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Adrenal exhaustion and chronic fatigue diagnosis - Highly Effective Treatments for Pain and Fatigue

Townsend Letter for Doctors and Patients, Oct, 2003 by Jacob Teitelbaum

The adrenal glands, which sit on top of the kidneys, are actually two different glands in one. The center of the gland makes adrenaline (epinephrine) and is under the control of the autonomic nervous system. Although it is known that this part of the nervous system is also on the fritz in chronic fatigue patients--contributing to such symptoms as hot and cold sweats, cold sweaty hands, neurally mediated hypotension, and panic attacks--it is not understood if or how this ties into the adrenal's ability to make adrenaline in CFIDS/FMS. More likely, adrenaline deficiency is a CNS (central brain) problem.

The outer part of the adrenal gland, the cortex, also makes many important hormones. These include:

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* Cortisol. The adrenal glands increase their production of cortisol in response to stress. Cortisol raises the blood sugar and blood pressure levels and moderates immune function, in addition to playing numerous other roles. If the cortisol level is low, the person has fatigue, low blood pressure, hypoglycemia, poor immune function, an increased tendency to allergies and environmental sensitivity, and an inability to deal with stress.

* Dehydroepiandrosterone sulfate (DHEA-S). Although its mechanism of action is not clear, DHEA is the most abundant hormone produced by the adrenal cortex. If it is low, patients will feel poorly. Patients often feel dramatically better when their DHEA-S levels are brought to the mid-normal range for a twenty-nine-year-old. DHEA-S levels normally decline with age, and appear to drop prematurely in chronic fatigue patients.

* Aldosterone. This hormone helps to keep salt and water balanced in the body.

* Estrogen and testosterone. These hormones are produced in small but significant amounts by the adrenals as well as by the ovaries and testicles. Half of a woman's testosterone is produced in the adrenals.

Causes of Adrenal Insufficiency

About two-thirds of chronic fatigue patients appear to have underactive adrenal glands. One reason may be that the hypothalamus does not make enough corticotropin-releasing hormone (CRH), which is the brain's way of telling the adrenals that more cortisol is needed. Others may have autoimmune damage to their adrenals. I suspect that many people also have adrenal burnout. Dr. Hans Selye, one of the first doctors to research stress reactions, found that if an animal becomes severely overstressed, its adrenal glands bleed and develop signs of adrenal destruction before the animal finally dies from the stress.

If you think back to our biology classes in high school, you may remember something called the fight-or-flight response. This is a physical reaction that occurs during times of stress. During the Stone Age, when a caveman met an animal that wanted to eat him, the caveman's adrenal glands activated multiple systems in his body that prompted him to either fight or run. This reaction helped the caveman survive. In those days, however, people probably had a couple of weeks or months to recover before facing the next major stress.

In today's society, people often experience stress reactions every few minutes. For example, when driving to work, a woman is delayed because of heavy traffic. While sitting behind the wheel, she frets about the consequences of her walking into the office late. Every time she hits a red light or pulls up behind a car that has slowed down, her adrenal glands' fight-or-flight reaction goes off again. When she finally arrives at work, she finds her boss waiting for her, which triggers the reaction once more. During the day, the person may also have to deal with stresses such as angry customers or difficult coworkers. Her husband or children may phone, forcing her to deal with family stresses. If the woman is ill--suffering from CFS, for example--she has another major stress. The different problems associated with CFS, such as sinus infections and pain, put more stress on her adrenal glands.

I suspect that many people suffer exhaustion of their adrenal glands but without the adrenal gland destruction that Hans Selye saw in his experimental animals. With the kinds of stresses common in modern society, a person's adrenal test may show cortisol levels that are actually higher than usual, since the adrenal gland tends to overcompensate to deal with stress. Over time, this may exhaust the adrenal reserve--that is, the adrenal's ability to increase hormone production in response to stress. In endocrinologist Dr. William Jefferies' experience (and in mine as well), people with either low hormone production or a low reserve often respond dramatically to treatment with a low dose of the adrenal hormone. Dr. Jefferies' opinion is that everyone who has unexplained, disabling chronic fatigue should be given a low-dose (20 mg/day) trial of cortef. Although I suspect that Dr. Jefferies is right on the mark, I tend to use this treatment at the beginning on patients who fail morning cortisol and/or cortrosyn stimulation tests, which test adrenal function, or have symptoms of adrenal insufficiency (see below). However, the cortisol testing can be interpreted in many different ways, and I tend to be much more liberal than most when interpreting the results.

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Adrenal exhaustion and chronic fatigue diagnosis - Highly Effective Treatments for Pain and Fatigue

Townsend Letter for Doctors and Patients, Oct, 2003 by Jacob Teitelbaum

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