You Don’t Have “Adrenal Fatigue”

adrenal fatigue woman

There are too many people walking around thinking that they have adrenal fatigue. This diagnosis was handed to them after a saliva test and a visit to a holistic clinician. I admit, I used to use this method of testing. I’ve ordered saliva tests on my clients and have coached them in recovering from the maladies of modern day lifestyles, and at that time I too called it adrenal fatigue. It was a good way to learn and it had some value, but the science of lab work is changing.

Many of my clients got better, because when we get adequate rest, deal with our stressors, eat nutrient dense food and take high quality supplements, our bodies usually respond well. But this didn’t mean that they had adrenal fatigue.

So if you don’t have adrenal fatigue, what do you have?

Most likely, you are experiencing dissonance between the optimal living and the way you actually live. This shows up in two main ways. The first is food. Our ancestors consumed wild game, fish, vegetables, starchy tubers, nuts, seeds and fruit in season. Nowadays, the 6 most common foods in the modern diet are pizza, sweet drinks, beer, bread, grain based desserts, and fried chicken.

The second, lesser known, mismatch between our bodies and our lifestyle is the activation of our stress response system. Our stress response system has two components, the sympathoadrenomedulary system (SAS) which is responsible for our immediate or short term stress response and the HPA axis, which is responsible for our intermediate or long term stress response. The HPA axis consists of the hypothalamus and pituitary glands (in the brain) and the adrenal glands (in the mid back). It helps us interpret threats to the body (whether those threats are a car accident, sitting in traffic or refined, nutrient poor food)

Both of these stress response systems exist for our benefit, yet can become harmful over the long term if over-utilized.

Here’s the perfect scenario for understanding this: Imagine you are living in the Paleolithic Era and are out for a walk on the savannah and all of a sudden a wild boar charges you. Its a good thing that your heart rate and blood pressure increase. It’s a crucial part of your physiology meant to ensure your escape and thus your survival. But at the same time these survival mechanisms go to work for you, your digestion and sex hormone production plummet. This is how it’s supposed to be, but it’s a problem when it is always on.

Enter the modern lifestyle….traffic, work deadlines, inflammatory food, over-exercise, or its opposite, couch potato syndrome, smoking, OTC drug abuse, lack of rejuvenating activities. The list goes on…I’m sure you get it.

The constant activation of the stress response via the SAS and HPA pathways erodes resilience and paves the way for metabolic breakdown.

The loss of resilience is associated why we are surrounded by so many sick people. Stress contributes to so many conditions.

Some Conditions Associated with Chronic HPA Axis Stimulation:

Rheumatoid arthritis
Thyroid disease

If you’ve gone to a holistically minded doctor and you’ve got any number of these problems and a saliva test, you’ve probably been handed an adrenal fatigue diagnosis.

The adrenal fatigue model is based on the work of Hans Selye and his general adaptation syndrome theory. Selye explained the progression of stress over time in 3 stages: alarm, resistance and exhaustion.

The adrenal fatigue model with the three stages of adrenal burnout is based on this model:

  • Stage 1 of adrenal fatigue is high cortisol with DHEA on its way down.
  • Stage 2 of adrenal fatigue is falling cortisol (which is sometimes in the normal range) and decreasing levels of DHEA
  • Stage 3 is even lower cortisol and lower DHEA.

But is the adrenal fatigue concept really sound?

I don’t think so. Consider 2  problems with the “adrenal fatigue” diagnosis:

Most people with “adrenal fatigue” don’t have low cortisol levels. The assessment of adrenal fatigue has depended on saliva measurement of cortisol taken at 4 distinct points throughout the day. Cortisol measured in saliva is only 2-5% of our total cortisol production. The vast majority (around 70%) of our cortisol is excreted in urine. This measurement is called metabolized cortisol. Free (salivary) cortisol is NOT the best marker for cortisol production. Metabolized cortisol, however, is a good marker for overall cortisol production.

It’s possible to have low free cortisol and high metabolized cortisol. Remember, the “free” cortisol reading is the measurement you get with a saliva test (2-5%). The total cortisol is not a value you get from salivary testing. It is important to have both values.

