Nikol Margiotta N.D.

Part 1: Adrenal Fatigue: The 21st Century Sickness

This article discusses:

– Role of the Adrenal Glands
– How chronic stress leads to adrenal fatigue
– Role of cortisol and DHEA

My Personal Story

I purposely chose adrenal fatigue as my inaugural article because it’s what started me on the path to becoming a Functional and Integrative Nutrition practitioner. By professional license, I am a Naprapath – a small subset of complementary medicine that specializes in the manipulation of connective tissue (e.g. ligaments, muscle, bone). While I really enjoyed the hands-on techniques, I actually loved physiology, biochemistry and nutrition more. Luckily, during my internship, I was introduced to the world of functional medicine.

For me, the concept of adrenal fatigue was foreign, as I was still working my corporate job for Kraft Foods. But after 20 years of 50 to 60 hour work weeks, sub-optimal nutrition and poor sleep, I became its victim. What is alarming, however, is the number of people in the U.S. alone, suffering from some sort of impaired adrenal function, ranging from mild adrenal stress to complete adrenal exhaustion. And sadly, the run of the mill M.D. will not acknowledge the existence of this disorder, let alone know how to do to treat it if convinced by their patients’ symptoms are real (most patients end up on anti-depressants).

What are the effects of adrenal dysfunction? Many and they can be profound: fatigue and weakness, blood sugar imbalances, anxiety, immune deficiency, low blood pressure and low body temperature, muscle weakness, moodiness, depression, hormonal imbalance, skin problems, autoimmune disorders and the inability to lose weight.

Luckily, adrenal fatigue can almost always be relieved when the patient and practitioner work together to find the underlying cause of the adrenal issue. What can cause adrenal fatigue? The answer is just about anything including:

– allergies
– anxiety/worry
– chronic illness, fatigue, infection, inflammation
– disruption in exposure to light (think night shift workers)
– excessive exercise/lack of exercise
– low blood sugar/blood sugar swings due to a heavily refined carbohydrate diet
– malabsorption/maldigestion
– nutritional deficiencies
– surgery
– overwork/physical or mental strain
– pretty much anything….

But here’s the good news, we are fearfully and wonderfully made and when given the right nutrients and the negative influences are reduced or removed, our bodies will restore themselves because that is what it wants to do. Our bodies do not want to be fat, tired, sore or sick. It wants to be healthy, strong and lean.

The role of the adrenal glands

To understand how adrenal fatigue develops, it is important to understand the original function of the adrenal glands. The adrenals are walnut-sized glands located on top of each kidney and are part of the endocrine system – the control centers for many of the body’s hormones. The outer layer of the gland, called the adrenal cortex, produces hormones including cortisol, DHEA, estrogen and testosterone. The center of the glands produces adrenaline and epinephrine.

Simply, your adrenal glands are responsible for marshalling the appropriate troops into “fight or flight” mode to ready you to fight your opponent or turn and run. That was all well and good back in the caveman days when fleeing from a tiger, because once they we safe – all the bodily functions that were “shut off” during the flight, would be restored to normal. Unfortunately, most people these days live with constant stress and your body doesn’t differentiate between types of stress – it just knows it is present. Instead of occasional, acute periods of stress followed by rest and relief, we’re over-worked, poorly-nourished, exposed to a variety of environmental toxins, often with no end in site.

Even what you think creates a demand on the adrenal glands. Our stressors are endless: poor sleep, a demanding boss, the threat of losing your job, financial worries, yo-yo dieting, death or illness of a loved one, skipping meals, reliance on stimulants like caffeine, sugar or carbohydrates (my favorites were Tootsie Rolls and pretzels…), excessive alcohol intake, digestive problems, over-exercise, illness or infection, the list goes on.

Physiologic Role of Cortisol and DHEA

Cortisol – The Catabolic Hormone

What is cortisol? Normally, cortisol helps us to react to all stresses – real or perceived by converting proteins and stored glycogen for energy, increasing blood pressure, slowing digestion and shutting down the processes of elimination. In the short term, that’s okay. But when stress is unrelenting, cortisol continues to rise – creating a “stressed and wired” state. But that’s not when most people get to the doctor – they still have some energy to perform their tasks. Typically I see patients at this point because of difficulty falling asleep or staying asleep. This period can last for years until one day, their body can no longer respond to the stress and their complaint becomes bone-crushing fatigue.

