Adrenal Fatigue – A Fraud Perpetrated On Unsuspecting Patients

I don’t know you.  I have no idea what your symptoms are.  But I can tell you, your adrenal glands are almost certainly working just fine.  The concept of “adrenal fatigue” (aka adrenal burnout) has absolutely zero scientific evidence to support it.  The “testing” performed to diagnose it has never been validated for that purpose, yet it is performed regularly by naturopaths, chiropractors, and other fringe practitioners with little to no endocrinology expertise, then used as justification to sell bottles of supplements that are worthless at best, downright dangerous at worst.

A bit of background before I really get rolling with a diatribe: adrenal insufficiency is a real diagnosis.  But adrenal insufficiency ≠ adrenal fatigue.  Adrenal insufficiency is rare – it’s hard to give an accurate prevalence, as there are many different causes of the condition.  But I can estimate 1 in 100,000 people, give or take.  And some charlatan medical practitioners are making the diagnosis of “adrenal burnout” multiple times per week?  Um…no.

The symptoms of adrenal insufficiency (AI) may start out mild-moderate and nonspecific (fatigue, loss of appetite, weight loss, nausea, vomiting, diffuse body aches, lightheadedness), but they can progress (often rapidly) to life-threatening hypotension and hypoglycemia with essentially collapse of normal bodily function.

While it’s tempting to believe that there could be a milder version of AI that could explain many of the symptoms we all face at some point in our busy, stressful, western-world lives, there is no evidence in high-quality, peer-reviewed medical literature to support it.  So what we have here is a made-up diagnosis, with proponents implying legitimacy through generation of fake controversy.

Huh?  What do you mean by “fake controversy?”

Do a quick Google search (I’m not going to link to any of the sites here, as part of my blog’s mission is SEDO* for quacky blogs) and you will find all manner of click-bait along the lines of: “Why doctors won’t treat your adrenal fatigue!”  If you believe in the manufactured controversy, then you’re more likely to think that perhaps there is something to this whole “adrenal fatigue” issue.  It’s actually a brilliant strategy – make people believe there’s a secret Illuminati-esque order of physicians somewhere, conspiring to keep patients from learning how to heal themselves without expert medical guidance, and of course they’ll want to hear all about it.

So how did we arrive at this current state of affairs?  A look at the history of AI is quite illuminating (thanks Dr. Barrett, the godfather of anti-quackery):

Beginning in the 1920s, Adrenal Cortical Extract (ACE) from cows and other animals was actually used to treat real AI.  But as more effective, synthetic, purified products became available, ACE became obsolete.  This led to a perfect opportunity for John W. Tintera, MD and a band of fringe practitioners to appropriate ACE for other uses.  In 1949, Dr. Tintera began promoting ACE as a treatment for hypoadrenalism and hypoglycemia, prescribing it to people who had neither AI nor hypoglycemia.

What were the symptoms exhibited by these people?  You guessed it – all the nonspecific things you can conjure: excessive fatigue, nervousness, irritability, depression, excessive weakness, lightheadedness, faintness, insomnia, headache, and inability to concentrate.

And where did Dr. Tintera publish his “findings?”  If you answered New England Journal of Medicine, you’re incredibly optimistic.  No, it was in a series of articles in a supermarket checkout-line magazine, Woman’s Day.  This led to censure by the New York Medical Society and ultimately to the Westchester Medical Society advising him to abandon his “hypoglycemia” treatment.

To be fair to the good doctor, his ideas were promoted by the Hypoglycemia Foundation – oh, wait…he founded that Foundation himself in the 1950s.  In 1968, the Journal of the American Medical Association essentially called the ideas promoted by the HF erroneous and bizarre.  In 1978, the FDA sent letters to 78 drug companies advising them that ACE products risked undertreating true AI due to the low potency of these products, which could lead to life-threatening complications.  Most companies abandoned ship, but not all…

Here we are in 2017, and I regularly see patients taking some form of adrenal extract, to treat their “adrenal fatigue,” which has been diagnosed by something like this:


Please, please, please do not try to analyze the graphic.  It’s merely one of many variations on the same worthless test.  The take-home point here is that, while the graphic is pretty and looks official, it is totally useless.  There is no good medical evidence supporting these reference ranges (caveat: bedtime salivary cortisol is the only salivary test we regularly use in endocrinology, to screen for Cushing’s Syndrome, an overproduction of cortisol – will discuss further in a future post).

