Why Is There Such a Controversy About “Adrenal Fatigue”? The Precision of Wording in Medicine

If you want to play your odds in getting some practitioners to go hyperbolic, say the term “adrenal fatigue.” Within one minute, you’ll either:

1. Be eyeing the nearest exit to escape the long-winded explanation of its non-existence (and berating me for daring you to bring up such a polarized term), or,
2. Getting a gentle correction in phrasing along with an explanation of a“dysregulated HPA axis.” (The hypothalamic-pituitary-adrenal (HPA) axis is in reference to the communication between the hypothalamus, the pituitary gland, and the adrenal glands. More on that later.)

Why words trigger various people is a subject for another post by an expert in psychology or sociology.

Still, although this term may be bothersome and nonspecific to physicians, it seems a bit extreme to make it downright controversial in medicine. Perhaps we should try to understand the underlying physiology of it before we dismiss it entirely. Do you agree?

For example, “leaky gut” was used by naturopathic doctors (NDs) for years. They were criticized and ridiculed for believing in such woo-woo. Then, the microbiome (the population of the microbes that inhabit the intestines, and their genes) came into vogue. With all the attention on the gastrointestinal system, and more research money to explore it, the term “intestinal permeability” now populates many medical journals.

NDs have gained scientific verification and vindication that the gut does, in fact, get “leaky.”  Still, caution is warranted. It is “intestinal permeability” that has become the proper reference to this breakdown in the barrier of the intestinal lining which is now linked to various disease processes.

Similarly, “adrenal fatigue” also refers to dysfunctional organ, is not a disease, and comes with plenty of symptoms. So, let’s put aside the semantics for a little bit in this article to explore the theory of “adrenal fatigue.”

The goal is to get a greater appreciation of how your endocrine system and adrenal glands can impact your mind and body.

What is the HPA Axis?

To understand what is meant by “adrenal fatigue,” we must understand the hypothalamus-pituitary-adrenal (HPA) axis. This concept describes how these three endocrine organs communicate via a feedback look.

The HPA axis links the central nervous system and the endocrine system. It regulates the balance of hormones in the body and affects the stress response.

In a 2018 article on the how the HPA axis is linked to health and disease, the author summarizes these complex, vital interactions as follows (parenthesis mine):

The Hypothalamic–Pituitary–adrenal (HPA) axis describes a complex set of positive and negative feedback influences between the hypothalamus, pituitary gland, and adrenal gland.

These positive and negative feedback mechanisms work in a neuroendocrine (the link between the nervous and hormonal systems) manner in order to modulate a number of physiological processes such as immunity, fertility, and the body’s response to stress.

The mechanism by which the HPA axis remains in homeostasis depends widely on the release and uptake of several key regulatory molecules.

(1) The hypothalamus contains neuroendocrine neurons that secrete corticotropin-releasing hormone (CRH).

(2) CRH will, in turn, act on the pituitary gland to stimulate the production and release of adrenocorticotropic hormone (ACTH) into the circulation.

(3) Circulating ACTH then induces the adrenal gland to synthesize and release corticosteroids, such as cortisol and corticosterone.

Cortisol is produced in the adrenal glands via conversion from cholesterol into its final structure. Most of this “stress hormone” that is floating in our blood is bonded to proteins (i.e., corticosteroid-binding globulin (CBG) or albumin). This keeps this powerful messenger inactivated until it reaches its target tissues.

When the body senses there is enough cortisol, ACTH and CRH stimulation ceases. From here, an enzyme converts cortisol to its inactive form, cortisone, in the kidney and pancreas.

CRH is also influenced by levels of norepinephrine, serotonin, and acetylcholine. This is known as the “fast response” to stress. These mediators are released from a different part of the adrenal glands. They also cause changes in physiology and behavior via a neuroendocrine link.

When this complex axis becomes dysregulated, a breakdown in the mind and body can result. HPA axis imbalances are linked to brain and liver pathologies, cardiovascular disease, inflammation, a suboptimal immune response, pregnancy and fertility issues, depression, and anxiety.

The Impact of Corticosteroids and Cortisol

Once in circulation, the corticosteroids influence a variety of bodily processes.

