As her health declined, she gained weight, the tiredness got worse, her skin became dry and her premenstrual tension was unbearable. A neck enlargement she'd had since she was a young girl was finally diagnosed as a goitre, although repeated thyroid tests came back normal.
Four years ago, she became nearly bedridden with terrible fatigue, deteriorating eyesight and memory loss.
When I first saw her at my clinic, it was clear from her symptoms that her adrenal function was poor and she had an underactive thyroid. Although I prescribed adrenal and thyroid support, which helped, during a hospital stay for a hysterectomy, the hospital declared this thyroid and adrenal treatment 'dangerous' and discontinued it. All improvement was lost and she became increasingly unwell. She lost most of her hair and had to spend much of her life in bed. The hospital finally told her she had ME (myalgic encephalomyelitis, or chronic fatigue syndrome) and would just have to live with her problems.
By the time I saw her a few months later she was very poorly indeed. I started her again on the thyroid and adrenal support, and she is now restored to near-normal health; she can do all her housework, look after her children and cook every meal. She says the return of her life and health is a miracle.
The level of circulating thyroid hormone, and the body's response to it, may be downgraded as a result of a large number of factors, and may be lowered by anything from just a few per cent to 100 per cent. How ill you are depends on how much loss there is, how long it's been going on, and the degree of damage done to the body's systems and biological mechanisms as a whole, because all your tissues require thyroid hormone to work properly. No two people are affected in quite the same way, and it's all too easy to miss the diagnosis in the early stages because not all the standard symptoms and signs are necessarily present, thyroid tests often miss the problem and also because adrenal issues could be at the root of the problem.
The adrenal connection
The adrenal glands, which are pyramidal in shape, sit like little hats on top of each kidney. Small as they are, they have a great deal of work to do; if for any reason they stop working, you'd be lucky to survive for more than three days. The adrenal medulla at the centre of the gland produces adrenaline (epinephrine) and noradrenaline (norepinephrine), two hormones that deal with immediate stress.
When you experience a surge of anger or fear, these hormones are released into the bloodstream, where they mobilize extra blood sugar and increase your blood pressure and heart rate-known as the 'fight-or-flight reaction'. This adrenaline surge provides an immediate increase in energy and muscle strength; your thinking speeds up and you're able to cope with the huge energy demands of dealing with a crisis.
The outermost layer of the gland, the cortex, produces glucocorticoids like cortisol and cortisone, which enable the body to mobilize, make glucose from fats and proteins, and maintain arterial muscle tone to regulate blood pressure. In this way, glucocorticoids work to protect the body from longer-term moderate and chronic stress. Our ability to produce this hormone depends on our capacity to fight off the effects of environmental challenges, such as injury, illness, deprivation and work-related or personal stress.
Cortisol is the stress-buster of the body-it's produced regularly and constantly in peaks and troughs. Levels are highest in the morning, decline as the day progresses and build up again in the small hours. In normal health, we make it all our lives, with a minimal falling off with age. Problems arise, however, when the adrenals go wrong.
When the adrenals pack up
In 1855, Thomas Addison described a disease where the patient became chronically ill, with lethargy, loss of appetite, low blood pressure causing attacks of fainting, hypoglycaemia (low blood sugar), poor immune response to even mild illness, and a risk of sudden collapse or death when subject to illness, injury or shock.
As he subsequently discovered, these patients pursued a steady downhill course until their death. What struck Addison was that there seemed little to find post mortem except that both adrenal glands
were taken over by tuberculosis bacilli and were no longer working.
Today the adrenals are more likely to be damaged by other processes, most commonly autoimmune diseases, but the principle is the same. There is a steady loss of function with accumulating symptoms of illness that, if untreated, will end in death. While gross adrenal failure is not difficult to diagnose, one condition that many doctors routinely miss is low adrenal reserve.
Far more common than fully established Addison's disease, low adrenal reserve is affected by the degree of thyroid deficiency present and characterized by a poor response to stress of any kind. Patients report feeling ill when stressed in any way. Illnesses like the flu or a cold are devastating, lasting longer than they should and causing much more severe symptoms than expected. Patients are chronically hypoglycaemic, and suffer from episodes of feeling faint and general unwellness, relieved only by eating or drinking something sweet.
Most patients are both cold- and heat-sensitive; they may feel extremely uncomfortable when it's hot and have cold clammy skin. They experience poor absorption of nutrients from food, primarily the result of a deficiency of hydrochloric acid in the stomach and/or weakness in the production of digestive enzymes, so they may be rather thin.
In such patients, the complexion is pale and almost transparent, often with dark shadows under the eyes and extra pigmentation, especially in skin creases. Often there is hair loss all over the body, but particularly of pubic and underarm hair. Men often lose the hair on their lower legs. Body temperature is low, the skin is cold and the Achilles reflex is usually slow. Patients often complain of bowel discomfort, with wind, diarrhoea and colic; many have previously been diagnosed with irritable bowel syndrome (IBS).
Constant fatigue and exhaustion are always a feature. Their batteries seem to run out quickly, and patients may even faint or collapse with little cause. Many of the symptoms overlap those of hypothyroidism, which is hardly surprising as the thyroid and adrenal glands work together to maintain metabolism.
The adrenal-thyroid connection
If thyroid hormone is not being produced as it should be, then nothing works properly-including the adrenals-and the situation is compounded by the fact that a low thyroid output is a stress-inducing situation. For the system to cope with not enough thyroid hormone, the adrenals are obliged to produce increased levels of cortisol. This may work well for a considerable period of time if the thyroid deficiency is relatively mild, but it will slowly worsen when the adrenals are called upon to further compensate for the stress this produces. Eventually the adrenals will cope less well and the continuing strain will cause adrenal exhaustion.
