Making A Difference In Adrenal Fatigue by Integrative Endocrinologist, Rashmi S. Mullur, MD

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Feb 14, 2019

No chief complaint unites endocrinologists in quite the same way as adrenal fatigue; the term itself, coined in the late 1990s by chiropractor James Wilson(1), has often been loosely defined as a “weakening or burnout” of the adrenal glands in response to chronic stress. Unfortunately, this improper characterization of the physiology of the hypothalamic-pituitary-adrenal (HPA) axis immediately places this syndrome at odds with traditional endocrinologists. We have all had experiences with patients presenting to our offices with vague complaints of fatigue, weight changes, difficulty with sleep, and changes in mood, wondering if their symptoms are the result of an undiagnosed hormonal abnormality. Unlike the well-recognized disorders of either adrenal insufficiency or Cushing’s syndrome, adrenal fatigue appears to exist as a hybrid condition. Patients are told that they are suffering from the negative impacts of excess cortisol while also being told that their adrenal glands are unable to effectively produce enough of this hormone. These patients, under the illusion that their adrenal glands have “burned out,” are often incorrectly advised by non-physicians to use glandular extracts as treatment.

We clearly need to break this false narrative. However, explaining to our patients that actual adrenal fatigue does not exist may come across as indifferent or callous. That approach, while tempting, simply deepens the chasm in our therapeutic relationship. Most patients resonate with the concept that their adrenal glands are “burned out”, since this is the same terminology we use to describe the mental fatigue and exhaustion that develops after severe chronic stress. Patients want to be heard, understood, and healed.

To bridge this gap, the Endocrine Society(2) and the Hormone Health Network(3) have both published official position statements addressing the issue. These statements clearly describe the symptoms of true disorders of the adrenal gland, and then suggest that patients who believe they are suffering from those symptoms undergo validated testing by an endocrinologist. For the patients who don’t have clear symptoms or whose hormonal testing falls into the normal range, most practice guidelines encourage the patients to seek lifestyle approaches to improve stress and wellness. Despite these well-intentioned publications, most patients continue to latch on to the idea of adrenal imbalance, often seeking solace from non-physician providers or buying glandular supplements on their own.

As I see it, our goals and the patients’ goals are misaligned. While we want to educate our patients on stress reduction and the physiology of the HPA axis, our patients simply want to feel better. The catch-22 seems to be that the more time we spend having these conversations, the further away we push our patients.

I, too, was stuck in this clinical quandary. My response was no different than any other endocrinologist—I was explained the physiology of the HPA axis and often dismissed questions about hormonal supplementation. I found myself providing generic advice about the negative impact of chronic stress without providing them any real assistance. My words and actions seemed inadequate to me and to my patients.

My approach to my practice — and to my life — was forever changed eight years ago, with the arrival of my first child. Shortly after his birth my son was diagnosed with a congenital brain malformation and given a dismal prognosis. A few months later, he developed epilepsy which has responded poorly to most medications, and remains treatment-refractory to this day. Struggling as a new mother with a special needs child took a burden on my mental and physical health. I had constant fears about his future. I attempted to cope in the ways I knew how; I arranged therapy sessions, fought insurance battles, and tried to put one foot in front of the other. While I knew I needed to take time for my own mental health and also find the appropriate work-life balance for my family, another thing that concerned me was how I managed my grief, fear and the burden of caring for a medically-fragile child. Dr. Elizabeth Blackburn’s seminal research on telomere length in mothers of sick children weighed constantly on my mind.(4) Was I doomed to shorten my life based on my perceived stress? Was this what my patients with adrenal fatigue worried about? While no one could provide me with a definitive answer, I heard familiar phrases about stress reduction that were well-intentioned, but not helpful.

In my new role as patient/advocate/doctor, I applied genuine curiosity and empathy to my patients who complained of adrenal fatigue. I found that these patients are not tied to the concept that their adrenal glands are malfunctioning. They merely want to convey that they are feeling overwhelmed by their circumstance and are not able to cope. While having a semantic argument about hormonal regulation may seem judicious, it misses the patient’s humanity entirely. Furthermore, simply providing him/her with a

handout on stress management techniques can be dismissive to his/her experience. I started to dig deeper, and I realized that for many, a common theme emerged: traumatic life experience.

I then turned to the literature to investigate if there were documented cases of adrenal dysfunction in response to trauma. Our colleagues in neurology and psychiatry have been researching these pathways in post-traumatic stress disorder (PTSD) for several years. Patients with trauma have documented evidence of changes in the circadian patterns of cortisol release, elevation of corticotropin releasing hormone (CRH) in the central nervous system, and alterations in the architecture and neuronal structure of their brains. (5–7) Furthermore, CRH has been shown to steer the stress response within the sympathetic nervous system and does not respond to traditional negative feedback after exposure to glucocorticoids in extrahypothalamic circuits.(8) With this new knowledge, I realized that my patients who complained of adrenal fatigue may also be experiencing chronic stress-related neuronal changes within their limbic system. They may have developed maladaptive neurohormonal responses such that any additional stress or burden feels overwhelming and unbearable to them.

