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Beating adrenal fatigue

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Professor Hans Selye, a Hungarian-Canadian endocrinologist (1907–82), was the first to address the physiological and pathological basis of stress together with the body’s reaction to such. He described the pathological picture that resulted, which he called the “general adaptation syndrome.” Although stress was a common term in physics, Selye introduced it into medicine to describe the “nonspecific response of the body to any demand.”

With short-term stress, he discovered that patients would experience adrenal swelling as the adrenals upgraded production of, and poured out, their hormones. However, with long-term unremitting stress, he found that adrenal glands would shrink, as would immune systems, then the person would suffer severe weight loss and the condition would culminate in death.

The pathological picture described by Selye was the same regardless of the stressor: overwhelming infection, sleep deprivation, cold exposure, chronic pain, emotional stress, starvation, social isolation, financial hardship and much more. It really was a “general syndrome.”

Professor Selye described what he saw, but not the “how”—the mechanism that lay behind it. He compared the human experience with a car motoring along and finally wearing out: adrenal glands swelling in response to acute stress, healing and repairing with rest, but shrinking to a state of atrophy with burnout following chronic, unremitting stress. Today, I think we can explain that “how” in terms of energy delivery mechanisms.

What are the adrenal glands?

The adrenal gland is the “gearbox” of our car, responsible for matching energy demand with energy delivery. It is additionally responsible for controlling the amount of inflammation in the body. It achieves this by secreting adrenaline (the short-term response, measured in seconds and minutes), followed by cortisol (a medium-term response, measured in minutes and hours), followed by DHEA (dehydroepiandrosterone, a longer-term stress hormone).

The Hungarian endocrinologist Hans Selye showed that if you stress rats, their adrenal glands enlarge to produce more stress hormones (including cortisol and DHEA) to allow the rat to cope with that stress. If the rat has a break and a rest, then the adrenal gland returns to its normal size and recovers. 

However, if the rat is stressed without a break or a rest, it will be apparently all right for some time but then suddenly collapse and die. 

When Selye looked at the adrenal glands at this point, they were shriveled up. The glands had become exhausted.

The current Western way of life is for people to push themselves more and more. Many can cope with a great deal of stress, but everybody has their breaking point. 

The adrenal gland is responsible for the body’s hormonal response to this stress. It produces adrenaline, which stimulates the instant stress hormone response (“fight or flight” reaction), and cortisol and DHEA, which create the short- and long-term stress hormone responses respectively. 

When the gland becomes exhausted, chronic fatigue develops, and tests of adrenal function typically show low levels of cortisol and DHEA. DHEA has only recently been studied because it had not been recognized as performing any important actions.

All steroid hormone synthesis starts with cholesterol. The first biochemical step takes place in mitochondria, where there is a conversion to the hormone pregnenolone. The body can then shunt from pregnenolone either into a stress or catabolic mode (to cortisol) or a rebuilding mode (anabolic hormones such as DHEA, testosterone and estrogen).

Stress and increased energy demands 

Stress is invariably accompanied by a demand for more energy. When energy is available, we can deal with whatever life chooses to throw at us. With energy, we can do it all and surmount all demands and obstacles. This brings reward, satisfaction and survival. After such achievement, we rest and recover.

If energy is not available in the short term, we cannot spend it because if energy spending exceeds energy delivery, we die. There is no energy to power the heart and other organs. 

Indeed, this is how our first marathon runner died, a Greek messenger named Philippides who  ran from the battlefield at Marathon to Athens after a battle against the Persians in order to relay the great news of victory. He had sufficient energy to say “We were victorious!” but then collapsed and died. He had overspent his energy reserves.

To prevent us all from dying like our heroic Greek through an energy overspend, the body gives us nasty symptoms. These symptoms have to be very unpleasant—if not, we could ignore them and go on spending energy. 

Symptoms and signs of low thyroid and overstressed adrenals


  • Poor energy delivery to the body, including chronic fatigue syndrome / myalgic encephalitis with poor stamina; all activities must be paced
  • The body runs cold
  • Intolerance of cold
  • Intolerance of heat
  • Obesity
  • Poor energy delivery to the brain, including foggy brain, poor short-term memory, and inability to multitask or problem solve. In children this amounts to low IQ; in adults, often mental illness; and in the elderly, dementia.
  • Addictions—Obvious addictions include caffeine, alcohol, nicotine and other such. However, the most pernicious addiction is to sugar, fruit sugar and refined carbohydrates.
  • Dark circles under the eyes
  • Susceptibility to infections
  • Slow healing and repair
  • Poor quality hair, skin and nails
  • Gut problems: leaky gut, allergies, inflammation
  • Anemia
  • Low numbers of white cells
  • Larger and stickier platelets, increasing the risk of thrombosis
  • Accelerated aging with organ failures (heart, brain, renal, etc.) and degeneration (arthritis, osteoporosis)
  • Inflammation—Where there is leaky gut, there is potential for gut bacteria, fungi and viruses to leak into the bloodstream and body tissues, which I suspect drives many arthritic conditions), temporal arteritis, venous ulcers, inflammatory bowel disease, intrinsic asthma, kidney disease, myocarditis, irritable bladder, possibly psychosis and cancer.

