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Do You Have Adrenal Fatigue? - Laboratory Assessments

Publication date: 20 March 2016

In my last blog post I considered the real nature of the stress condition known as "adrenal fatigue" - suggesting it is more a dysregulation of the adrenal control systems (which start in the brain) rather than a problem with the glands themselves. The idea that the adrenals get worn out or fatigued due to years of over-use is mostly inaccurate and not supported by science. On the other hand there is plenty of research showing adrenal dysregulation or adrenal maladaptation in real. But how do you know if you have it?

If you read about adrenal fatigue you'll soon get the idea that there are a set of classic symptoms including:

  • fatigue or lethargy, especially late afternoon
  • feeling wired, or anxiety, or poor stress tolerance
  • sleep disturbance, especially early waking (in the "burn-out" stage of adrenal dysregulation).

Can you "diagnose" adrenal fatigue based on symptoms? I don't think so because there's so much individual variation. I think it's much better to use lab testing to objectively determine what's going on with hormone levels.

The "standard" lab test for "adrenal fatigue" is based on saliva. It's common to see low levels of for example cortisol in saliva, which typically taken as evidence that the adrenal glands are depleted and need to be supported. But this can be misleading. How so?

The situation is more complex than apparent hormones in a number of ways. First, consider that most hormones exist in two forms: free and bound or stored. The free form is the active form. Bound hormone is stored hormone (it's good to have stores, of course). This is true of the adrenal hormone cortisol.

The adrenal saliva test measures your free or active cortisol, but it doesn't measure your bound cortisol.

Having low levels of free cortisol is significant to your experience of energy and resilience, etc. but it doesn't mean that your adrenals are worn out because your bound levels are good. In fact most of your cortisol at any time is bound. In other words, your total cortisol production can be fine, but you might not necessarily have it available. In fact evidence suggests that in about 85% of people with low free cortsiol, total cortisol production is fine. Only 15% of people with low free cortisol actually have an adrenal production issue. But if you only measure saliva free cortisol you don't know which side you're on.

Why might free cortisol tell a different story from total cortisol production?

One possibility is that free cortisol is cleared out of your system (metabolised) too fast. Another is that it may be possible to develop "cortisol resistance", where cells lower their sensitivity to cortisol and ignore its message, just as happens with insulin in diabetes and insulin resistance.

Another form that adrenal dysregulation can take, is loss of circadian rhythm. Cortisol should show a particular pattern over the 24 hour cycle - peaking in the morning when you get up, and dropping over the course of the day, so it's low at bed time, and then beginning to rise again in the early hours. Often this pattern is lost or disrupted (perhaps due to lifestyle factors) so you might have too-low cortisol in the morning (fatigue and lethargy) and too-high cortisol at night (making it hard to get to sleep).

So in assessing adrenal regulation and adrenal function, we need a lab test that's comprehensive enough to take account of all these factors. The saliva test, although it does look at the circadian rhythm of cortisol, doesn't measure total cortisol production. Blood tests of cortisol don't pick up the rhythm and may not differentiate between free and bound cortisol.

I think the best test currently available is offered by Precision Hormones in the form of a dried urine test. Firstly, because a urine sample is easy to collect, taking four samples over the day can give you an impression of the cortisol rhythm. And secondly, in urine you can measure cortisol metabolites which gives you a very good picture of total cortisol production, which you can't get from saliva. So the test distinguishes between free cortisol and total cortisol.

Stress Management

I recommend this adrenal stress test to all many of my clients. (I would recommend it to all, but sometimes I don't want to risk over-complicating things.) Whatever the test throws up, we have to address the individual findings, and as far as possible address underlying causes. In general the most important factor for recovering adrenal regulation is to learn to manage stress better. I think biofeedback is the best tool for doing this - at least for "emotional" stress. Of course there are other more physical forms of stress, and others due to lifestyle (e.g. staying up too late at night) and we have to address these too.

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