Adrenal Fatigue: 'Just a Myth'?
John Watson
March 07, 2019
Fatigue, anxiety and depression,body aches, muscle weakness, mood swings, and trouble concentrating—every clinician has encountered patients presenting with such nonspecific symptoms, a frustrating starting point to any clinical investigation. Depending on the nature of the complaints, physicians may find themselves with thousands of potential culprits to rule out, from the benign to the potentially life-threatening.
Patients suffering from these chronic symptoms may sit through seemingly unending consultations, only to walk away with no satisfying diagnosis. It's a scenario that has long been fertile ground for pseudoscience, which gallantly swoops in to offer certainty in the guise of newly minted conditions.
In endocrinology, this timeworn narrative has seen its most recent occurrence in the emergence of adrenal fatigue, a condition that mainstream medicine almost uniformly agrees does not exist, at least as it's commonly described.
Yet like so many other areas of modern life, scientific certainty has not proven to be the panacea it once was. Adrenal fatigue has been particularly immune to counterarguments, as evidenced by the growing cottage industry of supplements and off-label treatments meant to treat it, despite their carrying very real health risks.
This has led some to question whether simply labeling adrenal fatigue a "myth" is having the unintended effect of making patients feel unheard, pushing them further into the hands of dubious practitioners.
A Diagnosis Out of Step With the Evidence
The diagnosis of adrenal fatigue is attributed to James L. Wilson, DC, ND, PhD, a naturopath and chiropractor who deemed it "the 21st century stress syndrome" in a 2001 book of the same name.
Wilson and others describe adrenal fatigue as a consequence of sustained stress (physical, emotional, or mental), which they posit leads to diminished functioning of the adrenal gland and depleted cortisol levels, resulting in a constellation of symptoms, including exhaustion, impaired concentration, irritability, cravings for salty or sweet food, and fluctuations in sleeping patterns and weight.
A collision of marketing, Internet hype, and vocal backing by alternative medicine practitioners raised the profile of adrenal fatigue, and it wasn't long before endocrinologists were confronted with an increasing number of patients seeking treatment for it.
"I probably heard about it for the first time 10 or 15 years ago," said James W. Findling, MD, clinical professor of medicine and surgery, and director of the Community Endocrinology Center and Clinics at the Medical College of Wisconsin. "I was shocked that the theory was that the adrenal glands could somehow fatigue or become hypoactive due to chronic stress or physical illness, since I was quite aware of the fact that the contrary was true."
As Findling outlined in a 2018 presentation at the Endocrine Society's Clinical Endocrinology Update meeting, adrenal function actually responds to stress by producing more, not less, cortisol, an effect that has been noted in conditions ranging from HIV to post-traumatic stress disorder. In addition, chronic fatigue syndrome (perhaps the most conceptually similar condition) has never been shown to have significant impairment of pituitary adrenal function.
He added that "many endocrinopathies have a variety of nonspecific clinical signs and symptoms, which often puzzle patients and their providers. The nice thing about endocrine disorders, including adrenal insufficiency and thyroid hormone deficiency and excess, is that there are specific and relatively well-defined biochemical markers and tests that can be done that provide evidence of the adequacy of hormone function."
This is not the case with adrenal fatigue, as was reported in a 2016 systematic literature review in which the authors scrutinized nearly 60 studies analyzing cortisol levels and the adrenal axis in this condition. They concluded that the studies offered consistently conflicting results and inappropriate conclusions made on the basis of highly flawed designs that used unsubstantiated cortisol assessments.
The Dangers of Toxic, 'Natural' Treatments
Even as the mainstream endocrinology community has mounted a robust critique of adrenal fatigue's rising profile, debunking the shoddy biology on which it is based in the form of review commentaries and position papers from professional societies, it is commonly accepted that patients diagnosed with this disorder are nonetheless being treated at disconcertingly high numbers.
This can leave patients susceptible to significantly more deleterious symptoms than those for which they originally sought therapy.
The most commonly prescribed treatment for adrenal fatigue is probably corticosteroids, which can provide a false sense of improvement in the short term, with euphoric responses in the wake of its administration.
