrenal glands have time to rest and prepare for the next stressful event. However, if your stress levels remain chronically high (months-to-years), your adrenal glands will continue to produce higher than normal levels of these hormones. This can lead to:
- Impaired immune system strength (long-term exposure to cortisol suppresses the immune system)
- Increased production of free radicals
- Insulin resistance (leading to increased blood sugar, insulin levels and body fat)
- Increase bone breakdown (cortisol causes calcium to leach out of the bones)
- Etc…
So far, the majority of medical doctors will agree with what I have written.
The following (below) is where most medical doctors begin to disagree…
Theoretically (although I am convinced based on my clinical experience), if your stress hormone levels remain elevated for extended periods of time (years-to-decades), the ability of your adrenals to make cortisol and DHEA can be compromised. If this stress continues, the high levels of cortisol and DHEA begin to drop as the adrenals eventually “burn out.” At this point, the adrenals become exhausted/fatigued and can no longer sustain an adequate response to stress. Although they continue to produce these hormones, they do so at much lower levels. This is can lead to the following:
- Constant fatigue (lower than normal levels of cortisol & DHEA make you feel tired)
- Low-level depression (lower than normal levels of cortisol & DHEA can cause a depressed mental state)
- Poor memory and mental confusion (lower than normal levels of cortisol & DHEA can cause diminished brain function)
- Increased systemic inflammation (lower than normal levels of cortisol lead to increased systemic inflammation)
- Impaired immune response (short bursts of cortisol are needed to activate immune cells against infections)
- In men: decreased muscle mass and sexual libido (lower than normal DHEA levels lead to lower production of testosterone)
- In women: diminished sexual libido and increased hormonal symptoms, such as menstrual cramping, infertility, night sweats, hot flashes, emotional lability (lower than normal DHEA levels lead to lower production of progesterone, estrogen and testosterone)
- etc…
In my medical school training, I was taught that adrenal exhaustion was a bunch of nonsense and that the only time the adrenal glands produced lower levels of hormones was in the presence of some extremely rare tumors of the adrenal glands or pituitary gland or from a severe auto-immune condition that destroys the adrenal glands.
Thanks in part due to the new field of Functional Medicine I have been better able to understand the affects of chronic stress on the body and the adrenal glands, as well as how to diagnose and treat adrenal exhaustion.
The 3 stages of adrenal exhaustion:
Stage 0 (green part of the graph below) is when the adrenal glands are not under any significant stress and are producing cortisol and DHEA at normal levels that promote a healthy immune system, minimal-to-no inflammation and normal amounts of free radical production.
Stage 1 (yellow part of the graph below) is defined as the period of time in which stress causes a prolonged elevation of cortisol and DHEA. This can last from months-to-years, which is based on an individuals’ genetic ability of their adrenal glands to continue to produce high levels of these hormones under chronic stress. This will vary in each individual. Stage 1 is also called “overactive HPA axis.”
Stage 2 (orange part of the graph below) is the period in which the adrenal glands start to become compromised, and they can no longer sustain an adequate response to stress. Although the total daily amount of cortisol and DHEA may still be normal, there will be times during the day in which the levels are below normal levels.
Stage 3 (red part of the graph below) is the most severe level of adrenal exhaustion. At this point, the adrenals are producing lower total daily levels of cortisol and DHEA. Stage 3 is also called “underactive HPA axis.”
CAVEAT:
- The above representation of cortisol levels with the stage of adrenal fatigue is actually an oversimplification. When you see the cortisol levels above, what we are in fact measuring is the “free cortisol” level. Since only 1% of all the cortisol in our body is in this “free” state (unbound to protein), to more accurately know what’s really going on, we need to know what the amount of the other 99% of cortisol is up to (high or low.) This is only able to be measured using the “DUTCH” adrenal assay, not the salivary cortisol assay. (Read more about the DUTCH assay in the section below “How Do You Diagnose Adrenal Exhaustion?”)
- Sometimes you may have a free cortisol that is high, but the total cortisol production is normal or low.
- Authorities you may have a low free cortisol, but the total cortisol production is normal or high.
- Both of these situations need to be interpreted by your clinician to truly assess whether you have an HPA axis dysfunction or not.
What are the potential associations between adrenal exhaustion and cancer?
Cancer prevention:
We know that every one of us produce many millions of cancer cells in our body each day. When our tissues are more conducive to cancer growth, we have a greater chance of developing a cancerous tumor. Research shows that we may be able to prevent the development of 90%+ of cancers by ‘anti-cancerizing’ our bodies through living a healthful lifestyle and avoiding exposures to carcinogens.
Your body may be less able to prevent cancers from developing when your adrenals are not functioning properly, as you can have an impaired immune system, increased inflammation, increased insulin resistance, increased production of tumor growth factors, etc.
Read much more about stress and cancer on a previous IOE post.
After a diagnosis of cancer:
Studies have shown that the majority of people who have been diagnosed with cancer live with the fear that it could grow, spread or come back after treatment. These emotional feelings can become a chronic source of stress on the mind and body (leading to adrenal exhaustion).
Cancer treatment itself is often hard on the body. Depending on the specifics of the treatment, the affected tissues in your body can be subjected to injury and inflammation that may lead to chronic elevations in systemic inflammation and free radical production (leading to adrenal exhaustion).
Although no studies have yet been done on this, it would not surprise me if “chemo brain” and “cancer-related fatigue” could partially be explained by adrenal exhaustion…
How do you diagnose adrenal exhaustion?
The easiest way is through a simple, relatively-inexpensive (approximately: $100-$200), non-invasive saliva test. As an alternative, I also recommend a dried urine collection technique (Dried Urine Test for Comprehensive Hormones, “DUTCH”. The DUTCH test enables us to assess the metabolites of cortisol, which provides a broader understanding of your stress hormones (approximate cost: $150-250.)
Watch this video explanation of why I prefer to use the DUTCH test.
How do you treat adrenal exhaustion?
Fortunately, you absolutely can recover from adrenal exhaustion. It is treated mainly with lifestyle changes that reduce chronic stress (i.e. diet, exercise, stress reduction, elimination of toxic exposures, optimize sleep). In more severe cases, counseling/therapy, supplements and/or medications may be recommended.
The bottom line:
Adrenal exhaustion (or HPA axis dysfunction) is not yet commonly accepted in conventional medical practices, but this will likely change over the years as it becomes more widely recognized and studied in high-quality clinical trials. There is no need to wait until that point though. I believe that all patients who have had cancer and those who want to ‘anti-cancerize’ their body should consider getting this test to help guide them in their journey on living the healthiest lifestyle they can.