With this additional insight, it became clearer to me why patients with adrenal fatigue would want to hold on to the idea that their adrenal glands were dysfunctional. In our country, despite significant improvements, we continue to stigmatize patients suffering from mental health disorders, and this extends to patients suffering from chronic stress. Even if we offer them treatment options and referral to behavioral health experts, to send these patients away without validating their experience only reinforces the idea that “this is all in their head.” We can’t tell our patients to reduce their stress any more than someone can tell me not to worry about my chronically ill son. What we can do is give our patient tools to effectively manage their stressors.

As a double boarded specialist in endocrinology and integrative medicine, my search for answers has also expanded. Fortunately, there is solid evidence for the use of several mind-body techniques including meditation, yoga and tai chi, in not only improving a person’s quality of life, but also in changing and improving the structure of the brain which has previously been exposed to trauma.(9–12) Additionally, there are small studies that also support other integrative approaches like acupuncture and herbal remedies in improving fatigue and energy levels in patients with functional somatic disorders and chronic stress.(13,14) Opening my mind to these complementary and alternative techniques has enhanced my clinical approach to patients with adrenal fatigue.

In my current practice, I continue to try and bridge the gap between traditional and integrative medicine approaches. I still advise patients with adrenal fatigue to avoid glandular supplements and encourage them to seek lifestyle-based alternatives, but I have changed the tone of these conversations. Instead of having ineffectual discussions about hormone testing, I now spend more time trying to understand the patient’s life circumstance and health goals. Often, I use the visit to guide the patient to find mind-body techniques that they can easily incorporate and emphasize the benefits of these practices in improving neuronal structure and the adaptive stress response. I reassure my patients that normal lab results do not mean that their concerns and symptoms are invalid. I remind them that hormonal testing is only one part of our therapeutic relationship. I refer them to appropriate behavioral wellness resources that are tailored to their individual concerns and partner closely with my colleagues in psychiatry for those who need it.

While the shock and grief about my son’s illness has faded with time, my fears about the future persist. Recently, Dr. Atul Gawande suggested that we “open (ourselves) to others’ lives and perspectives” to improve equity in medicine through curiosity.(15) I know that applying empathy and curiosity in my own life and practice has drastically improved my capacity to cope with stress. This approach has also worked well as a bridge of support to my patients. I firmly believe that if we can change the way we talk to our patients complaining of adrenal fatigue, focusing on their underlying concerns and trauma, we are more likely to make a true difference in their care.

Rashmi S. Mullur, MD

REFERENCES: 1. Wilson… JL. Adrenal fatigue: the 21st century stress syndrome. Best-Seller-BooksCom. 2002;2. Seaborg E. The Myth of Adrenal Fatigue. Endocrine News: The Endocrine Society. 2017.3. Katherine Chubinskaya M, Luciano Kolodny M, Jason Wexler M, Carol Zapalowski, MD P. Myth vs Fact: Adrenal Fatigue [Internet]. Hormone Health Network. 2018. Available from: https://www.hormone.org/diseases-and-conditions/adrenal/adrenal-fatigue4. Epel ES, Blackburn EH, Lin J, Dhabhar FS, Adler NE, Morrow JD, et al. Accelerated telomere shortening in response to life stress. Proc Natl Acad Sci. 2004;5. Chrousos GP. Stress and disorders of the stress system. Nature Reviews Endocrinology. 2009.6. Lupien SJ, de Leon M, de Santi S, Convit A, Tarshish C, Nair NP, et al. Cortisol levels during human aging predict hippocampal atrophy and memory deficits. Nat Neurosci. DOI:10.4158/ACCR-2018-0168 © 2015 AACE.1998;7. Yehuda R, Yehuda R, Schuster MA. Post-traumatic stress disorder. N Engl J Med. 2002;8. Henckens MJAG, Deussing JM, Chen A. Region-specific roles of the corticotropin-releasing factor-urocortin system in stress. Nature Reviews Neuroscience. 2016.9. Tang YY, Hölzel BK, Posner MI. The neuroscience of mindfulness meditation. Nature Reviews Neuroscience. 2015. 10. Jin P. Efficacy of Tai Chi, brisk walking, meditation, and reading in reducing mental and emotional stress. J Psychosom Res. 1992;11. Epel E, Daubenmier J, Moskowitz JT, Folkman S, Blackburn E. Can meditation slow rate of cellular aging? Cognitive stress, mindfulness, and  telomeres. In: Annals of the New York Academy of Sciences. 2009. 12. Gothe NP, Keswani RK, McAuley E. Yoga practice improves executive function by attenuating stress levels. Biol Psychol. 2016; 13. Wang SJ, Zhang JJ, Qie LL. Acupuncture relieves the excessive excitation of hypothalamic-pituitary- adrenal cortex axis function and correlates with the regulatory mechanism of GR, CRH, and ACTHR. Evidence-based Complement Altern Med. 2014; 14. Provino R. The role of adaptogens in stress management. Aust J Med Herbal. 2010; 15. Atul Gawande. Curiosity and What Equality Really Means. The New Yorker [Internet]. 2018 Jun; Available from: https://www.newyorker.com/news/news-desk/curiosity-and-the-prisoner