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Adrenal Exhaustion
(Chapter 11 from Optimal Wellness)

     As our body's primary shock absorber, the adrenal glands determine our response to stress. In this chapter, we will discuss adrenal function and review the critical roles the adrenals perform to maintain and safeguard our health. We will list the causes, signs, and symptoms of adrenal exhaustion, cover medical testing, and finally present a program for adrenal restoration. Let's begin with the case history of Barbara, one of my patients.

Barbara
     The first thing Barbara said as she sat down in my office was, "I am totally exhausted." A thirty-eight-year-old grade school teacher, she was barely able to meet the demands of her work. Barbara was nearly desperate in her plea for help. She told me that by the end of each school day, her muscles and joints ached, her throat hurt, and she would develop a low-grade fever. She couldn't even imagine having the strength to prepare dinner for her family, or keep house. Fortunately, her husband did all the domestic activities. The elder of their two children pitched in as well.
     When Barbara was able to get nine hours of sleep, she would arise in the morning with the feeling that if she pushed herself hard enough, she could manage through the day. But she felt hardly any joy, spontaneity, or creativity qualities she considered essential to teach and to parent. For this reason especially, she was depressed, for she was falling far short of her expectations. But she was depressed all the time anyway, she said, even if she'd had a rare good day at school and everything was going well in her family.
     If anything out of the ordinary happened-like having a cookie, having a pleasant dinner with friends, staying up past 10:00 pm, shopping for groceries, or making love with her husband-then her usual end-of-the-day symptoms would be even worse. She usually needed several days or more to recover. If she drank milk or orange juice, she would suffer from migraine headaches-sometimes she'd get them regardless. Wheat would drastically increase her fatigue, and she would get ill from certain perfumes as well as from automobile exhausts.
     As a result of these symptoms, Barbara attempted to control each day. She had absolutely no reserves to deal with unforeseen events. She said she couldn't continue on this way. If she didn't get some relief soon, she was going to have to take a medical leave of absence from her work.
     I asked Barbara when she last felt well. She replied that she'd been functioning fairly normally until eighteen months before, when she'd been diagnosed with mononucleosis. She never seemed to recover fully from the mono, she continued, and it was in the following months that her current symptom picture began to develop. After a year of not getting any better, she was treated with an antidepressant. This medication had given her a little relief, but the overall effect was not substantial.
     Barbara had been on the antidepressant for several months when I saw her for the first time. After hearing her out, I questioned her about her earlier history. Her second child had been born nine years before her arrival in my office, a colicky and finicky baby who kept Barbara up many nighttime hours with her crying over an eighteen-month period. To make matters worse, when her son was just over a year old she'd been in a motor vehicle accident and suffered a whiplash injury to her neck that required months of physical therapy. Three years later, when it seemed that life was finally beginning to settle down to normal, a lengthy and nasty legal battle was sprung upon them involving her husband's ex-wife. These difficulties were not yet over when Barbara suffered a herniated disk in her lower back, which once again necessitated months of physical therapy.

When the Battery Runs Down
     Everyone encounters stress in their lives. However, when the intensity and chronicity of stress surpasses the level beyond which an individual can cope, something's going to break down. If you race a horse too frequently, if you keep running and whipping her when she's tired, very soon she won't be able to perform at all. If you keep your headlights on all night and run down your battery, the only way to get your car going is by a jump start. But if your battery is too depleted, even a jump start won't do the job.
     It wasn't surprising, with years of continual stress—pregnancy and lactation, sleep deprivation, injuries, illness, overwork, emotional anguish, and anxiety—that Barbara lost her strength and her health. The events of her life had forced her to keep performing beyond her limits. She never seemed to get enough of a break to rest and build up her strength.

