What Happens When Your Cortisol is Too Low? Addressing “Adrenal Fatigue” Symptoms with Testing and Naturopathic and Functional Medicine Support

“Adrenal Fatigue,” “Adrenal Dysfunction” … Whatever it’s Called, You’ll Feel Lousy with Low Cortisol Levels

Words are powerful.

In medicine, accuracy is important.

“Adrenal fatigue” is a hot button term as a result.

Many practitioners berate this reference. They dismiss the personification of an organ getting “fatigued” and abhor the imprecise description of a dysregulated hormonal feedback loop.

Perhaps, being more specific in the terminology, such as using “hypofunction of the hypothalamic-pituitary-adrenal (HPA axis),” may have made those who prefer conciseness in medical terminology more comfortable with the concept of “adrenal fatigue.” (The hypothalamic-pituitary-adrenal (HPA) axis refers to the communication between the hypothalamus, the pituitary gland, and the adrenal glands.)

This may have allowed them to explore how a preclinical condition could cause so many issues, and how to intervene before a disease process set in.

According to Dr. Wilson,

When stress continually exceeds the capacity of the adrenals to secrete sufficient hormones to make the physiological, and biochemical compensations necessary for that level of stress, adrenal fatigue occurs. In adrenal fatigue, the adrenals function but not optimally.”

As indicated above, it is not a pathology, but “adrenal fatigue” does have a distinctive cluster of symptoms.

In this post and video, I’ll review the signs of adrenal fatigue, or more appropriately dysfunctional HPA axis regulation, and naturopathic and functional medicine supportive interventions.

If you want to learn more about the controversy surrounding “adrenal fatigue” and its underlying physiology, click here for part I.

The Symptoms of Adrenal Fatigue

According to Mayo Clinic, there is a distinction in symptoms between adrenal fatigue and adrenal insufficiency:

Adrenal fatigue isn’t an accepted medical diagnosis. It is a lay term applied to a collection of nonspecific symptoms, such as body aches, fatigue, nervousness, sleep disturbances and digestive problems.

Your adrenal glands produce a variety of hormones that are essential to life. The medical term “adrenal insufficiency” refers to inadequate production of one or more of these hormones as a result of an underlying disease or surgery.

Signs and symptoms of adrenal insufficiency may include:

• Fatigue
• Body aches
• Unexplained weight loss
• Low blood pressure
• Lightheadedness
• Loss of body hair
• Skin discoloration (hyperpigmentation)

In the article, “Clinical perspective on stress, cortisol and adrenal fatigue,” Dr. Wilson discusses some of the most common tell-tale signs that he’s seen in those with the pre-clinical condition:

There are many signs and symptoms of adrenal fatigue, yet there is no single pathognomonic indicator, except possibly its unique pattern of fatigue.

Although fatigue is a common complaint heard by physicians – 85% of patients complain of fatigue as one of their major symptoms – there seems to be no other fatigue pattern like it.

He explains this type of exhaustion as follows:

• An early morning fatigue, even with sufficient sleep. There is often a need for caffeine and/or stimulants to get going.
• Feeling more refreshed in the morning if one can sleep two hours beyond the usual rising time. In fact, one may not even feel awake until after the noon meal.
• A mid-morning low which often leads to more caffeine intake and sugar and fat consumption. The latter is to compensate for hypoglycemia (low blood sugar) due to low blood cortisol.
• An afternoon lull (around 2:00-5:00pm) that lasts from 15 minutes to two hours. It can take the form of needing a short rest to having to lie down for an extended time.
• A noticeable improvement in energy after 6:00pm, with a second wind of energy from 11pm-2am, if still awake.