The trouble comes when corticosteroids are given for chronic conditions, as long-term use, even at moderate doses, has been shown to contribute to a variety of adverse health effects, including psychiatric conditions, ]glaucoma, metabolic disorders, and cardiovascular diseases.
Findling witnessed the dangers of this off-label intervention firsthand while treating a patient who had received corticosteroids from another practitioner for adrenal fatigue—and developed avascular necrosis of the hip shortly thereafter.
"It illustrates that even relatively low doses of steroids can be quite harmful in normal subjects. It's not innocuous."
Like many, Findling had assumed that the other popular treatment for adrenal fatigue—supplements widely available online and in brick-and-mortar shops—were harmless placebos, but this notion was upended by a publication released last year.
All [tested supplements] contained detectable amounts of the thyroid hormone triiodothyronine (T3), and most at least one steroid hormone.
According to its lead author, Halis Kaan Akturk, MD, assistant professor of medicine and pediatrics at the University of Colorado School of Medicine, the idea for the study came from his own experience treating patients with fatigue.
"The first thing I noticed was that patients presenting with fatigue who were also using some unusual supplements had hormonal abnormalities in their labs," Akturk said. "I suspected that the supplements were the culprit, because after they were discontinued, the labs were normal."
Selecting 12 best-selling supplements from a well-known online website, he and his colleagues set about testing their contents, which were advertised as being "natural" and able to "restore energy," among other nonthreatening claims.
Instead, their research found that all contained detectable amounts of the thyroid hormone triiodothyronine (T3), and most at least one steroid hormone.
Akturk said that although the observed levels of these hormones were relatively low, there were notable variations among the products, and sometimes among the pills contained in a single bottle. He noted that these hormones in excess can cause a host of problems, from heart arrhythmias and fertility issues to a complete shutdown of the adrenal glands, with possibly life-threatening consequences.
For sure, some of those in the over-the-counter industry promote adrenal fatigue because it is a money-making tool," he said. "You can sell anything easily in the United States if you use some key catchy words such as 'organic,' 'herbal,' 'natural,' 'plant-based,' etc. It gives a sense of false reassurance."
What Is the Real Diagnosis?
Akturk is adamant that the discussion about adrenal fatigue should not end with telling your patients that it doesn't exist, which he finds to be an ineffective approach.
"I would rather investigate in further detail other explanations for fatigue, such as an organic or other commonly missed cause, like obstructive sleep apnea, depression, or fibromyalgia," he said.
Findling also stressed the importance of taking patient complaints seriously, ruling out possible adrenal dysfunction, pulling them away from potential harmful interventions, and targeting the real source. In his own practice, he has found sleep apnea to be the most common underlying source of these symptoms, particularly in overweight patients.
Rashmi S. Mullur, MD, assistant clinical professor in the division of endocrinology, diabetes, and metabolism at the David Geffen School of Medicine at UCLA, and associate chief of integrative medicine at the VA Greater Los Angeles Healthcare System, has given considerable thought to how to approach patients reporting adrenal fatigue.
Saying 'adrenal fatigue doesn't exist' leaves patients feeling unheard, discounted, and disregarded, even with the best-meaning physicians.
"Patients come to us from an emotional and health-and-wellness point of view; they just want to feel better," she said. "Frankly, if we give them a diagnosis that isn't adrenal fatigue because they have something else truly wrong with them, they wouldn't hold on to the notion [that they have adrenal fatigue]."
Mullur has found that the trouble comes when rounds of initial testing fail to reveal a hormonal abnormality.
"We end up saying, 'Well, there's really nothing hormonally wrong with you.' And not only that, but, 'Adrenal fatigue doesn't exist.' It leaves patients feeling unheard, discounted, and disregarded, even with the best-meaning physicians."
As Mullur detailed in a 2018 commentary in the journal Endocrine Practice, she began to dig deeper with these patients, not just asking them to describe their symptoms but also focusing on the timing of their onset.
"No one just wakes up one morning feeling all of these symptoms. They've been building for a while."