The only positive thing I can say about this particular salivary cortisol report is that it clearly states at the bottom: “This state should not be confused with Addison’s disease, which is a near absence of adrenal hormones, and is a medical emergency.”  As far as the rest of it – advocating adrenal “support and restoration measures -” that’s all bogus.

Adrenal Support Demystified: 

Your adrenal glands respond to stress, whether it’s physical or emotional, by making cortisol.  The pituitary gland, in your brain, is the gland that tells the adrenals when to make cortisol and how much.  Similar to the feedback loop that exists between the pituitary and thyroid, the pituitary will respond to excess adrenal hormones by dialing down its stimulation of the adrenal glands.

So what does this mean?  If you take some sort of adrenal “support” formula that contains animal adrenal extract, your pituitary will think that there is too much cortisol in your body and will go to sleep, thereby leading to underproduction of cortisol by your own adrenals.  Crazy, right?  A product that purports to support your adrenals actually leads to shutdown of normal adrenal function!

And here’s the kicker: if you take enough of this stuff for a long enough period of time, you can cause suppression of your pituitary-adrenal function for up to a year.  I have even seen a couple of cases of permanent AI caused by long term use of adrenal supplements.  They don’t teach that in chiropractic school, do they?

All that said, I would be remiss if I didn’t make it crystal clear that adrenal insufficiency is very real, and very much a medical emergency.  The diagnosis can be suggested by the symptoms mentioned in the third paragraph of this post, as well as a very low, early-morning serum cortisol level (cortisol levels should be at their highest upon awakening, then fall over the course of the day).

The best diagnostic test for AI is called a cosyntropin stimulation test, which involves having your blood drawn for cortisol (and maybe ACTH, the pituitary hormone that stimulates the adrenals) at time 0, then getting an intramuscular injection of 250 micrograms of cosyntropin (synthetic ACTH), then having your blood drawn again for cortisol at time 30 minutes and time 60 minutes post-injection.

The blood cortisol should rise to a certain level by 30 or 60 minutes (cutoffs vary slightly depending on which source you consult, but 18 μg/dL is most common).  If the cortisol rises to that level, AI is highly unlikely.  If the cortisol doesn’t rise to that level, AI is likely.

As with most things in medicine, there are caveats to the above.  The stimulation test becomes much less useful in the setting of critical illness, very recent pituitary damage (like after pituitary surgery), etc.  Discussion of all the caveats is beyond the scope of this post, but I’m happy to answer questions about that if you have them, in the Comments.

Bottom line: support the troops, the Girl Scouts, or your local food bank, but leave your adrenal glands alone – they’re probably doing just fine without your “help.”

* Search Engine De-Optimization, the opposite of SEO (Search Engine Optimization).  Most blog owners constantly work on getting their sites to show up as early as possible in any search engine.  One way to have your site ranked highly is to be linked to by other sites.  Ergo, I try to provide hyperlinks only to sites I’m happy to promote, while simply describing quacky sites.  To the best of my knowledge, I invented the acronym SEDO; you can steal it if you ever find yourself in a relevant situation.  You’re welcome.

Have you seen patients who have been tested for adrenal fatigue?  What do you do when your patients come in to your office on adrenal supplements?  Are you a patient who has been diagnosed and treated for adrenal fatigue?  Did you have a durable response to treatment, or did you drift back to your baseline?  Comment below!

By interacting with me in the Comments, you agree that you have read and will abide by my Disclaimer.

30 Replies to “Adrenal Fatigue – A Fraud Perpetrated On Unsuspecting Patients”

  1. I love it almost as much as Chris does!
    quasi spiritual healing type, misguided, probably well meaning alternative medicinists – but still conscious or (hopefully subconscious) Charlatans!