The Adrenals: Our Body's Buffer Zone
     It is our adrenal glands that buffer stress and enable us to stand up to life's onslaughts. These glands give us the capacity to perform and to adapt flexibly to the demands of every day. It is also the adrenals that enable us to go beyond our usual limits of endurance when needed and help us to recover in a reasonable amount of time. Barbara had little capacity left to perform, adapt, or recover. It was my strong suspicion that she was suffering from adrenal exhaustion. I wasn't the first physician who suspected a problem with her adrenal glands. Barbara had numerous symptoms that fit the adrenal depletion picture in addition to nearly nine years of continuous stresses of varying magnitude.
     

Check the list of Adrenal Stressors on page 198 to see how your symptoms and stress history stack up.

The Function of the Adrenals
     The adrenal glands, each approximately the size of your thumb, sit on top of the kidneys (their position is on each side of the spine approximately at the level of the lower ribs). The adrenal cortex is central to this discussion. It is part of the gland that synthesizes a number of hormones from cholesterol, the very important ones being cortisol and DHEA (dehydroepiandrosterone). The adrenal medulla is the part of the gland that secretes adrenaline. Cortisol is akin to the drug cortisone (prednisone, prednisolone, etc.), and although cortisone has developed an unfavorable reputation for its well-known adverse side effects, our well-being depends on the adrenals' ability to produce adequate amounts of cortisol. DHEA is also essential. See the boxes on pages 200 and 201.

Testing Barbara's Adrenals
     One of Barbara's previous physicians had tested her adrenal function with a blood cortisol level. The sample was drawn at 8:00 A.M., which is when the level should be at its highest of the day. It was a "low normal."      Her physician subsequently performed an ACTH (adrenocortiecotropin) stimulation test. ACTH is the pituitary gland hormone that stimulates and controls functioning of the adrenal cortex. The pituitary gland is located in the brain and synthesizes several hormones, each controlling one of the body's many endocrine glands. Injecting ACTH should nearly double the blood cortisol level within an hour in an individual with normal adrenal function. Barbara's adrenal function was therefore declared "normal" because her cortisol level doubled.
     The problem with the ACTH stimulation test is that
it doesn't really measure the usual day-to-day functional capacity of the adrenals. By this, I mean the effect the adrenals have on an individual's everyday energy, stamina, mood, clarity of thought, immune function/resistance, and circulation. An injection of ACTH provides an abnormally high and very powerful adrenal stimulation, much like the pituitary might produce under the most extreme levels of fear or anxiety, such as running for your life.
     This means the ACTH stimulation test will therefore almost always be able to squeeze the double-normal levels out of even very tired adrenals. The adrenal cortex would need to be nearly nonfunctioning, as in Addison's disease, to fail this test and gain adequate attention from most physicians. This test recognizes only normal function or no function, nothing in between. It is clearly not sensitive enough to recognize the spectrum of diminishing adrenal function, which is where Barbara's and many other individuals' adrenal function lies. Thus it is unable to explain why they are not well.
     Another problem with standard blood cortisol testing is its lack of specificity for "free" cortisol as opposed to protein-bound cortisol. It is only the free, unbound fraction that is biologically active and is therefore the only fraction that accurately reflects adrenal status. The standard blood cortisol test measures both bound and unbound cortisol. If the result is "low", you can believe it; if it is "normal," it can mislead you into thinking the adrenals are fine when in fact they may be functioning far below normal.
     In my experience, measuring free cortisol and DHEA levels in saliva has proven to be the most dependable method of assessing adrenal function. This test has enabled me to explain why so many of patients have been unwell for r so long-the "walking dead," as many of them refer to themselves. And it has given me a base line from which to help these individuals return to the "living" and rediscover their well-being.
     I utilize the Adrenal Stress Index Test, which measures free cortisol at four specific times during a day (8:00am, noon, 4:00pm, and midnight) and DHEA/DHEA sulphate at the noon and 4:00pm collections. Salvia samples are collected at these times during an individual's normal day-during real-life conditions-without the added stress of being in a doctor's office or laboratory. On the other hand, having blood drawn has been shown to cause cortisol elevations all by itself, and thus interferes with accurate adrenal assessment.
     Comparing these four samples to the norm and looking at the cortisol/DHEA ratio can reveal both overstimulated and depleted adrenal states. Such information can pinpoint the most effective treatment recommendations, whether diet/nutritional therapy, herbal medicines, stress management, and/or pharmaceutical hormones.
     Under stress, healthy adrenals will respond by increasing the output of both cortisol and DHEA to higher than normal levels. Such temporary adaptive elevations enable an individual to maintain homeostasis and preserve health in the face of stress. However, if stress becomes chronic, eventually the adrenals can no longer maintain the production of extra DHEA. With continued elevated levels of cortisol and falling DHEA levels, an elevated cortisol-to-DHEA ratio ensues. This signifies an initial stage of adrenal exhaustion and has potentially devastating effects on health. These include:
• Decreased levels of secretory IgA (mucosal antibodies)
  -Increased absorption of antigens (foreign substances)
  -Decreased natural killer cell activity
  -Decreased levels of interleukin 2
  -Decreased T lymphocyte counts leading to increased susceptibility
  to infections, allergies, autoimmune disease, and cancer
• Reduces REM (rapid eye movement) sleep and therefore sleep
  that is not restful or restorative
• A catabolic state where tissue breakdown exceeds tissue
  repair/building, which leads to muscle wasting, weight
  loss, and bone loss/osteoporosis
• Greater percentage of body fat and smaller percentage of
  muscle mass; fat accumulation around the waist
• Diminished insulin sensitivity and therefore reduced glucose
  utilization at the cell level leading to elevated blood sugar
  levels and possibly diabetes
• Salt and water retention, leading to edema
• Elevated blood fat levels, levels, leading to atherosclerosis