She said that this process has more often than not led such patients to report having had traumatic experiences of various sources. This led her to question whether many of these cases are due to neuronal stress responses.
"There have been a thousand studies on cortisol variations during the day in patients with stress, but unfortunately, none of them are really conclusive," she said. "What we do know is that when a brain experiences chronic trauma and stress, the neurons of the limbic system form alternate pathways. Certain areas of the brain 'hyperreact,' where there is extraneuronal agitation, versus other pathways that are blunted, so they don't respond normally."
Mullur would like to see this hypothesis tested in a structured research study of patients reporting adrenal fatigue, in a partnership between neuropsychiatrists and clinical endocrinologists.
Focusing on the Patient, Not the Myth
Mullur advises endocrinologists to keep in mind the example of chronic fatigue syndrome, a condition that was once similarly discredited but which has since gained acceptance despite continued uncertainty regarding its etiology.
She takes umbrage with the ways in which adrenal fatigue is routinely described in the literature, with titles such as "The Myth of Adrenal Fatigue" and "Adrenal Fatigue Does Not Exist."[3] Although these publications contain nuanced arguments for taking patient symptoms seriously, she is afraid that patients will not get beyond the headlines, which may scare them away—not from self-diagnosing as having adrenal fatigue, but from the medical establishment that is their best chance for real improvement.
"I just wish we wouldn't write things like that. We can write it in a better, more patient-centered, respectful way and say that there isn't a hormonal issue, but it doesn't mean that what the patient is saying doesn't exist. It's having the opposite effect and sending patients away from us," she said. "I'd rather have the difficult conversation and make them feel heard so that they don't feel like they need to go looking for pseudoscience elsewhere."
How long will patients wait before moving on to someone who will give them answers, regardless of their scientific validity?
Clinicians and researchers have a challenging task ahead of them. They will need to continue exposing the unsound foundations of adrenal fatigue and the dangers inherent in its treatment. But to be truly successful in delivering patients from the clutches of pseudoscience, they will need to offer patients clear diagnoses for what's ailing them.
John Watson
March 07, 2019
Fatigue, anxiety and depression,body aches, muscle weakness, mood swings, and trouble concentrating—every clinician has encountered patients presenting with such nonspecific symptoms, a frustrating starting point to any clinical investigation. Depending on the nature of the complaints, physicians may find themselves with thousands of potential culprits to rule out, from the benign to the potentially life-threatening.
Patients suffering from these chronic symptoms may sit through seemingly unending consultations, only to walk away with no satisfying diagnosis. It's a scenario that has long been fertile ground for pseudoscience, which gallantly swoops in to offer certainty in the guise of newly minted conditions.
In endocrinology, this timeworn narrative has seen its most recent occurrence in the emergence of adrenal fatigue, a condition that mainstream medicine almost uniformly agrees does not exist, at least as it's commonly described.
Yet like so many other areas of modern life, scientific certainty has not proven to be the panacea it once was. Adrenal fatigue has been particularly immune to counterarguments, as evidenced by the growing cottage industry of supplements and off-label treatments meant to treat it, despite their carrying very real health risks.
This has led some to question whether simply labeling adrenal fatigue a "myth" is having the unintended effect of making patients feel unheard, pushing them further into the hands of dubious practitioners.
A Diagnosis Out of Step With the Evidence
The diagnosis of adrenal fatigue is attributed to James L. Wilson, DC, ND, PhD, a naturopath and chiropractor who deemed it "the 21st century stress syndrome" in a 2001 book of the same name.
Wilson and others describe adrenal fatigue as a consequence of sustained stress (physical, emotional, or mental), which they posit leads to diminished functioning of the adrenal gland and depleted cortisol levels, resulting in a constellation of symptoms, including exhaustion, impaired concentration, irritability, cravings for salty or sweet food, and fluctuations in sleeping patterns and weight.
A collision of marketing, Internet hype, and vocal backing by alternative medicine practitioners raised the profile of adrenal fatigue, and it wasn't long before endocrinologists were confronted with an increasing number of patients seeking treatment for it.