Other signs and symptoms of adrenal fatigue reported include:

• Decreased stamina and energy, aka feeling rundown and extremely tired
• Decreased productivity
• Lowered resilience (increased frequency of illness, extended time for recovery, and slower ability to rebound from stress)
• Cravings for salty foods
• Low blood sugar symptoms, especially with stress
• Feeling unrested, even with eight hours of sleep
• Decreased sex drive
• Problems with focus, concentration, and memory
• Irritability, intolerance, depression, feeling overwhelmed, and mood changes

Symptom- Based Assessment

Other preclinical signs can also help to point out if one’s stress response is overactive and the adrenal glands are hypofunctioning. These include:

• irritability under normal circumstances, a “short fuse”
• orthostatic hypotension- low blood pressure and/or a drop in blood pressure after standing up from a lying down or sitting position. This is common with adrenal fatigue, whereas high blood pressure may occur with elevated cortisol levels.
• extended pupil dilation- a proper functioning nervous system responds to light stimuli with pupil constriction (getting smaller) and pupil dilation (enlargement) in darkness. If one has low cortisol, pupil contraction can be compromised.

Testing for Adrenal Pathologies

There are several methods to diagnosis adrenal pathologies. Conventional measurements are related to peak cortisol levels based on stimulating its release. These include several stimulation tests:

• ACTH (adrenocorticotrophic hormone, excreted from the pituitary gland)- correlating its levels to cortisol can help to determine if the issue in cortisol production is coming from the pituitary or the adrenal glands. An abnormal result could indicate a tumor or other problems with one of these glands.
• The insulin tolerance test (ITT)- the gold standard to evaluate HPA axis deregulation, or secondary insufficiency of the adrenal glands (low cortisol related to a problem in signaling of another gland). As noted above, cortisol and insulin have a dynamic link. Cortisol increases blood glucose and excess cortisol can lead to insulin resistance and elevated blood sugar. Low cortisol can cause the the reverse. The glucagon stimulation test (a storage form of glucose) has also been proposed as a less cumbersome alternative to ITT.
• CRH (corticotropin-releasing hormone) – CRH is a hormone secreted from the hypothalamus that begins the feedback loop of cortisol release.

Other diagnostics include antibody tests and imaging.

 

Measuring for Adrenal Fatigue

Once a disease process is ruled out, integrative doctors will often measure cortisol directly if adrenal fatigue is suspected.

 

What Are Normal Cortisol Levels?

Cleveland Clinic reports that the average blood ranges for cortisol relate to time of day:

• 6 a.m. to 8 a.m.: 10 to 20 micrograms per deciliter (mcg/dL).
• Around 4 p.m.: 3 to 10 mcg/dL.

Salivary lab cortisol markers can also fluctuate depending on the clock. One study reported the reference interval for morning and late-night salivary cortisol was 2.09 – 22.63 nmol/L and <12.00 nmol/L, respectively.

 

Functional Medicine Labs to Test for Cortisol

Some practitioners wish to determine a more accurate representation of cortisol rhythm by measuring more than one point in time. These tests include:

• The CAR Profile (Cortisol Awakening Response)  which uses a six-point saliva collection to analyze cortisol patterns and assesses adrenal hormone/HPA axis dysfunction.
• A Rhythm + CAR Test which includes an Adrenocortex Stress Profile, the Cortisol Awakening Response, and the Comprehensive Melatonin Profile for complete hormone analysis. (Recall the relationship between melatonin and cortisol here.)
• Cortisol metabolites in the urine.

Due to the fact that cortisol levels can vary by circumstances, stressors, lab, and time of day, following patterns of cortisol over time, proper procedure for collection, and correlating values to a clients’ symptoms are important. Therefore, proper evaluation by a doctor is imperative.

 

A Final Note on Assessing for Adrenal Fatigue

In one article linking HPA axis dysregulation and chronic fatigue syndrome (CFS), several mechanisms underlye hypocortisolism (low cortisol levels). These include:

• Lower production of releasing factors (CRF, AVP, ACTH) or cortisol
• Increased stimulating factors downregulating cortisol output via the feedback loop
• Increased receptor sensitivity to cortisol, decreasing output as a result
• Reduced availability of free cortisol (more protein-bound cortisol)
• Supoptimal effects of cortisol on the target tissue -relative cortisol resistance

A physician should guide treatment based on all these possibilities, and not just treat a lab value. A truly integrative practitioner will look for the root cause and consider the whole person, their compilation of symptoms, and their lab results.

