Adrenal Fatigue is a Myth

Adrenal fatigue is a term used to describe a collection of symptoms that results from low functioning adrenal glands. Symptoms may include difficulty getting out of bed, low energy, sweet cravings, and difficulty falling asleep. Adrenal fatigue is a result of elevated and prolonged stress. The idea is that your adrenal glands get overtaxed and are unable to make adrenal hormones.

This is a myth.

Can your adrenal glands produce suboptimal levels of hormones such as cortisol and DHEA? Yes. But this is not because the adrenal glands are "burnt out" or "deficient". This is very crucial to understand if you want to get the correct treatment and restore normal levels of adrenal hormones for optimal energy and vitality.

The term "adrenal fatigue" promotes this idea that low levels of adrenal hormones are a result of a dysfunction or deficiency in the adrenal gland itself. But there is no evidence that this is true. And that is not how physiology works.

The adrenal glands do not govern the production of adrenal hormones. The HPA axis does (hypothalamic-pituitary-adrenal axis). So if we have abnormalities in adrenal hormones, either low or high, instead of focusing on the adrenal glands we need to look to the HPA axis to discover the root cause. 

To better understand the HPA axis, let's look at what happens in our body when we experience stress.

The Stress Response

  1. You encounter a stressor. A stressor could be a person, place, thing, situation, thought, anything.
  2. Your brain analyzes the person, place, thing, etc. to determine if it is a stressor and if the HPA axis should be activated.
  3. If it is a stressor, your hypothalamus is activated.
  4. The hypothalamus activates the sympathetic nervous system which tells the adrenal gland to release epinephrine (adrenaline). 
  5. Epinephrine acts quickly to increase your heart rate, direct blood flow to the muscles, to increase breathing to get more oxygen into the blood, and to liberate glucose from the liver and fat from fat cells to fuel your muscles. All of this is to help us run away.
  6. If we continue to feel stressed out for more than 10 minutes, the hypothalamus will then send a hormonal signal to the pituitary.
  7. The pituitary will then send another hormone to the adrenal gland that tells the adrenal gland to release cortisol.
  8. Cortisol acts to keep the body revved up and ready to run. It increases your blood sugar levels and keeps your blood pressure and heart rate high to get blood to the muscles. It also acts to slow down the digestive tract and suppress reproductive hormones because digesting and reproduction are not a priority when you need to run away.

As you can probably tell, the stress response doesn't really match our modern lives. Most of our stressors are our thoughts, our long to-do list, our work, and maybe even some relationships. And we can't just run away from these things. We carry them with us. So this stress response is really maladaptive when triggered by modern stressors.

HPA Axis and Chronic Stress

So what happens to the HPA axis when we experience chronic stress? Well, it gets activated day in and day out. Sometimes without giving our body much of a break. This leads to elevated levels of adrenal hormones, particularly cortisol, in the body.

Chronic elevations of cortisol can be very damaging to the body leading to symptoms such as:

  • weight gain, especially around your middle
  • insomnia (difficulty falling asleep or staying asleep)
  • high blood sugar, insulin resistance, prediabetes, and eventually type 2 diabetes
  • chronic pain
  • irregular menses, low libido, and infertility
  • frequent colds, low immunity
  • fatigue and exhaustion
  • anxiety, irritability, and depression
  • poor mental function, concentration, and memory

In the adrenal fatigue model, the idea is that the adrenal gland gets burnt out from making so much cortisol. But this is not true.

Remember, it is the hormonal signal from the pituitary that directly causes the release of cortisol. So what is actually happening is the high levels of cortisol in the blood are causing negative feedback. Both the hypothalamus and the pituitary sense the high levels of cortisol and stop sending hormonal signals to the adrenal gland to release cortisol. When adrenal glands don't get a signal to release cortisol, they stop releasing cortisol. From this perspective, "adrenal fatigue" is a protective mechanism in response to chronic elevations of cortisol.

But why doesn't this negative feedback lead to normal cortisol production? Why do we see people with low cortisol levels and symptoms of low cortisol. Well, evidence suggests that in these people with "adrenal fatigue" symptoms, their total cortisol is not actually low. On saliva tests and blood tests, their free cortisol may be low, but their cortisol metabolites (the products of your body breaking down cortisol) are high. So part of the problem may be cortisol metabolism.