"I probably heard about it for the first time 10 or 15 years ago," said James W. Findling, MD, clinical professor of medicine and surgery, and director of the Community Endocrinology Center and Clinics at the Medical College of Wisconsin. "I was shocked that the theory was that the adrenal glands could somehow fatigue or become hypoactive due to chronic stress or physical illness, since I was quite aware of the fact that the contrary was true."
As Findling outlined in a 2018 presentation at the Endocrine Society's Clinical Endocrinology Update meeting, adrenal function actually responds to stress by producing more, not less, cortisol, an effect that has been noted in conditions ranging from HIV to post-traumatic stress disorder. In addition, chronic fatigue syndrome (perhaps the most conceptually similar condition) has never been shown to have significant impairment of pituitary adrenal function.
He added that "many endocrinopathies have a variety of nonspecific clinical signs and symptoms, which often puzzle patients and their providers. The nice thing about endocrine disorders, including adrenal insufficiency and thyroid hormone deficiency and excess, is that there are specific and relatively well-defined biochemical markers and tests that can be done that provide evidence of the adequacy of hormone function."
This is not the case with adrenal fatigue, as was reported in a 2016 systematic literature review in which the authors scrutinized nearly 60 studies analyzing cortisol levels and the adrenal axis in this condition. They concluded that the studies offered consistently conflicting results and inappropriate conclusions made on the basis of highly flawed designs that used unsubstantiated cortisol assessments.
The Dangers of Toxic, 'Natural' Treatments
Even as the mainstream endocrinology community has mounted a robust critique of adrenal fatigue's rising profile, debunking the shoddy biology on which it is based in the form of review commentaries and position papers from professional societies, it is commonly accepted that patients diagnosed with this disorder are nonetheless being treated at disconcertingly high numbers.
This can leave patients susceptible to significantly more deleterious symptoms than those for which they originally sought therapy.
The most commonly prescribed treatment for adrenal fatigue is probably corticosteroids, which can provide a false sense of improvement in the short term, with euphoric responses in the wake of its administration.
The trouble comes when corticosteroids are given for chronic conditions, as long-term use, even at moderate doses, has been shown to contribute to a variety of adverse health effects, including psychiatric conditions, ]glaucoma, metabolic disorders, and cardiovascular diseases.
Findling witnessed the dangers of this off-label intervention firsthand while treating a patient who had received corticosteroids from another practitioner for adrenal fatigue—and developed avascular necrosis of the hip shortly thereafter.
"It illustrates that even relatively low doses of steroids can be quite harmful in normal subjects. It's not innocuous."
Like many, Findling had assumed that the other popular treatment for adrenal fatigue—supplements widely available online and in brick-and-mortar shops—were harmless placebos, but this notion was upended by a publication released last year.
All [tested supplements] contained detectable amounts of the thyroid hormone triiodothyronine (T3), and most at least one steroid hormone.
According to its lead author, Halis Kaan Akturk, MD, assistant professor of medicine and pediatrics at the University of Colorado School of Medicine, the idea for the study came from his own experience treating patients with fatigue.
"The first thing I noticed was that patients presenting with fatigue who were also using some unusual supplements had hormonal abnormalities in their labs," Akturk said. "I suspected that the supplements were the culprit, because after they were discontinued, the labs were normal."
Selecting 12 best-selling supplements from a well-known online website, he and his colleagues set about testing their contents, which were advertised as being "natural" and able to "restore energy," among other nonthreatening claims.
Instead, their research found that all contained detectable amounts of the thyroid hormone triiodothyronine (T3), and most at least one steroid hormone.
Akturk said that although the observed levels of these hormones were relatively low, there were notable variations among the products, and sometimes among the pills contained in a single bottle. He noted that these hormones in excess can cause a host of problems, from heart arrhythmias and fertility issues to a complete shutdown of the adrenal glands, with possibly life-threatening consequences.
For sure, some of those in the over-the-counter industry promote adrenal fatigue because it is a money-making tool," he said. "You can sell anything easily in the United States if you use some key catchy words such as 'organic,' 'herbal,' 'natural,' 'plant-based,' etc. It gives a sense of false reassurance."
