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!
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