How to diagnose poor adrenal function (adrenal fatigue)

 Mainstream medical doctors never diagnose adrenal fatigue. They only recognize complete adrenal failure, or Addison’s disease, and diagnose this on very low serum cortisol and a short synacthen test—that is, the degree to which serum cortisol rises in response to kicking the adrenals with adrenocorticotropic hormone (ACTH). 

However, complete adrenal failure is rare, whereas reduced function is common. This is another medical situation where you will largely need to sort yourself out, ideally with a good naturopath.

Again, diagnosis is hypothesized on some of the following symptoms, signs and tests and confirmed by response to treatment.

Interpretation of an adrenal stress test

Poor energy-delivery symptoms: Because the adrenals are an essential part of energy delivery mechanisms, adrenal fatigue may present with all the symptoms of poor energy delivery. 

A useful clinical measure of the sum total of energy-delivery mechanisms is core temperature. This makes perfect sense. Starvation, mitochondrial failure, an underactive thyroid and underactive adrenals will all present with low core temperature, and for such to normalize, all aspects of energy delivery need to be addressed. 

Being a night owl: It is the combination of adrenaline and cortisol that wakes you up. This means the person who has late surges of adrenaline and cortisol will only come to life during the late afternoon or evening.

Wired but tired: As adrenal glands fatigue, those hormone levels that we measure clinically drop in a particular order—first sex hormones, then DHEA, followed by cortisol and finally adrenaline (see the chart on page 43 for an explanation of the hormones). 

Normally, the stimulating effects of adrenaline are mitigated by cortisol and DHEA. This does not happen with adrenal fatigue, which I suspect is the mechanism behind this symptom, with inability to drop off to sleep, poor quality sleep and exaggerated startle reflex.

Salt and water imbalance problems: Adrenal fatigue can be associated with a craving for salt, tendency to dehydration, possibly frequency of micturition (needing to pee often), tendency to low blood pressure and muscle cramps. Regulation of salt and water balance occurs via steroid hormones known as mineralocorticoids.

Inflammation: Adrenal hormones control inflammation in the body. With adrenal fatigue, there is a tendency to inflammatory conditions such as allergy and autoimmunity together with an increased susceptibility to infection.

Adrenal stress test (saliva): This test measures levels of cortisol and DHEA (and melatonin on request) over 24 hours. It is the most useful test for adrenal function because salivary levels of DHEA and cortisol are accurate (arguably better than blood tests because blood tests are skewed by protein binding and the stress of undergoing blood testing). Tests can be done in the less stressful environment of home and are easily available to all.

Normally one expects to see high levels of cortisol and DHEA in the morning, which fall as the day progresses. The level of DHEA should be commensurate with the cortisol.  

Treating adrenal fatigue 

There are two key steps to treatment. First take the pressure off the adrenals and feed them. Then reduce their workload with herbals and adrenal glandulars.

1. Take the pressure off the adrenals and feed them 

Essentially, the adrenals get fatigued because the body does not have the energy to deal with demands. In the short term, much can be achieved on adrenaline, but this is not sustainable in the long term. Look for ways to reduce the demands on your life—nutritional, physical, mental, emotional, financial, social, etc.  The largest stress comes from addictions: carbohydrates, caffeine, alcohol, nicotine, etc.

The adrenal glands are restored with rest: good sleep, naps in the day, meditation, weekends and holidays. Make sure you give them this opportunity if you can.

The adrenals are also particularly demanding of vitamin B5, vitamin C, salt and fats. These are all part of the Groundhog Basic regime (see page 45). 

2. Reduce the work of the adrenals with herbals and adrenal glandulars 

There are no hard-and-fast rules here, and it really is a case of trial and error. The most useful to try, possibly in combination, are:

  • Ashwagandha: start with 1 g (some people take up to 4 g daily) 
  • Ginseng: 1–3 g of the root powder
  • Bovine adrenal glandular: cortex 150–450 mg 
  • Pregnenolone: the most upstream of the adrenal hormones, also dubbed the “memory hormone” (by upstream I mean that subsequent hormones are synthesized from it: DHEA, cortisol, all the sex hormones, aldosterone (a mineralocorticoid)—all downstream of pregnenolone. Cholesterol is the starting point for all). 25–100 mg 
  • DHEA: 25–100 mg
  • All of the above supplements should be taken on rising or split into two doses taken on rising and at midday. This is done to mimic the normal diurnal (24-hour) rhythm of adrenal hormones.