The most highlighted hormone in the literature related to “adrenal fatigue” is cortisol. It is responsible for dialing down our “rest, digest, and reproduce” functions and upregulating our “fight, flee, or freeze” responses. This means cortisol:

• Increases our breathing rate
• Slows down our gut and reproductive functions
• Enhances skeletal muscle tone
• Increases blood glucose
• Breaks down fat (catabolic)
• Increases heart rate and blood pressure
• Suppresses inflammation (to focus on our survival and enable our bodies to move without pain)
• Enhances alertness

(You can learn more about cortisol here.)

The adrenal glands also produce the hormone DHEA and mineralocorticoids, which also play a role in blood pressure and electrolyte balance. These can be negatively impacted with chronic stress and exacerbate cortisol imbalances.

When stress is long-term and cortisol levels become too high, diabetes, elevated lipids, high blood pressure, nervous system deregulation, mental health issues, and osteoporosis can result.

Cortisol can also become depleted, and that comes with its own set of problems.

This is where “adrenal fatigue” emerges.

Stress and Adrenal Deregulation

Isabella Wenzt, RPh, recently wrote a book that may spur someone who despises personifying organs. Yet, armed with her clinical experience and success in working with others struggling with chronic diseases, Adrenal Transformation, is helping many.

In a recent post, Isabella discusses how chronic stress can lead to adrenal dysfunction causing many bodily issues leading to diseases. These include mental health disorders, such as anxiety.

With enough chronic stress, the HPA axis becomes overwhelmed and desensitized to the usual feedback loop and stops sending messages to the adrenals to produce more hormones or less hormones, no matter what’s happening.^[1]

Other common causes of adrenal dysfunction include sleep deprivation, blood sugar dysregulation, and chronic inflammation (which are all forms of stress on the body).

…

Anxiety is a hallmark symptom of adrenal dysfunction. When the adrenals are compromised, your resilience to stress starts to go down, and you might start to feel more anxious.

Of course, anxiety and adrenal dysfunction run on a two-way street. Chronic stress and anxiety can tax the adrenals, and weakened adrenals can contribute to feelings of anxiety.^[2]

There’s another connection here that I’d like to highlight, and that is the thyroid. The thyroid is impacted by adrenal function, and anxiety can also be connected to thyroid conditions. In fact, I’ve noticed that up to 50 percent of my clients with anxiety have Hashimoto’s, an autoimmune thyroid condition.

What is Adrenal Fatigue Referring To?

Dr. Wentz uses the term “adrenal dysfunction,” which is becoming a more accepted reference, yet it is essentially referring to adrenal fatigue. (Flashback to the “intestinal permeability and “leaky gut” conversation above.)

In 2013, Dr. Wilson’s article, “Clinical perspective on stress, cortisol and adrenal fatigue,” was published. The abstract reads:

After 30+ years of clinical practice, it is this author’s experience that adrenal fatigue is a common stress-related disorder in which the symptoms are strongly influenced by circulating cortisol levels.

Although adrenal fatigue has appeared in the medical literature by various names for over 100 years, its prevalence is just now coming to the forefront. Healthcare professionals can make a dramatic difference by monitoring patients’ health to check for signs and symptoms of adrenal fatigue.

Despite the frequency with which this health condition occurs, even many skilled clinicians have not had the opportunity to learn about it or its importance to their practice.

The intent of this article is to provide the practitioner with clinically relevant information about the diagnosis and successful treatment for adrenal fatigue.

The article reviews the vital role of cortisol in the body and why its levels are tightly controlled:

Cortisol plays a crucial role in maintaining health. But in order to do so, circulating levels must be maintained in a fairly narrow range.

(1) If levels drop much below optimal, signs and symptoms of adrenal fatigue occur

(2) if they drop precipitously low, as in Addison’s disease, it can be life-threatening

(3) If levels climb and remain above optimal for a period of time, signs and symptoms of metabolic syndrome appear

(4) pathologically high, and Cushing syndrome manifests

What Dr. Wilson clearly states in the article is that he is not diagnosing a pathology, rather a critical preclinical condition that occurs based on lowered cortisol levels:

In adrenal fatigue cortisol levels are no longer able to rise adequately to meet the demand and people begin noticing signs and symptoms that give them a clue something is not right.

