“Adrenal fatigue” a medical misnomer, underlying causes to be addressed

Adrenal fatigue (AF) cases are seeing an uptick in preponderance, but it is not an accepted medical diagnosis, says a prominent expert.

Speaking at the recent 12^th Malaysian Endocrine and Metabolic Society (MEMS) Annual Congress (MAC 12), Professor Dr Chan Siew Pheng, consultant endocrinologist, said AF had been debunked as early as 2016 in a systematic review of over 58 studies which arrived at the conclusion that AF has no substantiation as a medical condition. [BMC Endocr Disord 2016;16(1):48]

The reason patients resort to alternative and sometimes dubious channels is because they have been consulting with many doctors only to walk away with no satisfying diagnosis. Such a scenario has long been fertile ground for pseudoscience, which can comfortably offer certainty to patients under the guise of newly minted conditions.

However, Chan cautions against dismissing a patient by saying “adrenal fatigue doesn’t exist” to their face. Doing so could leave the patient feeling unheard, discounted and disregarded. This has the unintended effect of pushing them further into the hands of dubious practitioners. Therefore, while there is no scientific evidence to support adrenal fatigue as a medical condition, the responsibility still falls upon specialists and physicians to get to the bottom of patients’ complaints. This involves proper history taking and investigations to rule out any life-threatening causes.  

According to Chan, the adrenal gland does not go into fatigue and produce less hormones. Instead, when the need arises, such as when a person is under stress, the glands will work harder and make more hormones.

  Symptoms often blamed on adrenal fatigue include:

·        Feeling tired and fatigued every day

·        Difficulty in waking up in the morning

·        Difficulty handling stress

·        Craving salty food or sweets

·        Body Aches

·        Mood changes

All these are non-specific and do not point to any particular medical disorders. Many people complain of having such symptoms like feeling tired and lethargic / being unable to cope with stress.

This ambiguity is what causes the patients to feel frustrated as the doctor is unable to give them a definite answer to their complaints of feeling unwell. 

What is the more likely cause of AF?

Rather than AF the actual diagnoses may be obstructive sleep apnoea syndrome, depression or anxiety, excessive work (exhaustion), night-shift workers with inverted biological rhythm, chronic fatigue syndrome, or other health problems.

If there is actual adrenal insufficiency, which is a legitimate medical condition; the most common causes are exogenous steroid use/abuse, usually from traditional and complementary medicines or opioid abuse, which causes central suppression of the hypothalamic-pituitary-adrenal (HPA) axis.

Adrenal insufficiency is not adrenal fatigue. 

Adrenal insufficiency is diagnosed when there is definitive evidence of low serum cortisol (below the normal range of blood cortisol) or low serum cortisol after performing a Synacthen test (the gold standard). 

Many practitioners of Wellness programs diagnose adrenal fatigue even when blood cortisol levels are well within the normal range; the diagnosis being made on an arbitrary range (with no scientific evidence). This is wrong and is misleading to patients.

Adrenal fatigue and the dangers of adrenal health supplements

The term was first coined by James Wilson in the late 90s and early 2000s, where he described adrenal fatigue as a diagnosis to identify “below optimal adrenal function” resulting from chronic exposure to stressful situations. This is thought to lead to overuse of the adrenal glands, and thus AF. The term is AF is also used to distinguish it from Addison’s disease, which is potentially deadly if untreated. Wilson went on to say that AF is a condition where “conventional medicine does not yet recognize it as a distinct syndrome.” [BMC Endocr Disord   2016;16(1):48]

It is worthwhile to note that Wilson is a naturopath and chiropractor, and not a medical doctor. This is not to disparage naturopaths and chiropractors, but the fact remains that his website sells a plethora of supplements catered to the unrecognized disease known as AF, with the following disclaimer: “This statement has not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease.”

Therefore, it is immediately obvious that supplements are not regulated or approved by the US FDA. Many contain steroids in the form of cortisone or dexamethasone in addition to thyroid hormone mainly in the form of T3, said Chan. In Wilson’s website, he sells the costly “adrenal fatigue quartet” supplement.

Chan warned that the dangers of consuming unregulated supplements, especially those containing steroids and hormones, may lead to serious negative outcomes. Patients may feel better temporarily possibly due to a placebo effect or the effect of the external hormones itself. The steroids will induce a sensation of euphoria. These effects are transient and even at physiological doses of steroids in these unregulated supplements over the long term, may cause avascular necrosis of the hips, weight gain, and with it other metabolic or cardiovascular risks associated with the weight gain. Physiological doses mimic what the body produces normally in a day.

Some supplements contain pharmacologic or prescriptive doses of hormones, which can lead to adrenal atrophy and thus result in the inability of the adrenal glands to produce cortisol when a person is truly stressed. Pharmacological doses are usually much higher than physiological doses. Other conditions associated with such high doses of steroids are hyperglycaemia, uncontrolled diabetes, hypertension, weight gain and osteoporosis, among others. Chan said: “You [physicians] have to be able to explain to your patients, why it is not safe to continue taking [these supplements] and also be able to recognize that the state of euphoria is transient.”

With prolonged intake of these steroids (hydrocortisone/dexamethasone) the adrenal glands atrophy, it may take many months before the glands start functioning again. In times of real stress, patients may present with life-threatening acute hypoadrenal (Addisonian) crisis: hypotension, hypoglycaemia and possible mortality. The other common practice of adding bioidentical thyroid hormones in people with normal thyroid glands, may result in hyperthyroidism, resulting in palpitations/tachyarrhythmia that may worsen symptoms in patients with cardiac disorders.

Thus, AF is not an accepted medical diagnosis. The responsibility of making the exact diagnosis of adrenal insufficiency (hypoadrenalism) should be by trained and experienced endocrinologists or physicians; not by GPs who practice “Wellness Management.”  There are real dangers as a result of prescribing unregulated, unnecessary supplements that contain adrenal steroids and thyroid hormones.  The medical fraternity needs to take steps to reduce this dangerous practice.    

 Unfortunately, the diagnosis of Adrenal Fatigue is particularly immune to counter-arguments as evidenced by the growing cottage industry of supplements and the off-label treatments meant to treat it despite carrying real and serious health threats.