Mainstream medicine and ‘alternative’ medical community rarely see eye-to-eye. This is particularly true in regards to adrenal fatigue. In this area, holistic practitioners are more likely to assess any impact that adrenal health may be having on the individual. Mainstream doctors are not trained to consider the function of these organs in consultations, and this shows in their attitude and responses when asked to do so. In any case, patient reports show a clear pattern of responses from doctors when they have requested their practitioner consider their adrenal balance, with the following comments scoring highly:
“Adrenal fatigue isn’t real.” This is a non-argument based on nomenclature. While the Physician’s Desk Reference does not list the term ‘adrenal fatigue’, it has become a phrase that both professionals and patients have accepted as an umbrella term for adrenal insufficiency brought on by acute or chronic stressors. Whether or not practitioners choose to use the term or not is irrelevant; if your cortisol levels are on the floor, you have a problem and the name of the problem is not important.
“You cannot diagnose adrenal fatigue based on questionnaire.” I agree with this one. While a skilled practitioner will be able to pick up on the warning signs of adrenal imbalance from carefully collecting a case history and assessing a range of telltale signs, there is simply no way that any intervention can be confidently made without testing levels of adrenal hormones.
“There are no tests for adrenal fatigue.” It is beyond doubt that a great number of alternative practitioners are diagnosing their patients with adrenal fatigue without measuring adrenal function. This is unacceptable and lazy, but to say that no tests exist is ignorant and totally inaccurate. Perhaps the adrenal stress index test, the definitive starting point in assessing adrenal function? 24-hour urinary cortisol? ACTH Challenge test, also known as the Synacthen test? Insulin challenge test? While all tests have their advantages and drawbacks, it cannot be said that no options exist to fully assess adrenal function. Admittedly, the 24-hour cyclic rhythm of the adrenal glands means their function is less convenient to measure than that of the thyroid (and explains why a morning blood draw for cortisol is normally useless) but it is ridiculous to think that no tests exist and irresponsible to say so.
“Salivary tests are not valid.” I most often hear this having referred patients to their GP after an adrenal stress index. This can be broadly translated to mean ‘I don’t understand the test as it was not covered in med school, and I wish you would stop asking me awkward questions now’. Of course, salivary levels of steroid hormones (like cortisol) have been shown again and again to correlate to blood levels (Obminski and Stupnicki, 1997). This makes it the preferred sampling method when several measurements are required over the course of a day, which is necessary to get an idea of adrenal function.
“Your 9am blood draw was within reference range.” Some doctors will even go as far as doing a single blood test for adrenal function. While this is at least something and demonstrates more of a concern for the patient’s welfare than a blunt refusal to help, it does show a serious lack of knowledge as to the basic physiology of the adrenal glands. As mentioned above, the adrenals work in a 24-hour rhythm, with cortisol levels high in the morning before dropping gradually over the course of the day. I see plenty of individuals who have normal (or borderline high/low) levels at 9am, but see their cortisol plummet over the course of the day. Normal levels of cortisol at 9am have no correlation with the blood concentrations you will find at 3pm or 9pm. And, as with all tests, ‘reference range’ does not mean ‘healthy’. It normally means your results did not fall in the bottom (or top) 1.25% of the population, that’s all.
“There are only three types of adrenal function; Cushing’s Disease, Addison’s and normal.” More than any other statement, this remains the most dogmatic. It seems the more ASIs I send to endocrinologists proving otherwise, the louder they shout this mantra. Both blood and saliva tests demonstrate that individuals may exhibit high levels of cortisol with low levels of DHEA, and vice versa, both may be high or both may be low. Due to the cyclic nature of the glands, the pattern seen in the morning may change by the evening. This demonstrates how adrenal imbalance can vary and necessity of individualized attention for each patient. Unfortunately, regardless of symptoms or the test results, the NHS approach classifies all of these individuals as ‘normal’ and dictates they be treated in exactly the same way (offered anti-depressants).
“Adrenal extracts don’t do anything.” This is not true. The implication here is that individuals who spend money on these products are receiving only a placebo effect. The reality is that the extracts, which contain specific ribonucleic acids and fatty acids unique to the adrenal glands, can have both positive and negative impact on adrenal health depending on how and when they are deployed. If the patient is still in a ‘fight or flight’ state, the extracts can stimulate more adrenaline and trigger the symptoms associated with this emergency hormone. If the individual is well along a route to healing, they can be of great use.
“Treatment with hydrocortisone is not warranted because, if they are withdrawn, might result in a drop in adrenal hormones*.” The warning came from an NHS specialist who felt that test results showing low cortisol output did not merit any intervention as low adrenal hormones were of no concern to him. His opinion was that it was a ‘bad idea to treat a make-believe disease as dependency may occur, thus the removal may induce low adrenal hormones. And that would cause a lot of problems…’ I feel no need to comment further on this.
“You’re just depressed. Take these anti-depressants.” Of the individuals I see that have previously spoken to their GP, 70 percent have been offered SSRIs. These pills boost serotonin levels and are offered under the assumption that a) the patient is actually depressed and b) that this is caused by low levels of the neurotransmitter, known for it’s calming effect. How does the GP measure your serotonin levels before issuing these dangerous drugs? Erm, they don’t; it turns out that, in the crazy world of medicine, it is quackery to suggest that a patient increase their intake of vitamins and minerals to support their adrenal glands but it is fine to prescribe a drug that permanently alters brain structure on just a hunch.
So why such ignorance? Doctors only know what they’ve been taught. They spend seven years in medical school becoming highly knowledgeable in a specific skillset – to assess symptoms, give this group of symptoms a name, then prescribe the drugs that the Physicians Desk Reference tells them to. This is what they are taught. In seven years, they get three days of nutrition training. They get only one lecture on adrenal function. Why? Because it is the drug companies that fund the lion’s share of their training costs do not stand to profit from nutritional intervention or improving adrenal health. The same cannot be said for the use of thyroid medications or anti-depressants. This is why your GP will offer you a thyroid test or encourage you to gobble down SSRIs, but look blankly if you ask them to investigate your adrenal balance.
This may change, but only if the current structure of our entire medical system changes. Until that time, patients are likely to hear more of the above comments during consultation with doctors. Self-education prior to the discussion may be the only way to ensure that one of you knows something about adrenal health.
*this point is actually valid, and the main reason that I do not favour the use of hydrocortisone in most cases.
Obminski Z and Stupnicki R (1997). Comparison of the testosterone-to-cortisol ratio values obtained from hormonal assays in saliva and serum. Journal of Sports Medicine and Physical Fitness, 37, 50-55.