Cortisone cream 

Cortisol is the hormone that is in most demand, and the adrenals make this in preference to all else; consequently, hydrocortisone cream 1%, 1–2 mL (10–20 mg), rubbed into the skin is often remarkably helpful in providing adrenal support. This dose is physiological and so there is no adrenal gland suppression. You can purchase it over the counter.

The risk of suppressing adrenal function

The use of any of the above products in these doses does not suppress adrenal function. The idea is to plug a gap where such exists—to prop up and support while the adrenal glands recover. This renders these treatments extremely safe.

By contrast, mainstream doctors prescribe adrenal hormones in huge, non-physiological, immune-suppressing doses that switch off endogenous production and cause long-term, life-threatening side effects. 

The commonest steroid used is prednisolone (not to be confused with pregnenolone!). Even the dose of steroids in asthma inhaler medications, nasal sprays and skin creams may be sufficient to cause adrenal suppression.

Salt and water imbalance 

If you have symptoms of salt and water imbalance, start with increasing salt and fat in your diet, then add in liquorice 1–5 g of root powder (not the sweet, black stuff sold as candy).

Which of the above preparations you use depends on your core temperature readings and the “How do you feel?” factor. It is, as noted, a trial-and-error experiment, but one that is well worth it.

Monitoring treatment of adrenal and thyroid remedies using core temperature

If all energy delivery mechanisms are working well, we should have an average and stable core temp of 36.7–37.3 °C (98–99 °F). If we do not, then we need to act accordingly.

Assess this by using a FIR skin thermometer (very quick and easy) in a warm room (say, 20 °C  or 68 °F) to check your temperature several times a day. Interpretation must take into account that:

  • Thyroid hormones are long-acting and “base load.” The average core temperature reflects thyroid function.
  •  Adrenal hormones act in seconds, minutes and hours. With perfect matching of energy demand to delivery, the body’s core temperature is remarkably stable. We can use fluctuations of core temperature to assess adrenal function.

If, despite reasonable rest and good doses of adrenal support (as above), there is still marked fluctuation of temperature, this may point to the immune system being active in an attempt to deal with a chronic infection.

This can be a useful clue in treating patients with ME (characterized by poor energy delivery and chronic inflammation).

These temperature readings allow one to balance the underactive thyroid and adrenal glands, and in practice we address the two simultaneously as they often coexist. In essence, the procedure is this:

  • If core temperatures fluctuate “too much” (this will be measured by the actual temperature fluctuations themselves, but also consider the “How do I feel?” factor), then our adrenals are not at their personal optimal function and so we should consider support with one or more of the above supplements—herbals, glandulars, pregnenolone, etc.
  • If the average core temperature is “too low” (and this will be measured by the actual temperature—say, less than 36.7 °C (98 °F)—and also considering the “How do I feel?” factor), then the thyroid is not at our personal optimal function and so we should consider support with thyroid glandular.
  • As noted, we normally do these two things in tandem—they are often linked.

Avoiding your personal “dangerous corner” 

The first stage of adrenal support is to take the pressure off the adrenals, and you  should not forget that making sure you sometimes have fun in your life is a good way of doing this.

Groundhog Basic

The supplements noted above are what I call the “basic package”—they are what we (and especially children) should all be taking all the time.

It is so important to have all the below in place and then, at the first sign of any infection, take vitamin C to bowel tolerance and use iodine for local infections, because:

  • You will feel much better very quickly.
  • Your immune system will not be so activated that it cannot turn off subsequently. So many patients I see with ME started their illness with an acute infection from which they never recovered—their immune system stayed switched on.
  • The shorter and less severe the acute infection, the smaller the chance of switching on an inappropriate immune reaction, such as autoimmunity. Many viruses are associated with one type or another of arthritis—for example, “palindromic rheumatism.” I think of this as viral allergy.
  • The shorter and less severe the acute infection, the smaller the chance the microbe concerned has of making itself a permanent home in your body. Many diseases, from Crohn’s and certain cancers to polymyalgia and Parkinson’s, have an infectious driver.

Excerpted from The Underactive Thyroid: Do It Yourself because Your Doctor Won’t by Dr Sarah Myhill and Craig Robinson (Hammersmith Books, 2023)

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Article Topics: adrenal fatigue, cortisol
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