We are still learning about the specifics of the HPA axis and exactly how and why low levels of free cortisol occur in people. There is evidence to suggest that the cortisol receptor plays a role in modulating the HPA axis to cause low cortisol levels. Oxidative stress, methylation issues, epigenetics, and other hypothalamic hormones (vasopressin) may all play a role in HPA axis dysregulation that results in low cortisol levels thought to be "adrenal fatigue".

Treating HPA Axis Dysfunction

Treating HPA axis dysfunction to restore normal levels of free cortisol and cortisol metabolites is not a quick fix or one-size-fits-all approach. Treatment needs to be customized to your specific cortisol levels and taking into account the overall state of your health. 

Here is a quick example of how general treatments can not only be ineffective, but also potentially harmful. Many people and misinformed health practitioners like to use "adrenal support" supplements. These supplements are usually a combination of vitamins and minerals (typically vitamin C, B vitamins, and magnesium) and herbs that are specific to the adrenal gland, called adaptogens. Most formulations contain every adaptogen imaginable. However, adaptogens have very different actions. Some are considered stimulating. Some increase the length of time that cortisol is in your blood and other may actually promote the release of cortisol from your adrenal glands. Others are considered calming. Calming adaptogens can reduce free cortisol levels through a variety of mechanism.

So if you were in the early stages of HPA axis dysfunction where the HPA axis is overstimulated and cortisol levels are high, taking a supplement with a stimulating adaptogen, such as licorice, will exacerbate your condition and your symptoms.

I hope you can now understand that treating HPA axis dysfunction is not a simple cookie cutter protocol involving diet and supplements. To get an effective and safe protocol, you need to work with a doctor who understands the physiology of the HPA axis and who can do the proper testing to assess your free cortisol levels, cortisol metabolites, and even neurotransmitters.

While you find a doctor to take care of your physiology, you can start taking care of your mind. Remember, this whole dysfunction started with your brain deciding to activate the HPA axis. You have an opportunity to prevent his activation when you encounter your stressors.

Many people believe that stress is something that happens to them and they have no control over it. This is not true. This is a false belief that you need to get over quickly if you want to take charge of your health and live fully with vitality and joy.

Stress is how we choose to respond to something. Yes, there is a choice. It can be difficult to recognize the moment of choice and it can also be difficult to make a choice other than the one that leads to HPA activation. The pattern of HPA activation has been repeated so many times that it is wired into our neurobiology. So if we don't step in, the default mode of our brain will be to stress out in response to a stressor. But we can rewire our brains to change our default setting. 

The first part of hacking the stress response is to recognize that it is happening. We need to get really familiar with what exactly is happening in this default setting. What are the specific thoughts that are a part of this neural loop? Are there any specific feelings we can identify? Are there physical changes that cue us to this process? 

Here are a few tips to get you started on this process:

  1. Identify all your stressors. Write a list of everything you can think of that causes stress in your life.
  2. Identify the top 3 triggers.
  3. Determine the exact stress response for these triggers. Think about the last time you encountered this trigger. What was the first thing that happened? Did you feel tightness in your chest? Did your shoulders tense? What was your first thought? What was the thought after that? What was the feeling accompanying the thought? 

Basically, the goal is to create a flow diagram for your stress response. Really get inside it and understand exactly what is going on. Because once you do, all it takes is thinking a different thought and you have hacked your stress response. While it is really that simple, it can often be difficult to change our negative thought loops. It takes a lot of awareness and a strong desire to change to fully reprogram the brain. For another little known strategy to change these negative thought loops, check out this article.

This type of work directly addresses the root cause of HPA axis dysfunction and is the most important work to do. Just taking a supplement will not fix this. I see a lot of doctors who use natural therapeutics to modulate cortisol levels only. And while this helps the patient feel better, this work is only addressing the symptoms. So what happens is the patient feels better and continues to live their life in the exact same way that caused the HPA axis dysfunction in the first place. So a year later, they start feeling tired again, they have trouble sleeping, they start gaining weight, and they are right back to where they started. So make sure you work with a doctor who takes a truly holistic approach and helps you work on the root cause. 




I'm Dr. Carly and my mission is to create a health revolution. I believe that another prescription is not the answer. I believe in using natural therapies that go beyond the symptoms. And I believe that doctors should spend way more than 7 minutes with a patient.