Adrenal fatigue describes a condition where the body produces insufficient amounts of cortisol. While this condition receives all the spotlight, there are other cortisol imbalances that could be causing your symptoms.
Selye called his theory the General Adaptation Syndrome. This is the framework we use today to explain adrenal fatigue. For more information on the history of adrenal fatigue, please see my previous post.
It is important to understand that this model is used to better explain adrenal fatigue, not diagnose its different aspects. The three-stage model is based on research done on animal models. (2) At the time of this writing, it may or may not describe the way humans respond to stress. Adrenal fatigue often does not progress in a linear fashion from stage one through to stage three.
The common adrenal fatigue model
The commonly discussed adrenal fatigue model describes three stages of increasing severity. It typically looks like:
- Acute HPA axis activation or adrenal stress
- High levels of cortisol
- Symptoms often include:
- Heightened levels of anxiety
- Inability to sleep
- Feeling stressed
- Stress maladaptation
- Cortisol dominance with low DHEA
- This stage is often labeled as adrenal fatigue
- Symptoms in this stage often include a combination of stage II and stage III. There are no hallmark symptoms of stage II adrenal fatigue.
- HPA axis down-regulation
- Low cortisol and DHEA levels
- This stage is often labeled adrenal exhaustion
- Symptoms often include:
- Low energy levels
- Lack of motivation
- Low appetite
While useful for helping explain adrenal fatigue, the three-stage model is an oversimplification. In clinical practice, there are more than three stages of cortisol imbalance. To further complicate things, progression and healing rarely occur in a step-by-step fashion.
Measuring cortisol & DHEA
When testing for adrenal fatigue, cortisol measurements should be taken at different points in the day. Remember, cortisol follows what is called a diurnal rhythm. Meaning its activity level is more prominent during the day.
DHEA is the most abundant steroid hormone in your body. (3) It is made from cholesterol by the adrenal glands, which sit atop each kidney. For the first few years of life, the adrenals make very little DHEA. Around age six or seven, they begin churning it out. Production peaks in the mid-20s, when DHEA is the most abundant hormone in circulation. (4) From one’s early ’30s on, there’s a steady decline in DHEA production, so the average 75-year-old has only 20% of the DHEA in circulation that he or she had 50 years earlier. At all ages, men tend to have higher DHEA levels than women.
In healthy models (low perceived stress, no history of trauma, sleeping 7-8hrs/night on a regular basis, BMI less than 25, and taking no medication that influences the HPA axis) the following will occur on his/her lab values:
- There will be a dramatic difference between morning and evening cortisol values.
- The majority of cortisol levels should drop within the first three hours after waking.
- The graph to the right illustrates a healthy cortisol rhythm.
- Each dot on the graph represents the time cortisol was measured.
- In this example, the subject woke up at 6:30 am.
- The spike in cortisol shortly after waking is called the cortisol awakening response. It should be 35-60% higher than the value at the time of waking.
- While not shown in this graph, morning DHEA levels should be higher than bedtime levels.
- Generally, a 50-100% difference between morning and evening DHEA levels is ideal.
Ok, now that you know what a healthy HPA axis looks like, let’s examine the different conditions often labeled as adrenal fatigue.
Elevated cortisol waking response
The cortisol waking response is the large surge of the hormone generally seen an hour after waking. If you go back to the previous image, an elevated cortisol awakening response will see the second value on the graph near the top of the chart.
In this example, all other cortisol values will remain within range.
Elevated cortisol awakening response is typically indicative of high levels of anticipated daily or job stress. In the 3-stage model of adrenal fatigue, this is generally considered stage 1. Those who experience melancholic depression will often have an increased cortisol awakening response. (5)
How to treat an elevated cortisol awakening response: (6)
- Identify avoidable life and/or job stressors.
- Try to regulate sleep time, duration, and quality.
- Support blood sugar balance through a healthy diet. For more on blood sugar and how it contributes to adrenal fatigue, please see this post.
- Supplement phosphadadatyl choline
- 100-200mg 3x/day
Elevated cortisol (hypercortisolism) occurs when levels are elevated throughout the day (at most time points) but the diurnal rhythm remains intact. (7) If high cortisol does not have a rhythm to it, Cushing’s syndrome should be suspected.
Elevated cortisol occurs in those with long-term or ongoing stress(es), or in those with melancholic depression. (8) Cortisol levels become elevated in response to a stress. (9) Remember, often the long-term stressors are blood sugar imbalance, sleep disruption, or inflammation.
How to treat elevated cortisol: (10)
- Identify and remove (if possible) the main source of stress.
- A thorough examination of blood sugar imbalances, hidden sources of inflammation, and sleep rhythm should be explored.
- Supplement phosphadadatyl choline
- 100-200mg 3x/day
- Add supplements known to lower cortisol:
- For a more thorough investigation into supplements shown to assist high cortisol levels, please see this post.