What Is the Real Diagnosis?
Akturk is adamant that the discussion about adrenal fatigue should not end with telling your patients that it doesn't exist, which he finds to be an ineffective approach.
"I would rather investigate in further detail other explanations for fatigue, such as an organic or other commonly missed cause, like obstructive sleep apnea, depression, or fibromyalgia," he said.
Findling also stressed the importance of taking patient complaints seriously, ruling out possible adrenal dysfunction, pulling them away from potential harmful interventions, and targeting the real source. In his own practice, he has found sleep apnea to be the most common underlying source of these symptoms, particularly in overweight patients.
Rashmi S. Mullur, MD, assistant clinical professor in the division of endocrinology, diabetes, and metabolism at the David Geffen School of Medicine at UCLA, and associate chief of integrative medicine at the VA Greater Los Angeles Healthcare System, has given considerable thought to how to approach patients reporting adrenal fatigue.
Saying 'adrenal fatigue doesn't exist' leaves patients feeling unheard, discounted, and disregarded, even with the best-meaning physicians.
"Patients come to us from an emotional and health-and-wellness point of view; they just want to feel better," she said. "Frankly, if we give them a diagnosis that isn't adrenal fatigue because they have something else truly wrong with them, they wouldn't hold on to the notion [that they have adrenal fatigue]."
Mullur has found that the trouble comes when rounds of initial testing fail to reveal a hormonal abnormality.
"We end up saying, 'Well, there's really nothing hormonally wrong with you.' And not only that, but, 'Adrenal fatigue doesn't exist.' It leaves patients feeling unheard, discounted, and disregarded, even with the best-meaning physicians."
As Mullur detailed in a 2018 commentary in the journal Endocrine Practice, she began to dig deeper with these patients, not just asking them to describe their symptoms but also focusing on the timing of their onset.
"No one just wakes up one morning feeling all of these symptoms. They've been building for a while."
She said that this process has more often than not led such patients to report having had traumatic experiences of various sources. This led her to question whether many of these cases are due to neuronal stress responses.
"There have been a thousand studies on cortisol variations during the day in patients with stress, but unfortunately, none of them are really conclusive," she said. "What we do know is that when a brain experiences chronic trauma and stress, the neurons of the limbic system form alternate pathways. Certain areas of the brain 'hyperreact,' where there is extraneuronal agitation, versus other pathways that are blunted, so they don't respond normally."
Mullur would like to see this hypothesis tested in a structured research study of patients reporting adrenal fatigue, in a partnership between neuropsychiatrists and clinical endocrinologists.
Focusing on the Patient, Not the Myth
Mullur advises endocrinologists to keep in mind the example of chronic fatigue syndrome, a condition that was once similarly discredited but which has since gained acceptance despite continued uncertainty regarding its etiology.
She takes umbrage with the ways in which adrenal fatigue is routinely described in the literature, with titles such as "The Myth of Adrenal Fatigue" and "Adrenal Fatigue Does Not Exist."[3] Although these publications contain nuanced arguments for taking patient symptoms seriously, she is afraid that patients will not get beyond the headlines, which may scare them away—not from self-diagnosing as having adrenal fatigue, but from the medical establishment that is their best chance for real improvement.
"I just wish we wouldn't write things like that. We can write it in a better, more patient-centered, respectful way and say that there isn't a hormonal issue, but it doesn't mean that what the patient is saying doesn't exist. It's having the opposite effect and sending patients away from us," she said. "I'd rather have the difficult conversation and make them feel heard so that they don't feel like they need to go looking for pseudoscience elsewhere."
How long will patients wait before moving on to someone who will give them answers, regardless of their scientific validity?
Clinicians and researchers have a challenging task ahead of them. They will need to continue exposing the unsound foundations of adrenal fatigue and the dangers inherent in its treatment. But to be truly successful in delivering patients from the clutches of pseudoscience, they will need to offer patients clear diagnoses for what's ailing them.
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