Some conditions with associated with low free cortisol and high total (aka metabolized) cortisol:
Insulin resistance
Long term glucocorticoid use

Also, it is possible to have high free cortisol and low metabolized cortisol. The # 1 reason for this presentation on the DUTCH test is hypothyroidism.

Therefore, a saliva test is an incomplete picture of true cortisol production.

Even when total cortisol is low, its rarely because the adrenals are tired and unable to churn it out. The brain and central nervous system direct the production of cortiso, not the adrenal glands. The adrenals produce cortisol but the regulatory mechanisms are primarily outside the adrenal glands. Therefore we should not be calling the problem of low cortisol “adrenal fatigue”, but instead it should be called “low cortisol”.

So Why Does Cortisol Drop?

1)Down regulation of the HPA axis – when we are exposed to stress for a long time, there can be a down regulation in cortisol receptor sensitivity. This is the body’s attempt to protect itself from the damaging effects of chronically high cortisol levels. The problem with this is that it actually ends up hampering the body’s ability to produce cortisol. This is something that should be short term. It’s harmful when it becomes the way the body does business.

2) Impaired cortisol signaling – High cortisol levels will lead to cortisol resistance. This can be caused by a decrease in cortisol receptor sensitivity and/or a decrease in cortisol receptor expression.

Wiith the DUTCH (dried urine total complete hormones) method of testing, which tests both free and metabolized cortisol, we have a greater understanding of the health of the adrenal glands. (We also get to look at sex hormone production and estorgen metabolite breakdown.)

True adrenal fatigue, if the term is to be used at all, should be reserved for those who have Addisons, an autoimmune inablity to produce cortisol.

But for the vast majority of us, our “adrenal fatigue” is simply a miscommunication between the brain/adrenals exacerbated by how we were designed to live (nutrient dense food, infrequent activation of the stress response, plenty of exposure to sunlight, connection with nature) and how many of us actually live (too much exposure to electronic screens, nutrient poor food and go-go-go lifestyles).

So what’s a woman to do?
You can get your adrenal hormones accurately (key word here!) and this is called the DUTCH test. This test uses dried urine to measure hormone levels. Precision Analytical laboratory in Oregon is the maker of this test.

I have done over 50 tests in the last 6 months and have yet to find someone with BOTH low free and low metabolized cortisol. In fact, 75% of my ladies have an overactive HPA axis which shows up as high free cortisol and high total cortisol.

The science of lab testing has taken a huge leap forward. Its time to move away from the diagnosis of adrenal fatigue and really find out what’s going on in your body. The DUTCH test can be a great first step.

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28 Responses to You Don’t Have “Adrenal Fatigue”

    • Hi Anita: Yes, the DUTCH test can be shipped pretty much anywhere in the world. And mailing your samples back to the lab couldn’t be easier. It goes back in a regular envelope without the need for additional postage.

  1. Can you also confirm what you refer to as ‘worn out’ adrenals? I think I grasp the concept of what you are trying to say but another article you wrote says ‘look after your adrenal health’ as during menopause adrenals get ‘worn out’. Whilst I get the Dutch test is more accurate and salivary isn’t; the concept of adrenal problems still seems to exist do they not? So if you are saying adrenal fatigue is addisons; what is the term for adrenals being ‘worn out’? Is that not addisons also? Addisons has always been referred to as insufficiency rather than fatigue as fatigue can be corrected without medication, using lifestyle, supplemental and nutritional adaptions, whereas insufficiency (much like type 1 diabetes) cannot be treated without medication as the gland cannot produce what is needed at all. I personally do not believe adrenal fatigue should be used in the same breath as addisons. As the adrenals in addisons aren’t ‘tired’; they don’t work at all.
    Are ‘worn out’ adrenals a side effect of hpa axis dysregulation? And not adrenal issue as a stand alone issue?
    And if it’s not a standalone issue then why refer to adrenal health at all in the first instance and not hpa axis dysregulation as the main cause which causes adrenal problems and look into treating that rather than focusing on adrenal issues (whatever you want to call them) alone?

