Is Adrenal Fatigue Real?

Overview

Adrenals interact with the rest of the body. While it is often thought that low cortisol is the result of adrenals, becoming fatigued and not working anymore, it may more be that it is an adaptation. In fact, when you look at adrenal function in children that suffered tremendous stress (Post Traumatic Stress Disorder [PTSD]), you find low cortisol, but not because of decreased adrenal function, but because of increased metabolism of cortisol. When cortisol production increases, metabolism increases, but in those with poor adaptation to tremendous stress, these liver enzymes and kidney enzymes stay upregulated. This keeps cortisol levels low. Also, receptors respond to cortisol change. For example, receptors become more sensitive to cortisol and send feedback to the pituitary to make less cortisol, also keeping levels lower. This pattern can be transmitted from parent to child and is one more way that stress response moves beyond our generation. Clinically it means that it is not only important to improve adrenal function, but that we must work on metabolism of cortisol and receptor function reading cortisol as well. Therefore, it is imperative that we adapt a whole person functional medicine response and treat the whole person, not just a singular pathway.  

Introduction

Hello! My name is Dr. Cheryl Burdette and I’m the Clinical Director for Origins Incubator. And this week in our clinical curriculum classes we talked about adrenal fatigue and the question brought up was “Does adrenal fatigue actually exist?” This is an interesting question because if we think of it in terms of “Where is the ICD-10? Where is the diagnostic code that goes with that?”, the answer would be “No.” Because when we think about the function of the adrenal glands, diagnostic criteria are given if the adrenal glands are completely on overload or if they’re completely shut off (Cushing’s Syndrome or Addison’s Disease). But as we know, so many things exist in a spectrum. 

Functioning Level of Tissue

There’s not tissue in the body that is merely all on or all off. Your heart doesn’t completely function or not at all. The lungs don’t completely function or not at all. The retina in your eye doesn’t completely function or not at all. All tissue is on a spectrum and all of it can be increased and improved or decreased. There are so many things that affect the functioning level of the tissue of the adrenals. But when we continue to look at this issue, it is further talked about that, of course, it is not merely the adrenals itself and that is important to realize that it is the whole hypothalamic pituitary axis, and it is how sensitive the adrenals are to the signaling. In addition to that, there are changes that will happen at a tissue level when we experience extreme levels of stress. 

High Level Trauma Studies

So, we looked at some studies in which children had experienced a high level of trauma. Normally, the trauma was a sexual trauma or stress from having survived the Holocaust. When children had experienced this excessive stress, there were large changes to how their bodies recognize and metabolize stress hormones, such as cortisol. Often, we’ll define adrenal fatigue as a decrease in the adrenals’ ability to make cortisol. So, in these studies, what we saw in these children is that indeed they did have lower levels of cortisol. But this was only in part because of decreased cortisol made by the adrenals and might not have been at all because of dysfunction in the adrenals. In fact, what the research went on to say is how cortisol was read and interpreted at a receptor level varied post trauma. This cortisol, this group of corticoids, when somebody had been under significant stress, upregulated enzymes in the kidney and in the liver to break down cortisol at a faster rate.

We can see why this would make sense because initially when we are under more stress, lots of cortisol, you’ve got to keep up with that overproduction that heightened amount that occurs; however, if we are in the population that was not resilient, that had PTSD (more long-term effects from severe stress), you saw a different outcome in terms of what their bodies did with cortisol. So, they continued to have that increased metabolism of cortisol, but the receptor became more sensitive to it. When we think about this from an evolution perspective, we can understand why the biochemistry would be this way. 

Stress from Starvation

Well, cortisol is not only a stress hormone, but it also goes up for what is probably evolutionarily the larger stress to our system - starvation. So, if we are starving, we produce more cortisol. It tells the liver to increase glycogenesis to make more sugar to help us survive. It tells the kidney to reabsorb salt, so if we’re in a starvation situation where we are not getting calories and we are not getting salt, then the metabolism has changed, so that the liver and kidney will deal with that situation and continue to keep us alive, even under the stressful situation of starvation. So, when you starve, your stress hormone goes up (cortisol), and then an adaptation to that is to make the receptor more sensitive to that cortisol. 

From there, after long-term stress, what happens is there’s an increase in metabolism of cortisol, your body trying to get back to homeostasis, but if we don’t respond and if we’re not resilient to the trauma, the receptor stays the same so now the cortisol goes down, yet the receptor is more sensitive to it. So, when this person experiences more stress that would peak cortisol again, they feel it more intently. Normally we’re under stress (this is an adaptation - we see the bear, we need to run, we produce the cortisol in the right amount, so that we’re able to stay focused, and we’re able to run, getting out of there), but the person that produces that same heightened cortisol, but also with a receptor that is more sensitive to it, now they feel out more intensely, more palpitations, inability to focus, more in the direction of a panic attack. Initially, we might look at this low cortisol and say the adrenal gland is failing, but it might not really be the adrenal gland in and of itself but these responses that happen. 

Stress Response is a Trait

It is fascinating to learn that these changes in how the liver metabolizes cortisol and these changes in how the kidney metabolizes cortisol can stay with us more lifelong particularly in people with PTSD. And in addition to that, when your cortisol is low if we can get it back in the normal range, people have benefit from that, not a sudden stress where it was heightened and your receptor is more sensitive, but a normal level of cortisol which would allow that receptor to begin to read it over time at a normal level, which would send the appropriate feedback to the pituitary gland to put the whole system back in balance. Such a “take home message” to realize that stress affects us right down to the tissue, right down to our glucocorticoid receptor. 

This research went on to say that this was not a state, but it was a trait that you could pass on, this change in metabolism of cortisol to your offspring. In fact, they looked at women who were pregnant during the Holocaust and women who were pregnant within a mile radius of 911, and found that yes, this metabolism in their cortisol changed and they passed it onto their offspring. 

Conclusion

How fascinating is it to think about that something like adrenals and fatigue and cortisol level is not merely the adrenal, but it is how the brain is reading that and how the tissue is receiving it and how the liver and kidney are ultimately metabolizing it. And it shows us why we must work within a functional paradigm that realizes it’s not just an adrenal gland, but it is a person that surrounds the adrenal gland that there is a metabolism and a read. It changed that cortisol based on what we’ve experienced in the past and even based on what our mother and father have experienced in the past.

There’s always so much to learn even on a topic that we think might just be as simple as the adrenals. We realize these inner connections are what makes the functional medicine approach so important that it is all so epigenetic, and it is a diet and lifestyle paradigm that recognizes these epigenetics and how all of these pieces work together.