In a nutshell, adrenal fatigue is the persistent suboptimal functioning of the adrenal glands, especially under stress…

Adrenal fatigue is not Addison’s disease, which is the virtual failure of the adrenals primarily caused by either an infectious or autoimmune process that damages and often destroys the glands [referred to above by Sajous as ‘‘organic lesions’’].

Stress rather than pathological damage is the primary cause of adrenal fatigue [14,13].

When the amount of 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.

The term has gotten a lot of slack, and so has Dr. Wilson, because many claim adrenal fatigue does not exist and is not a disease. From what I gather from Dr. Wilson’s article on adrenal fatigue:

(1) he noted it was referred to by other names (or the same name) in scientific literature for years, and,

(2) he was explaining a physiological dysregulation, not a disease process. This was made evident from his explanation of the difference between it and Addison’s disease.

Perhaps, being more specific in the terminology, such as hypofunction of the hypothalamic-pituitary-adrenal (HPA) axis, may have made those who prefer accuracy in medical terminology more comfortable with the concept of “adrenal fatigue.” (R, R, R, R, R)

This may have allowed them to explore how a preclinical condition could cause so many symptoms, and how to intervene before a disease process set in, rather than dismissing it entirely.

Summary: Adrenal Dysfunction vs. Adrenal Fatigue

Regardless of how you name it, a dysregulation in the HPA axis can cause a variety of serious issues. When your adrenal glands are producing inappropriate amounts of cortisol, trouble is around the corner. This means that making sure that your adrenal response is optimized is a good idea for a more vibrant, functioning body and mind.

There is a legitimate concern for over diagnosing and/or misdiagnosing someone with adrenal fatigue without ruling out other conditions, especially if it’s based on fatigue alone. However, a truly integrative practitioner will look for the root cause and consider the whole person, their compilation of symptoms, and their lab results.

In the next post, I’ll review the symptoms of adrenal fatigue, or more appropriately dysfunctional HPA axis regulation, testing, and supportive interventions.

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References:

1. https://www.verywellhealth.com/hypothalamic-pituitary-adrenal-hpa-axis-5222557
2. https://pubmed.ncbi.nlm.nih.gov/29719288/
3. https://www.mdpi.com/1422-0067/19/4/986
4. https://psychcentral.com/lib/what-is-a-trigger#what-to-do-if-youre-triggered
5. https://my.clevelandclinic.org/health/diseases/22724-leaky-gut-syndrome
6. https://www.webmd.com/digestive-disorders/features/leaky-gut-syndrome
7. https://pubmed.ncbi.nlm.nih.gov/34513903/
8. https://dr-lobisco.com/cortisol/
9. https://www.ncbi.nlm.nih.gov/books/NBK538239/
10. https://europepmc.org/article/PMC/3079864
11. https://www.labcorp.com/resource/acth-stimulation-test
12. https://fullscript.com/blog/cortisol-balance
13. https://sci-hub.hkvisa.net/10.1016/j.aimed.2014.05.002
14. https://pubmed.ncbi.nlm.nih.gov/23627245/
15. https://pubmed.ncbi.nlm.nih.gov/8027206/
16. https://pubmed.ncbi.nlm.nih.gov/17596739/
17. https://pubmed.ncbi.nlm.nih.gov/22876569/
18. https://www.ncbi.nlm.nih.gov/books/NBK537260/
19. https://www.health.harvard.edu/blog/is-adrenal-fatigue-real-2018022813344
20. https://www.ncbi.nlm.nih.gov/books/NBK541120/
21. https://www.mayoclinic.org/diseases-conditions/addisons-disease/expert-answers/adrenal-fatigue/faq-20057906
22. https://health.clevelandclinic.org/the-truth-about-adrenal-fatigue/
23. https://www.endocrine.org/patient-engagement/endocrine-library/adrenal-fatigue
24. https://chriskresser.com/overcoming-adrenal-dysfunction-with-dr-izabella-wentz/
25. https://thyroidpharmacist.com/articles/are-your-adrenals-sabotaging-your-health/
26. https://www.everywomanover29.com/blog/are-adrenal-issues-causing-your-anxiety-highlights-from-the-book-adrenal-transformation-protocol-by-izabella-wentz-pharmd/