  2. Great post thank you! I have Addison’s Disease (for those unaware = AKA Addrenal Insufficiency) and also Hashimoto’s Disease. I swear every second person in my Hashimoto’s support groups are told they have ‘adrenal fatigue’ and are supplementing with this or that therapudic concoction. Its frightening. I hate seeing people take supportive stuff for their adrenal fatigue – often I see people on cortisol treatment!! And often wonder if that would just kill the adrenals and lead to Addisons which I wouldnt wish on anyone!

    I also see people who have Addison’s getting confused and thinking they can take these support conocotions instead of proper steroid treatments for their Addisons. As some herbalist, or naturopath has told them, or they’ve read an article on ‘adrenal fatigue’ which states that they can wake up their adrenals using this or that alternative treatment instead of the steroids which is downright life threatening.

    Thank you for writing this post!

    1. Very insightful comments, Olivia. Thank you for the firsthand view on Addison’s, which is very real and very serious.

  3. I have central adrenal insufficiency, cause known, because like you said there are literally 100s of potential causes. For the cause is unimportant as it’s been too long to hope for any recovery of adrenal function, provided we could correct the cause. What really drives me nuts about the whole adrenal fatigue thing is when I hear from friends (when finding out I have AI), “oh, I had that I took this natural stuff and now I’m all better! You should get some your really need to get off all of those meds, if you take this you will be cured in a few months!” So not how it works and frustrating to have to explain because no one wants to hear that their adrenal fatigue was never even there to begin with.

    I kind of feel like endocrinology gets hit hard by all the quackery because of all the “natural” and “safe” hormone supplements that can be sold OTC. Of course, at best they have nothing in them and are simply a waste of money and at worst whatever is in them is not anything that will help you and will in fact likely harm you.

  4. Thanks for this! I am a patient with actual AI, and find it incredibly frustrating – and downright dangerous – how often people, even medical professionals I encounter, don’t understand the difference between adrenal insufficiency and “adrenal fatigue” or “adrenal suppression” and won’t treat my AI on that basis. Even having notes from my endocrinologist saying I NEED IV steroids ANY time I go to the ER for ANY reason (since generally if I am sick enough to show up at the ER, I definitely need them), I have never had an ER doctor willingly give them to me automatically – it has always taken me hours and convincing them to call endocrinology at best, and at least half of the times that I have had to go to the ER over the past several years, I have left without getting any steroids at all, and talked to endocrinology and been told to either take large oral doses or inject myself because the ER wouldn’t do it. I think that a lot of the quackery around things like “adrenal fatigue” has created a lot of disbelief of patients who actually have life-threatening AI so that we aren’t taken seriously and aren’t treated when we need to be. Similarly, I have had countless people (including medical professionals) tell me “don’t you know how bad steroids are for suppressing your adrenals!” in response to my saying that I am on steroids for AI. I have not ever had actual medical professionals try to tell me that I should be taking some sort of supplement to help my adrenal function (but I have had numerous random people bring it up if I have ever talked about AI), but I have had several tell me that I should *stop* taking my hydrocortisone because it could be what is causing my AI (never mind the fact that I wasn’t taking it when I developed AI…). It scares me to know how many other people are hearing – and potentially taking – this advice. I have run across other AI patients, especially those who are newly diagnosed or who have not researched it at all, who are considering – or who HAVE – stopped taking their replacement steroids in favour of a “natural supplement” to help their adrenal function, and who have no idea how dangerous that is. But if I hadn’t researched it and had taken the word of “well meaning” (if you can really call them that) people whose aunt’s third cousin’s cat’s breeder who was “cured” by some supplement – or worse, the medical professionals (doctors, nurses, PA’s, NP’s, EMT’s…) who have told me that I am harming myself by taking my daily steroids – I could have ended up in the exact same situation. False information and misunderstanding that AI is a totally different (and legitimate, serious) thing than adrenal suppression or fatigue not only harms those treating something that is not even a legitimate medical problem, it endangers those of us who have AI, too!

