Adrenal fatigue syndrome: myth or menace?

Dr Angela Murphy describes how the term adrenal fatigue syndrome came about and sets the facts straight about it.

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What are adrenal glands?

The adrenal glands sit on top of each kidney, measuring 5cm x 31cm and weigh up to 10g. They produce hormones that are involved in the regulation of blood pressure, metabolism, immune function, and the body’s response to stress. These hormones are listed below.

1. Cortisol is essential for processing carbohydrates, proteins, and fats, and also contributes to blood pressure control. It’s an important stress hormone as it helps to suppress inflammation and increase energy sources available for the body’s fight response. Cortisol levels are controlled by both the hypothalamus in the brain and the pituitary gland.
2. Adrenalin and noradrenaline are our flight and fight hormones activated at times of stress. They cause an increase in heart rate, blood pressure and metabolism.
3. Aldosterone is a hormone integral to water balance in the body and thus, blood pressure control.
4. Androgen steroid hormones are weak male sex hormones that are precursors to either oestrogen which is then made in the ovaries and testosterone which is made in the testes.

Disorders of the adrenal glands

Various conditions can affect the adrenal glands and cause either over production of these hormones or a relative or absolute deficiency.

Overactive adrenal glands

• Excess of cortisol – Cushing’s Syndrome
• Excess of aldosterone – Conn’s Syndrome
• Excess of adrenalin – Pheochromocytoma

Adrenal insufficiency

• Addison’s disease – primary damage to the adrenal glands.
• Secondary to pituitary disorders.
• Congenital adrenal insufficiency – genetic.

Each of these conditions present with suggestive signs and symptoms that would be investigated and then treated appropriately.

Adrenal fatigue syndrome

Adrenal fatigue syndrome was first described by American chiropractor, James Wilson, in 2001. He proposed that the excessive stress of 21^st century-living causes a progressive decline in adrenal function.

Dr Wilson lists a collection of symptoms that suggest the condition: fatigue, weakness, body aches, weight loss or gain, depressed mood and cravings are a few. He drew up a questionnaire, which can even be done at home, to assess these symptoms and confirm the diagnosis of adrenal fatigue. He then published a protocol of treatment for this condition consisting of four adrenal supplement formulations that he developed and sold.

Dr Ian Ross, South African endocrinologist and adrenal expert wrote, in 2018, in The South African Medical Journal that the cost of equivalent supplements in our own country is up to R1200 per month.*

There are no confirmed diagnostic tests or evaluations for adrenal fatigue syndrome. No endocrine society has endorsed the term adrenal fatigue syndrome. In addition, no scientific study has proven that patients with symptoms of adrenal fatigue syndrome have biochemically impaired adrenal function.

The Endocrine Society of the USA, among others, has issued a warning that the adrenal fatigue syndrome doesn’t exist. However, the symptoms that people present with do exist and it’s important to diagnose what the cause of these symptoms may be.

The following are conditions which may present with a similar spectrum of symptoms as adrenal fatigue syndrome:

1. Chronic fatigue syndrome

This complex condition, also known as myalgic encephalomyelitis, is characterised by severe fatigue that is not improved by rest and is significantly worsened by exercise. Associated symptoms such as muscle pains, recurrent infections and poor concentration also occur.

This is a clinical diagnosis made once other possible conditions are excluded, e.g. thyroid disease, primary adrenal insufficiency, anaemia and sleep disorders. In many cases there is also evidence of a mood disorder such as depression or post-traumatic stress disorder.

It’s thought to be caused by a variety of triggers on the background of genetic susceptibility. The most common triggers are infections, particularly viral, and trauma which can be physical or emotional. There has been a significant increase in cases after COVID-19 with many overlap features with long COVID. Chronic fatigue syndrome is treated with a combination of medication, psychotherapy, and lifestyle.

2. Mood disorder

Depression, anxiety, post-traumatic stress disorder and burnout are all conditions with overlapping symptoms. These can be diagnosed clinically, and the correct management prescribed.

3. Menopause

In women, many of the symptoms being discussed such as fatigue and weight gain occur at menopause (a time when the ovaries are no longer producing oestrogen). Oestrogen replacement therapy can be extremely effective in treating the symptoms. The choice of therapy must be discussed with your healthcare provider.

4. Andropause

Men can experience low testosterone levels although this doesn’t occur as definitively as menopause. Risks for low testosterone include obesity and metabolic diseases such as diabetes. Testosterone replacement therapy is an effective option in relieving symptoms in men with biochemically low testosterone levels.

5. Thyroid disease

Both under and overactive thyroid disease can cause symptoms as described in adrenal fatigue syndrome and should be tested for.

6. Sleep disorders

The most common one we see is obstructive sleep apnoea. This is diagnosed by doing an overnight sleep study. If present, people are prescribed a CPAP machine which delivers air under increased pressure. It’s sometimes necessary to refer a person to the sleep specialist for a full overnight sleep study.

Management of the symptoms associated with adrenal fatigue syndrome

If a specific condition is found, this must be treated. In most cases, there will be significant benefit adding a healthy lifestyle as well. A healthy lifestyle incorporates:

• Healthy diet including all food groups and especially fruit and vegetables.
• Regular exercise – aim for 150 minutes per week.
• Maintain a healthy weight.
• Get a good night’s sleep.
• Stop smoking.
• Keep alcohol intake to safe values: 2 units daily for a woman; 3 units daily for a man.
• Stress management – this can be done with medication and/therapy.

Summary

As Dr Ian Ross and colleagues wrote in the 2018 article, * “Until there is objective, reproduceable clinical evidence for its diagnosis, adrenal fatigue does not exist, and patients should be appropriately investigated and managed for their symptoms.”

Most of the symptoms ascribed to adrenal fatigue syndrome are non-specific. It is thus, essential for the healthcare provider to take a detailed history, perform a thorough examination and order appropriate laboratory tests. A working diagnosis of the likely cause of the symptoms should always be made. In this way an appropriate treatment plan can be prescribed with the aim of alleviating the symptoms.

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Reference

*We are tired of ‘adrenal fatigue’ | Ross | South African Medical Journal (samj.org.za)