    • Anita: Ha! Good catch on my seemingly contradictory articles. Along with everyone else, my understanding of the adrenals and the proper testing along with the terminology is changing. Adrenal problems-do they exist? Yes they do, but I dont believe they exist like most think they do (of course we have Addisons and Cushings, but I’m not referring to that here. Most adrenal problems are not adrenal problems but problems with the stress activation system. I agree that Addisons would be best described as insuffiency as opposed to fatigue, but what I was trying to say (albeit perhaps a bit confusing) is that IF anyone truly HAS adrenal fatigue, it would be those w Addisons. Just my thoughts on that, but I see how it could be misleading. I appreciate your thought provoking questions.

  2. Great article Maria. One of the more concise, well written ones I’ve seen on this topic. My only issue (and it’s not with you – it’s with everyone writing about this) is that y’all need to come up with a better name for the condition. Low cortisol mechanisms or HPA Axis dysregulation isn’t as concise and to the point as “adrenal fatigue” for the majority of us laypeople, so we are all going to probably keep saying “adrenal fatigue” until something works better. Like I can say to my random neighbor “i have adrenal fatigue” and they can kind of get the point right off the bat. Something is fatigued about me, and that’s why I always look tired. But if I say “I have low cortisol mechanisms” they will probably look at me like i have 3 heads and need explanation. So even on my blog, etc I still say I have suffered from “adrenal fatigue” for lack of a better term and since it’s so widely accepted as a diagnosis, even though in my head I know it’s more like what you are saying. And in the end I think it’s the same treatment, right? Diet & lifestyle adjustments to mitigate stress and inflammation. Just my two cents from a lay person’s perspective (in this digital age where we all share our diagnoses everywhere, ha!) – but I will definitely share this and point people towards your great explanation when they need more info!

    • Thanks for your comment Michele. My problem w the adrenal fatigue verbiage is that people become attached to a diagnosis, but this could be said for many diagoses. The problem w the AF diagnosis is that there is something else going on and deeper digging needs to be done in most cases.

  3. The person I first learned about the adrenals from is Dr. Sara Gottfried, and she did use the term “adrenal fatigue” but she said that it was common not to have high or low cortisol, but to simply have levels that weren’t appropriate for the time of day (ie. so having low in the morning and high at night). She recommended the 4x/day urine cortisol test. But she DID describe the common path to getting to that point as constant stress that kept the HPA active and the adrenals pumping out high levels of cortisol, which eventually led to problems that could then show up as the wacky levels we don’t want.

    My question is, do you disagree with this? Or are you mostly just saying that the path to that outcome isn’t stressed-out adrenals?

  4. Very clear description of what is happening in the body. I marvel at how delicately every hormone is balanced. And it is tragic that culture and the powers that be support what upsets this balance. We’re fearfully and wonderfully made! Learning to return to the basics is the key to finding good health. I agree with Michele that most lay people don’t understand the nuances, nor do they really need to. The average woman just wants her life back. Continue to share what you have learned, many benefit from it!

  5. Wow! This makes a lot of sense! Thank you for taking the time to write about this and provide us with such valuable information! I need to come in to see you asap!

  6. I had all of the above, and I had the salivia testing done, several years ago and my cortisone levels were normal, I had a total hysterectomy a couple years prior to my testing, It also said my all my hormones were normal, a little low in testosterone and progesterone,so added creams to my routine…I felt a little better, but the best time I felt the best was when I did whole30, I felt alive again. Its really hard to eat this way with all the bad the bad carbs around me, sugar and flour products, and my addiction to sugar…trying to get back to eating whole awesome foods again and exercise to feel better. I know I have learned a lot about eating from my maria:) I think one of the things that has always stuck with me, was switch up,for example, we do a different nut each week, whatever nut I choose that’s what I make my milk and flour with that week…I also switch up my fruits each week and I learned to not fear the avocado…I agree with the dutch testing to be more accurate….and if you are eating right and still feel like crap, its your hormones and those can be adjusted after testing…thanks for the info maria, like always I learn something daily from you:) thank you

    • Thank you Connie….I love how you are always so supportive of me and my work. Being an online health coach, it can get a little lonely out here in cyber land. And yes, switching up our food is UBER-IMPORTANT….so many people get stuck on the same old routine…the same old few foods, the same old thinking. I’m glad you switch things up!