    1. Absolutely, great points. The only thing I would say is that I think the reluctance of some Emergency Medicine doctors to give steroid has less to do with a concern that the patient has been misdiagnosed with adrenal fatigue, and more to do with a general lack of understanding of the hypothalamic-pituitary-adrenal axis. I remember that, before I did an Endocrinology fellowship, I did not understand adrenal insufficiency very well.

      Additionally, when I am on call, I get questions from ER docs and hospitalists that clearly indicate to me they don’t understand adrenal stuff very well.

      1. True. I don’t have a problem with the fact that they aren’t knowledgable about every single thing, but I do get really frustrated that when they don’t understand the adrenal issues, that they won’t ASK someone who does. It’s so frustrating to have to convince people to call endo and just ask them (since they aren’t convinced by looking at medical records or notes from endocrinologists, apparently) because EVERY time someone has actually talked to an endocrinologist, they have then given the steroids, but I have had numerous practitioners flat out refuse to call endocrinology when I explain that I have AI, I need steroids, and to please contact endo if they have any questions or want to confirm that this is correct treatment, etc. I have actually had a couple of people in that context who responded (to my saying that I have complete AI) by going “oh, so what, you get tired?” or something, which is what I have generally taken to be implying that they think I have adrenal fatigue or something vs. an actual life-threatening condition.

        And I’m glad that there ARE good endos on call who are willing to help educate ER doctors and hospitalists who don’t understand what is going on with their AI patients!

  5. Thank you for this! I have friends who equate their “adrenal fatigue” to my adrenal insufficiency. Obviously, there is no comparison between what’s real and what’s made up.

  6. So I saw an ND who was also an MD when I was a lot younger because my in-laws swore by him and I was having so much trouble getting any regular doc to even listen to me. I was handed a Zoloft scrip THREE TIMES and recieved 0 labs after going in about daily IBS and fatigue. I was told by the ND (who actually ran a bunch of tests) that I had adrenal fatigue, crytosporidium (sp?) and other bacteria/parasites, food “intolerances” and a list of other things that I’ve since come to suspect were even a thing. I took the antibiotics and stuff he prescribed but the last round made me really sick and put me in the ER overnight. I never took any supplements. I’m too forgetful and was too broke. Fast forward five years and I was just finished with school and sicker/more tired than ever and I went to a different ND who gave me a long list of labs she thought I should get. I took them into the regular doc and said I wasn’t leaving without getting as many as my insurance would cover. Come to find out I did have hypothyroid! Lame that it took almost 7 years to find out and I’ve never solved the IBS mystery because I do better without certain foods in my diet whether there is an actual “intollerance” or some other thing going on who knows? I just wish the regular doc would have just taken me seriously in the first place instead of wasting most of my twenties exhausted. Why is it so hard to just get regular answers? Why can’t doctors be advocates instead of rolling their eyes and acting all high and mighty when sick (& yes, ignorant) folk come in trying to sort things out. I’m only healthier now because I’ve worked so hard to put the picture together myself by seeking out information and experts who are actually willing to answer questions. I guess this is a bit of a rant but I’m also sharing hoping that if someone else going through something similar sees it they’ll know how to persist and hopefully not waste so much time with Nonsensical ND docs and regular MD docs who don’t listen. Go find somebody who will!

  7. Excellent article. I thought adrenal fatigue sounded bogus when a coworker described it. (Diagnosed by their naturopath or chiropractor or something.)

    Are the ads that show up at the end of your post meant to be illustrative of the bs? Or ironic? Or are they just automatically populated by Amazon based on keywords? Given the blog subject, ads for adrenal health supplement and a book about the 21st century epidemic that “very likely affects millions” seem a little out of place….

    1. Oh crap…I was afraid that might happen with the ads. I wish I could claim to have had ironic intent, but no. Thanks for the heads-up, Anita. I will need to reconfigure that.