- Avoid taking licorice root or adrenal glandulars if you have elevated cortisol levels
Elevated evening cortisol
Sometimes, cortisol levels can remain in balance at all times except for the evening. When cortisol levels are elevated at the evening time point, falling asleep often becomes challenged. (11) In general, this occurs in those with ongoing, chronic inflammation. Identifying and removing the source of inflammation is paramount to success. Identifying and removing potential food allergies and sensitivities is the perfect place to start.
How to treat elevated evening cortisol: (12)
- Identify the source of inflammation:
- Undiagnosed food sensitivities/allergies and gut infections are common culprits.
- Improve bedtime routine
- Avoid the use of electronics before bed.
- Consider the use of blue light blocking glasses.
- Relaxation or meditation techniques.
- Supplement with herbs known to promote relaxation:
- Valerian root, passionflower, and skullcap are herbs commonly used to promote relaxation.
- Work with your healthcare practitioner to determine the appropriate dose for you.
- Avoid stimulants after 12 pm.
Low cortisol awakening response
A blunted (or, lowered) cortisol awakening response is very common. Unfortunately, it is often missed in diagnosis as most labs do not test for it. A lowered cortisol awakening response has been associated with chronic fatigue syndrome, post-traumatic stress disorder, burnout syndrome, and seasonal affective disorder. (13)
Low cortisol (Hypocortisolism)
Low cortisol or, hypocortisolism, is the condition that is known as adrenal fatigue. Hypocortisolism is defined when the expected cortisol levels are at or below the reference range. If you’re using a 4 point cortisol test, most time points will indicate low levels.
The reason hypocortisolism is referred to as adrenal fatigue is that early research suggested chronic states of stress caused our adrenal glands to “fatigue” and not be able to produce enough cortisol. There is no evidence to suggest that the adrenal glands decrease their cortisol output. This is why your doctor likely gives you a skeptical look when you say that you have adrenal fatigue.
The current theory as to why adrenal fatigue (hypocortisolism) occurs is in an effort to protect both our brain and metabolism. An initial stressful event causes an increase in cortisol levels. This is the stage I described above where cortisol levels are elevated (hypercortisolism). Over time, having an excess of cortisol itself becomes a stress. In response to this, our brain signals to decrease cortisol production. (15, 16)
At the time of this writing, it is thought that the down-regulation of cortisol is designed to decrease the burden of high cortisol levels in our tissues.
In conventional medicine, hypocortisolism is referred to as primary adrenal insufficiency or Addison’s disease. (17) Addison’s disease is much more severe than adrenal fatigue. Addison’s disease is typical of an autoimmune disorder where the body attacks its own adrenal cortex. (18)
In a 4-point cortisol test, Addison’s disease will show cortisol levels near zero at all time points. Whereas adrenal fatigue will show cortisol levels below the lab range but well above zero. (19)
Hypocortisolism or adrenal fatigue results as a consequence to being exposed to a severe acute stress and/or a chronic intermittent stress.
Studies have shown that hypocortisolism occurs in: (20)
- Those chronically exposed to stressful environments.
- Those with unpredictable schedules.
- Regular travel across multiple time zones.
- Those with traumatic early life experience(s).
- Those suffering from recurrent infections.
How to treat low cortisol
- Ensure no corticosteroids were performed before testing.
- Corticosteroids are known to strongly decrease cortisol levels.
- Common examples of corticosteroids include:
- Those with low cortisol should ensure they have a strong exposure to morning sunlight. If you live in northern latitudes, consider purchasing a sun lamp to ensure morning light exposure.
- This will help to increase the cortisol awakening response.
- Identify and remove avoidable work/life stressors.
- Develop regular sleep habits.
- Going to bed and waking at a consistent hour each day.
- Eat a nutrient-dense, whole food diet.
- Consider food allergy/sensitivity testing.
- Supplement licorice root in the morning.
- Up to 100mg/day of glycyrrhizin.
Ok, now you have a thorough understanding of the different cortisol imbalances. So, while you may not have adrenal fatigue you may have another cortisol imbalance that also requires treatment.
The treatment of adrenal fatigue is not as simple as taking a supplement marketed for treating it. The treatment protocol for someone with high cortisol is very different than for one with low cortisol (adrenal fatigue). Proper testing before treatment ensures that your treatment plan is aligned with your condition.
If you’re taking supplements for adrenal fatigue and not noticing any results, it could be because you don’t really have adrenal fatigue. You could have elevated levels of cortisol. Before purchasing supplements, ensure that your treatment plan is aligned with the specific type of cortisol imbalance you have.
Now, I want to hear from you:
Do you have adrenal fatigue? Or, some other cortisol imbalance?
Looking for more information about adrenal fatigue? Check out our other blog posts.
Also published on Medium.