     People whose test results show a significant cortisol elevation at midnight commonly experience an endogenous, or biochemically induced depression in contrast to one produced by circumstances. It also sometimes correlates with insomnia. Figure 11-2 shows the results of Barbara's Adrenal Stress Index test.
     Barbara's 8:00am cortisol level should be at the highest of the day (between 13 and 23 nanomolars), giving her a strong start and enabling her to meet the day's demands. What is most striking here is the significantly low cortisol level of 4 at 8:00am. She also experienced a low level of 2 at 4:00pm and a borderline low of 4 at noon. Considering Barbara's history-especially her daily struggle to get out of bed, even with more than eight hours of sleep-and the need she experienced to push herself all day long, her uniformly low cortisol levels come as no surprise. Over time, continued stress and lack of effective intervention usually first results in the abnormally elevated cortisol/deficient DHEA state, and later in Barbara's more deteriorated state of both cortisol and DHEA depletion.
     To help restore Barbara's depleted adrenal glands, I recommended most of the measures on pages 203-205. These make up the bulk of my adrenal restoration program.

Additional Cortisol and DHEA
     Besides the above primarily self-care measures, individuals like Barbara with severe adrenal exhaustion often require a prescription of small doses of cortisol in the form of hydrocortisone. I recommend up to 20 milligrams a day in divided doses. Such a dose is approximately half of what normal adrenal glands produce every day. It has never, in my experience, produced any of the common side effects caused by pharmacologic doses, usually over 40 mg daily of hydrocortisone, the equivalent of over 10 mg of prednisone.
     If, like Barbara's, an individual's DHEA is too low, or the cortisol/DHEA ratio is too high, supplemental DHEA is often needed, I recommend individualized doses, gradually working up to the desired level. For women this might be up to 10 mg twice a day; for men, up to 20 mg twice a day. Some of my patients have required somewhat higher doses. If using the more absorbable alcohol-based DHEA tincture, reduce the maximum doses by one-half.
     In addition to its own functions, DHEA can be converted in the body to estrogen. Too high a DHEA dose in women causes breast tenderness or spotting between periods. DHEA can also be converted into testosterone{the male hormone} and, in women, too much DHEA can trigger acne and male pattern hair growth. A woman's appropriate dose is one that brings the desired results without any of the adverse side effects. Too much DHEA can suppress cortisol production to abnormally low levels. Monitoring these hormone levels with periodic follow-up testing is essential to assure adequate levels and to safeguard against overdosing.
     DHEA should not be taken routinely by women who have conditions that can be worsened by supplemental estrogen, such as endometriosis, fibroids of the uterus, or estrogen-sensitive breast cancer. Nor should it be taken routinely by men for conditions worsened by testosterone, such as prostate cancer. Although the immune systems of these individuals with low DHEA levels could benefit from increasing these levels, supplementing with any doses of DHEA beyond physiologic levels carries potentially serious risks. Close periodic monitoring of levels and supervision by a qualified health professional are essential.
     By supplying safe doses of cortisol and DHEA to a body deficient in these essential hormones, an individual begins to feel normal again, with strength and mental powers returning. This "borrowed" health enables them to manage their stress, and any other ailments they may be battling more effectively. This, in turn, eases the demand on the adrenals, which allows these glands a partial rest and gives them a chance to restore their strength.