  8. As a former Naturopath student it is great to read articles like this! I started studying Naturopathy with good intentions, believing that I would find evidence that the “natural” way can be effacious. However, I was extremely disappointed by the lack of science and evidence in teachings, so much so that it has lead me to study Pharmacy.
    Articles like this need to be more common knowledge, however, with the booming instagram wellness gurus, pandering to the vulnerable and offering magic cures to almost everything, evidence/science based medicine isn’t as “fashionable” to the masses at the moment. Nutritional/naturopathic medicine pracitoners are certainly good at marketing themselves with pretty social media accounts.

  9. Some groups of people tend to have lower than average cortisol, and may benefit from low-dose cortisol. For example, in one study people with PTSD were given 10mg/day cortisol, and they suffered less from traumatic memories. See “Low-Dose Cortisol for Symptoms of Posttraumatic Stress Disorder”
    Similarly, in another study people with CFS benefited from low-dose cortisol.
    I tried 10 mg/day of hydrocortisone for awhile, which was prescribed by my allergist on a trial basis, to see if it would help with my reactions to allergy shots and the thick-headed (not able to think well) feeling that I get from allergic reactions.
    It didn’t help to take it every day, and I stopped taking it.
    But, I did find that if I take maybe 2.5 or 5 mg of hydrocortisone when I haven’t taken it for awhile, it clears up the fuzzy-headed feeling very well. But other stimulants like caffeine don’t help. So it’s not just the stimulant effect of the hydrocortisone.
    Also, when I go out and do stuff in the world, I feel a lot less fuzzy-headed than when I’m at home feeling sick. It seems like raising my cortisol level with the psychological stress of being out doing stuff, also helps.
    My morning cortisol was just under 10, that was when I was in a very stressed state, very nervous, also not fasting. I got an ACTH stimulation test, my cortisol went up to 21. So according to the endocrinologist, I don’t have adrenal insufficiency. But it seems possible that a low-ish cortisol is contributing to that fuzzy-headed feeling that I have so much.

    1. “Some groups of people tend to have lower than average cortisol, and may benefit from low-dose cortisol.”

      No. I’m sorry, but no. Either one has adrenal insufficiency and needs cortisol replacement therapy, or one does not have AI and does not need cortisol replacement therapy. There are certainly myriad conditions that may respond to steroid treatment, but that’s often because steroids treat just about anything. The fact that a medical condition gets better with steroids does not necessarily imply that it’s because the person is steroid deficient. In fact, it almost never implies that, because AI is very rare. Remember, steroids are a potent class of medication that can have serious side effects, and they should not be used unless absolutely indicated.

      1. Some groups of people have lower than average cortisol, but I get the impression that the cause is not that something is wrong with their adrenal or their pituitary, but rather something else – post-traumatic stress, CFS or whatever.
        So what I was inquiring about was the concept that the functioning of the HPA system is influenced by outside factors, such as traumatic experiences.
        And the best remedy for that isn’t necessarily supplementation with hydrocortisone. Maybe their cortisol levels could best be increased in some other way.
        Or maybe for those people with PTSD, or for people with CFS, if low-dose hydrocortisone does help them, the benefits outweigh the risks. Any medical treatment has a balance of risks vs benefits, after all. Doctors do prescribe steroids for conditions other than AI sometimes, although there are often better alternatives.

  10. From “The impact of stress on the development and expression of atopy”

    “Chronic stress may induce a state of hyporesponsiveness of the HPA axis, whereby cortisol secretion is attenuated leading to increased secretion of inflammatory cytokines typically counterregulated by cortisol. A state of stress-induced HPA hyporesponsiveness has been demonstrated in some research participants with chronic inflammatory disorders.”

    So they’re saying that chronic stress leads to a lower cortisol response to stress.

    This doesn’t mean that someone develops “adrenal fatigue” in response to chronic stress, or that they have adrenal insuffiency as measured by an ACTH stimulation test.

    But somehow, there’s a lower cortisol response anyway.