  7. I think when people are feeling like crud and then are given a diagnosis such as adrenal fatigue, all their focus is on one area/organ/etc. of the body. Until we start addressing the body as a whole, people will continue running in circles trying to fix one area/organ/etc at a time. So inefficient and not focused on the core/root of the problem! Thank you for bringing this to light Maria. I hope it encourages people to think about their own health, that the body is a complex and beautiful creation to take care of, as a whole.

    • You are a very wise health coach Miss Laura! And I too agree that getting an adrenal fatige diagnosis is very limiting.

  8. Thanks Maria. This information is new to me so I devoured every word of it. I learned so much and I will be in touch for further information. I think I finally found what i really need. Thank you.

    • Thanks for commenting Susan. My goal is to empower women to be in the driver’s seat of their health. It starts with knowledge 🙂

  9. Maria, Thanks for this great information! Eventually when I can afford it I would like to get this test done on me.

  10. Maria, thank you for this great information. Eventually when I can afford it it I would like to get this test done on me.

  11. Maria, thank you for writing this article! Such an eye opener! These past few years I have ignored the fatigue, thought it was still left over Lyme. Now, i have some options for fealing better. Enjoy your blog immensely!

  12. Maria, thanks for this article. I completed this Dutch urine test in May and my metabolized cortisol was so high (4800 at 32 years old) that my doctor said he couldn’t help me and I needed to see someone for PTSD, can you help??

    • Hi Chris-Yes, I believe I can help, but would need to know more about you. I have seen metabolized cortisol at even higher #s than yours and I would love to know what the pattern of your free cortisol is as well. AS great as the DUTCH test is, it is still just a test and needs to be correlated to the person who is taking the test, what are their symptoms. Often, other tests are needed. Feel free to contact me through the form on my website.

  13. Do you have anything more you could share about what it could mean if you have a LOW result on Dutch test for metabolized cortisol? My results were midrange for 24 hr free cortisol (121.0) and below range for metabolized cortisol (2590.0). If that means I’m not producing adequate cortisol, where do I go from here? I’m 37 and also show low T3 on bloodwork. Doctor wants to start T3 and also do 3 months of low dose hydrocortisone. Any thoughts on this?

    • Hi Melissa: Yes, the #1 reason for low metabolized cortisol on a DUTCH test is hypothyroidism. 60% of T4 to T3 is converted in the liver and 20% is converted in the gut. I hope you are working on liver and gut health too in order to boost your free T3.

    • Hi Melissa: sorry for my late response. The #1 reason for low metabolized cortisol is hypothyroidism, which it looks like you’ve already uncovered with your Dr. I would encourage you to look at the health of your liver and gut as T4 to T3 conversion occurs primarily in those organs.

  14. Just found this article- endocrine system is so confusing!
    Dutch test:
    Morning 40 (low end of normal — 2 hours after waking)
    Afternoon 27 (high end of normal)
    Night 4 (normal)
    DHEA 41 (low end of Norma)
    TSH slightly elevated at 3.8, normal T3T4
    VitaminD 38 (up from 28 2 years ago– working on it)

    I don’t seem to be getting that AM cortisol spike— line is fairly flat.

    Main complaint severe PMS. Estrogen/testosterone normal.Results go along with that it takes me a long time to feel awake (usually around 11 am I feel awake). I do work nights and often stay up 24 hours, but this test was taken after being off 12 days.

    I’m wondering if it’s just years of staying up 24 hours once or twice a week? My health coach seems convinced that functional med dr woiluld start me on armor (lots of hypothyroid symptoms), but I’m worried to start armour if it’s night shifts that are doing this!!

    Any thoughts? Have you worked with shift workers? I know nights can mess up your system- I only work 1-2 nights a week, but maybe that is the cause?? Want to learn as much as I can before making functional medicine appt.

    • Hi Nicole_ yes, unfortunately, shift work is a huge issue and influence on the HPA Axis and can affect your results AND your health at some point. Sure, I’ve worked with shift workers before. Also please note, you need to attend to the adrenals before, or while, you are addressing thyroid issues as they are intertwined. Good luck!

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