Your general health, nutrition, lifestyle and other life stresses all play a part, including the length of time the thyroid problem has gone on for and how bad it has become. I have found radioactive iodine thyroid treatment or surgery to be a particular problem for the adrenals.
Another very real problem is incorrect treatment. Supplementary thyroid hormone can itself cause stress if the system cannot cope with it; it is even possible to trigger a thyroid/adrenal crisis and collapse if the wrong dose is given and the need to provide adrenal support (see box, page 30) is ignored-that is, without first ensuring that the adrenals can cope with the strain. Indeed, it is possible that using thyroxine when the patient cannot convert it properly can cause a full adrenal crisis, which may be fatal.
Thyroid hormones require processing in the body; the chief one, thyroxine (T4), has to be converted into the active thyroid hormone triiodothyronine (T3) via the action of 5'-deiodinase enzymes. With low adrenal reserve, this reaction doesn't proceed as it should, and the body may become toxic with unused/unusable T4.
And the problem doesn't end there. T3 has to be taken up by receptors in the cell wall to pass into the cell. This intake is degraded in adrenal insufficiency; the receptors may become dormant or resistant and even disappear.
In this case, even when T3 is available, it cannot be used properly and may become toxic as it builds up. This shows how important the adrenal glands are and, equally, how important it is to provide adrenal support when low adrenal reserve is present.
In fact, the failure of thyroid supplementation to restore normal health may well be largely down to an adrenal problem. But this is hardly ever considered by physicians, who often don't recognize low adrenal reserve and may even miss the diagnosis of established Addison's disease.
Adrenal insufficiency should always be considered when beginning treatment. Failure to respond to thyroid supplementation or feeling worse after taking it is likely to reflect a low adrenal reserve syndrome. But it's not difficult to keep your adrenals in optimal health and provide support when there's damage (see page 28).
A final caveat
Bringing your metabolism back in line with thyroid hormone may cause adrenal stress with temporary loss of adrenal function. This will interfere with the processing and uptake of thyroid hormone, which can then build up, unused, and result in so-called 'T4 toxicosis'. Symptoms include feeling generally unwell, a rapid heart
rate and even chest pain similar to angina.
In this case, thyroid supplementation should be stopped and adrenal support put in place; only after an interval should thyroid support be started again. This is why it's vital to work with a qualified practitioner
who is experienced in natural adrenal support.
How to find out if your adrenals are running at low speed
It's useful, though not always possible, to confirm adrenal weakness by a blood test that measures cortisol output. But cortisol levels are extraordinarily variable, depending on the time of day and amount of stress present when the test is taken. Having a white-coated physician plunge a needle into an unwilling arm could easily double serum cortisol levels in just a few moments.
The picture is even more complicated because a result showing a normal cortisol level still won't rule out low adrenal reserve. A widely used test of adrenal function is the synacthen test, in which ACTH (adrenocorticotropic hormone) is given by injection, and the amount of cortisol produced by the adrenals measured over the following hour. However, the test often produces false negatives and only reveals a problem when adrenal function is almost totally exhausted. I've found the following tests to be far more useful.
Serum DHEA sulphate. The adrenals produce more DHEA (dehydroepiandrosterone) than any other hormone, so low DHEA levels mean poor adrenal function.
In patients with long-term low adrenal reserve, there may be a block in the biochemical pathway in the adrenal glands, where the prohormone pregnenolone is converted to cortisol. This means the amount of DHEA may build up, with cortisol showing an abnormally flat response throughout the day.
Salivary adrenal stress index (ASI). This is an invaluable measurement, although its worth is often not appreciated by mainstream medicine. Over 24 hours, amounts of the two chief adrenal cortex hormones, cortisol and DHEA, are measured in saliva samples. The levels reached throughout the day provide valuable information on the amount of stress the adrenals are under, as well as their response.
The 24-hour urine test. This reveals breakdown products of cortisol metabolism and offers a helpful 24-hour overview of both cortisol and thyroid hormone production.
When is adrenal support needed?
- When abnormally low DHEA and abnormally high cortisol levels show adrenal stress, or abnormally low cortisol and DHEA blood tests show weak adrenal function
- When many symptoms and clinical signs, notably postural hypotension, suggest a weak adrenal response
- When thyroid deficiency persists for a considerable time and worsens
- When previous thyroxine treatment is unsuccessful or even made the problem worse
- After thyroid surgery or radioactive iodine treatment
- When thyroid blood tests are normal, but the patient is clinically hypothyroid
- After major surgery or trauma/shock from an accident or life event.
Symptoms of low adrenal reserve
- Weight loss
- Poor response to thyroxine
- Irritable bowel syndrome
- Bowel upset/diarrhoea
- Sensitivity to cold/heat
- Fainting attacks
- Cold sweats
- Poor response to infections
- Repeated infections
- Generalized muscle weakness
- General depression/anxiety
- Memory loss/confusion
- Back/loin pain
- Autoimmune disease
- Poor exercise tolerance
- Hissing in ears
- Internal shivering
- Aches/pains in muscles/joints
- Waking at night with anxiety or a sense of doom
Reasons to suspect low adrenal reserve
- Prolonged/slow Achilles (ankle jerk) reflex
- Cold hands/feet
- Ragland's sign (systolic blood pressure drops on standing)
- Abnormal skin pigmentation (in creases, gums, areolae)
- Dark shadows under eyes
- Loss of body hair
- Dry thin skin
- Unstable pupillary reflex
- Lower-leg hair loss (in men)