    1. Hi 🙂
      great post!!
      I have two questions:
      1. You talked about the ACTH stimulation test. But what about just measuring ACTH (not the stimulation test, just the level the body had produced)? Lets say you measure ACTH in the morning and it is always high, and you feel always crappy, cant get out of bed in the morning and so on .. maybe you measure cortisol and it is always low…
      Since, as you mentioned, a feefback loop exists with ACTH and cortisol, isnt it reasonable in this situation to conclude that the brain isnt satisfied with the amount of cortisol in the body (since ACTH is high)? So if the brain wants more cortisol and therefore secretes a lot of ACTH, but cortisol doesnt go up, it suggests a production-problem in the adrenals… doesnt it?

      2. Your response to a previous comment:
      >>”So they’re saying that chronic stress leads to a lower cortisol response to stress.
      This doesn’t mean that someone develops “adrenal fatigue” in response to chronic stress, or that they have adrenal insuffiency as measured by an ACTH stimulation test”<<
      What causes the lower cortisol response to stress then? May it be that the body simply doesnt want cortisol to be constantly elevated and therefore doesnt give order to produce it? In this case ACTH should be low. Is this generally seen in those stressed individuals?

      1. 1. If the ACTH is high, in the setting of a very low morning cortisol, say < 5 mcg/dL, then that is consistent with true adrenal insufficiency, assuming symptoms are present. In that case, a stimulation test may not be needed. But most people with numbers like these will be seen in the hospital/ER, because they're pretty sick. 2. I suspect there are different answers to this, but one possibility is that the body adapts to chronic stress, so the cortisol response is not as high due to the adaptive response. The ACTH would likely be in the normal range, though remember that ACTH is secreted in a pulsatile fashion and varies widely from moment to moment. So it is possible to get very different ACTH levels at almost any time of day.

        1. Thanks, that makes sense.
          Then i would asume, if one doesnt have AI but some form of “HPA-axis dysfunction”, the solution is to lower stress?
          And whats your opinion on coffee in such a situation?

          1. Correct, the solution is to address the underlying cause – stress. I don’t have much of an opinion about coffee other than that I love to drink it. If it worsens stress for someone, then I would recommend avoidance, but not because I’d worry about the adrenals.

  11. Seven months ago I was given a 10 mg injection of dexamethasone (steroid) and an antibiotic injection in the ER for bronchitis. I had never had steroid injection before. I had a horrible reaction to it a week later – many side effects that have lasted a long time. I think it has affected my thyroid (continually lowered my TSH – now 1.05 and F T3 in low normal range) I suspected that it affected my adrenals. I still have many of the symptoms for AI listed in your article except that I have never had vomiting during these 7 months. I occasionally will feel a bit of nausea. 3 days ago my PCP had me do an 8:00 am cortisol blood draw. I don’t know the results yet. Can a steroid injection cause AI? I hate to think of having steroids administered to treat something after having such a severe reaction to a steroid to begin with.

    1. Yes, a single steroid injection has the potential to cause AI, but it usually will not be permanent. Sometimes people will need to be treated with physiologic replacement doses of something like hydrocortisone, while waiting for their adrenals to recover. Replacement doses of steroid usually do not cause severe side effects, unlike large, pharmacologic doses of steroids.

  12. Did you ever make the post about Cushing’s? I looked but didn’t see it and figured I’d ask before diving into questions that are related to the opposite end of this spectrum: high cortisol. Love your writings!

  13. Hi HD, I’m not sure if this question would be related to your post (but since we are talking about adrenals I thought I’d ask)… When someone has a diagnosis of Non-classical CAH (diagnosed via ACTH stim test, not treated with glucocorticoids, just managing symptoms) AND hypothyroidism, could one suspect that the NCAH caused or contributed to the hypothyroidism? I’ve read on Alt-Med blogs that cortisol issues can affect the thyroid but am not sure what to believe at this point. Have you seen a correlation in your clinical practice?

    1. To the best of my knowledge, the enzymatic conversion defects associated with CAH do not cause hypothyroidism.

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