The diagram above shows all the physiologic processes in which cortisol plays a factor. Cortisol is the only hormone that increases with age. It works in opposition to DHEA as well as other steroid hormones and must remain in balance with all the other hormones for optimal health. When cortisol levels are too high, it will inhibit the repair of muscle and bone, impair detoxification, digestion and absorption, reduce mental function, interfere with healthy endocrine function and even redirect the hormone cascade to produce something called “pregnenolone steal” where the production of other hormones, especially progesterone, is reduced in an effort to produce more cortisol. High levels of cortisol will also decrease the availability and therefore effectiveness of the thyroid hormones. Is cortisol the bad guy? Yes and no…without it we would die, however, too much cortisol makes life pretty miserable, too.

DHEA – The Repair Hormone

DHEA (dehydroepiandrosterone) has anabolic activity – which means it plays a role in rebuilding and repairing tissue. It is a precursor (it comes before) to testosterone – the male hormone that helps with maintaining muscle mass and libido, among other things. It is also a precursor to the three estrogens and progesterone, so it helps with premenstrual syndrome (PMS) and is therefore critical to fertility. DHEA production decreases as we enter our twenties, but declines under periods of prolonged stress. DHEA has been shown to have a protective effect on the immune system, helps the body deal with stress, can stimulate bone production, lower LDL cholesterol, improve energy and vitality and help with insomnia. DHEA replacement can help with adrenal fatigue, but it is not advised to take DHEA without the supervision of a practitioner who understands how to use this steroid hormone, as you can take too much. Women are more sensitive to the effects of DHEA and typically need less.

PART II – How Do I know if I Have Adrenal Fatigue?

This article discusses:

– How to test for adrenal fatigue – Can I recover from adrenal fatigue?

Testing for adrenal fatigue

One of the things my mentor in functional medicine drilled into my head was to honor the symptoms my patients were reporting to me, but to validate the symptoms with appropriate diagnostic tests. Testing of the adrenal glands is very important largely because many of the symptoms reported for other illnesses, most notably hypothyroidism (low thyroid), can be reported for adrenal fatigue. If you suspect you may be suffering from adrenal fatigue, the following questionnaire is a great first step in helping you frame what stage of adrenal fatigue you are in. I have adapted the following questionnaire from the book: Adrenal Fatigue: The 21st Century Stress Syndrome by James Wilson. I frequently have my patients read his book, as it goes into much more detail than I am able to in a one-hour visit.

The Adrenal Fatigue Test:

Simply check the box if your answer is “yes”

Even three or four “yes” answers to the above symptoms indicates you may be experiencing some level of adrenal fatigue. Regardless of your score, the next step would be to perform a salivary adrenal stress test.

In our practice, we test cortisol levels four different times during the day: between 6:00 am – 8:00 am (within one hour of waking), between 11:00 – 12:00 noon, between 4:00 – 5:00 PM and between 10:00 – 12:00 PM. This test will also measure DHEA, the hormone that works in opposition to cortisol. Once the labs are received, I want to see elevated cortisol levels in the morning, lower but steady readings during the day for sustained energy and finally the lowest levels at bedtime to ensure deep, restful sleep. Unfortunately, that’s not usually the case.

There are actually several stages to adrenal fatigue. Think of these stages as a roller coaster – you are inching slowly towards the top of the track (this is Stage I), where cortisol levels are higher during the day and may even continue to rise through the evening (“hyperadrenia”). You may also begin to see a decrease in DHEA. A person can actually be in Stage I for years.

In Stage II, cortisol actually starts to flatten in the AM, noon and mid-afternoon (the 3 o’clock crash in energy is a dead-giveaway) – DHEA is very low. Typically in this stage I see patients heavily dependent on caffeine, sugar, carbs and energy drinks to force a release of cortisol – though most of us have no idea that’s what we are doing.

On the roller-coaster ride, you are poised at the top, ready to “free-fall” (hypoadrenia) into Stage III. Here the drop can be fast and furious. Every cortisol reading is low – AM, noon mid-afternoon and bedtime. In this stage, the adrenals are so exhausted from overwork that cortisol can never reach normal levels. I know this stage first hand and I am living proof it is possible to return from this stage, though the road to recovery is not easy or short. Usually adrenal fatigue of this type takes 1-2 years for a complete recovery. But by responding to early-stage symptoms of adrenal fatigue, we can reverse the developing dysfunction before it is too late.

Conventional medicine will detect only the extremes of these conditions – Addisons or Cushings, so don’t expect to go to your Primary care for them to diagnose adrenal fatigue…

Even three or four “yes” answers to the above symptoms indicates you may be experiencing some level of adrenal fatigue. Regardless of your score, the next step would be to perform a salivary adrenal stress test.