Addressing Adrenal Deregulation

Once one determines that the adrenal glands need support, how does one go about getting it?

Stress, in various forms, is the most common underlying trigger for “adrenal fatigue” and hormonal imbalances in general. This must be addressed.

Four of the most common stressors include:

1. Sleep problems
2. Underlying inflammation
3. Metabolic/blood sugar dysregulation
4. Emotional/physical stress

Intervening in all these areas are important for optimizing adrenal health.

Below are some more specific approaches to address adrenal fatigue, which I also shared on my post on cortisol here.

 

Lifestyle Factors

Optimizing sleep, movement, having fun, nurturing positive relationships, and limiting stress with mind-body practices can all effectively modulate cortisol.

Click here to explore various sleep optimization strategies and here for mind-body practices.

 

Food and Diet

A nourishing diet can help the body deal with the excess demands of stress. Some key nutrients include:

• B vitamins
• Magnesium
• Omega-3 fatty acids
• Protein
• Probiotic-rich and/or fermented foods (via the gut-brain axis)

It is also important to avoid blood sugar swings.

Low blood sugar is very stressful for the body, just as high blood sugar is. So, making sure you are properly nourished is important. Those with low cortisol levels do not do well with fasting, cutting carbs, or skipping meals.

 

Aromatherapy

Previously, I discussed nine ways aromatherapy can modulate stress, impacting many of the resulting physical and emotional symptoms. They have the ability to:

1. modulate brain signals (neurotransmitters)
2. shift our brainwaves
3. calm our emotions
4. enhance our cognition
5. support cellular physiology
6. work directly on our emotional brain, causing an immediate shift in our perception
7. evoke memories and transform our mood through their aroma
8. interact with odor receptors throughout our whole body, influencing our biochemical pathways and physical state
9. modulate cortisol

Some oils have been shown to reduce cortisol. Clary sage oil, bergamot oil, and lavender oil have all been reported in small clinical trials to lower cortisol levels.

Other oils can also modulate cortisol and energize the body such as peppermint, rosemary, citrus oils, sage, and jasmine oils.

 

Herbs

Herbs that are calming (nervines) and ones that help the body adapt to stress (adaptogens) can help with balancing cortisol. These include:

• Nervines: Valerian officinalis (valerian), Matricaria recutita (German chamomile), Humulus lupulus (hops), and St. John’s Wort
• Adaptogens: Withania somnifera (Ashwagandha), Rhodiola Rosea (Rhodiola), and Ocimum sanctum (Holy basil)

 

Supplements

Two amino acids that have been shown to calm the brain and modulate cortisol include:

• L-theanine, an amino acid extracted from green tea
• Phosphatidylserine (PS), another amino acid derivative

 

Summary: Supporting Adrenal Deregulation, AKA “Adrenal Fatigue” Naturally

Deregulation in the HPA axis and downregulation of adrenal stress hormones can cause a variety of symptoms. Getting to the root cause of the triggers and proper assessment are vital.

Making sure that your adrenal glands are effectively responding to life stressors can ensure a more vibrant, functioning body and mind.

If your struggling with symptoms of adrenal fatigue, measuring cortisol and correlating it with other symptoms and signs are best done with a naturopathic and/or functional medicine provider. From there appropriate support such as lifestyle, nourishment, herbs, supplements, and aromatherapy can be personalized for the individual.

Naturopathic Medicine and Holistic Resources for Hormonal, Mood, and Digestive Support

• Free resources and more education on essential oils and mind-body wellness are available to you here.
• An Integrative Mental Health and Stress Resource Guide.
• Tools for coping with isolation and separation.

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Many blessings.

 

References:

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