These hormones also directly allow the adrenals to rest by lowering the pituitary's ACTH stimulation to some extent. Just like a tired horse, exhausted adrenal glands will only grow weaker if they are continually overstimulated, overstressed, and whipped into action. By providing safe, temporary small doses of hydrocortisone and/or DHEA, this potentially damaging ACTH stimulation is lessened.
     Once the adrenals are thus rested, they can begin to restore their strength. Over time-four to twelve months commonly-supplemental hormones can be slowly tapered and discontinued as the adrenal glands start to function better on their own again. However, this rejuvenation program is equally dependent on a diligent maintenance of the adrenal restoration measures discussed above, most especially stress management. Lifestyle changes are an inherent part of bringing your body to a state of optimal wellness. Avoiding excessive and prolonged hormone supplementation will also help make successful weaning possible.

Aggravating Conditions
     There are many conditions that, if present can be additional sources of adrenal stress and need to be identified and treated in order to achieve the best outcome. Food allergy, hypoglycemia, inhalant allergies, yeast overgrowth, intestinal parasites, chronic sinusitis and other infections, and chronic inflammation and pain are common drains on adrenal strength. On the other hand, adrenal exhaustion will also render an individual susceptible to some of these very same conditions.
     An optimal wellness approach must fully consider this cause/effect continuum and pinpoint all associated conditions. Barbara, y adrenal exhaustion patient, was indeed suffering from more than just one of the ten common denominators of illness. My diagnostic evaluation of her condition also disclosed hypoglycemia, food allergy, and yeast overgrowth.
     However, I had evaluated enough patients to recognize that for Barbara, the resolution of her adrenal status was critical. The treatments for her other conditions could then have a better chance of succeeding. Nevertheless, this isn't always the case. I've had patients whose chronic sinusitis was the most deep-seated condition, and it was only after resolving it that adrenal depletion and other conditions could be successfully addressed.

Restoring the Adrenals: A Golden
Opportunity for Stress Reduction
     Stress abounds in our world today, and our adrenals serve as shock absorbers to help protect our bodies from the physical and mental wear and tear of our lives. But like any gland or organ to our bodies, there's a limit to how much the adrenals can withstand. Past a certain point, they will begin to weaken and affect our health in very serious ways.
     Without adequately functioning adrenal glands, it would be difficult to feel or function anywhere near your best. You'd be subject to a multitude of physical and mental symptoms that your doctors might have a hard time pinpointing. They might even tell you that it's all in your head.
     If you have adrenal dysfunction you can make a substantial improvement in how you feel with the self-care measures outlined in this chapter. I cannot stress enough the critical role stress management will play in you recovery. However, also consider seeking the assistance of a medical professional to help in adrenal assessment and restoration. The body's delicate balance of hormones and chemical messengers needs skilled professional monitoring.

This information is provided for educational purposes only and is not intended as a substitute for professional advice. Although the material may help you understand a diagnosis or treatment, it cannot serve as a replacement for the services of a licensed health care practitioner. Any application of the material set forth is at the reader's discretion and sole responsibility.

Email your questions for Dr. Golan to use a subject for his website article.

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