In our practice, we test cortisol levels four different times during the day: between 6:00 am – 8:00 am (within one hour of waking), between 11:00 – 12:00 noon, between 4:00 – 5:00 PM and between 10:00 – 12:00 PM. This test will also measure DHEA, the hormone that works in opposition to cortisol. Once the labs are received, I want to see elevated cortisol levels in the morning, lower but steady readings during the day for sustained energy and finally the lowest levels at bedtime to ensure deep, restful sleep. Unfortunately, that’s not usually the case.

There are actually several stages to adrenal fatigue. Think of these stages as a roller coaster – you are inching slowly towards the top of the track (this is Stage I), where cortisol levels are higher during the day and may even continue to rise through the evening (“hyperadrenia”). You may also begin to see a decrease in DHEA. A person can actually be in Stage I for years.

In Stage II, cortisol actually starts to flatten in the AM, noon and mid-afternoon (the 3 o’clock crash in energy is a dead-giveaway) – DHEA is very low. Typically in this stage I see patients heavily dependent on caffeine, sugar, carbs and energy drinks to force a release of cortisol – though most of us have no idea that’s what we are doing.

On the roller-coaster ride, you are poised at the top, ready to “free-fall” (hypoadrenia) into Stage III. Here the drop can be fast and furious. Every cortisol reading is low – AM, noon mid-afternoon and bedtime. In this stage, the adrenals are so exhausted from overwork that cortisol can never reach normal levels. I know this stage first hand and I am living proof it is possible to return from this stage, though the road to recovery is not easy or short. Usually adrenal fatigue of this type takes 1-2 years for a complete recovery. But by responding to early-stage symptoms of adrenal fatigue, we can reverse the developing dysfunction before it is too late.

Conventional medicine will detect only the extremes of these conditions – Addisons or Cushings, so don’t expect to go to your Primary care for them to diagnose adrenal fatigue…

Should you get an adrenal test?

In general, if you feel happy and well, have steady energy and emotions, sleep soundly seven to nine hours a night, wake up feeling rested, recover well from stress, and maintain a healthy weight without dieting, then your adrenals are probably fine and you don’t need to test.

On the other hand, if your energy lags during the day, you feel emotionally unbalanced much of the time, you sleep poorly or less than seven hours a night, can’t lose excess weight even while dieting, use caffeine or carbohydrates as “pick-me-ups” – these are all red flags and an adrenal stress test can be a wonderful diagnostic tool.

Restoring healthy adrenal function

In addition to perfuming an adrenal stress test, our office routinely runs a number of diagnostic tests to check other systems – adrenal and digestive are two majors ones to rule out other aggravating factors like hypothyroid, parasites. In my experience, many patients with mild adrenal fatigue can see significant improvement by implementing these two simple steps:

• Dietary changes to help with blood sugar control and reduce dependence on caffeine, sugar or other stimulants: There are a number of key nutritional supplements that are essential to restoring healthy adrenal function
• Practice good sleep hygiene: Sleep is the great adrenal healer. Bedtime at or close to 10:00 PM is critical to adrenal repair. Try to sleep in the darkest setting possible, as any type of light will disrupt melatonin production. Remember, no TV or computer work one hour before bedtime, as it will increase cortisol release. When the opportunity presents itself, sleep in and don’t set the alarm, let the body wake when it is ready. Give your body the rest it needs, knowing it will take time to heal.

People with more severe symptoms or those who have reached complete adrenal exhaustion usually need greater intervention. Each patient, regardless of their stage of adrenal fatigue has a personalized therapy plan based on reported symptoms, test results and their unique physiology. Our office uses superior nutritional supplements and compounded hormones when needed. Interested in testing your adrenals? Call the office to schedule and appointment to see Dr. Nikol Margiotta. When was the last time you felt good?

For further reading on Adrenal Stress:

Adrenal Fatigue: The 21st Century Stress Syndrome by James Wilson, N.D., D.C., PhD

The Cortisol Connection: Why Stress Makes You Fat and Ruins Your Health by Shawn Talbott

References:

21st Century Endocrinology: Thyroid and Adrenal as Sentinel Organs: The 14th International Symposium on Functional Medicine: The Institute for Functional Medicine May 23 – 26, 2007

HRT: The Answers – A Concise Guide for Solving the Hormone Therapy Replacement Therapy Puzzle by Pamela Wartian Smith M.D. MPH

Page modified on 5/15/2011