Adrenal Thread

[marianco]

Frustration and Adrenal Fatigue

No doctors can get my FT to raise above v.v low levels. My TT can be very high, but FT will not go up. (SHBG is vv low as well) Actually the higher TT goes, the lower FT goes. I had E2, Estrone and Estriol tested and they are all low normal. I am so frustrated, I have been like this for 1.5 years, no sign of getting better.

When bioavailable testosterone levels and total testosterone levels and estrogen levels are good but sexual dysfunction/depression/anxiety/frustration/etc. persists, then the most important step I've found is to check for adrenal fatigue.

When many of my patients describe feeling "frustrated", "desperate", "crabby", "grouchy", "moody", "snappy", "touchy" - when they are irritable, have frequent mood swings, have frequent panic - I look for adrenal fatigue.

Whenever a patient repeatedly calls me in a crisis, I look for adrenal fatigue.

The inability to maintain a stable temper or mood often indicates that one's ability to adapt to stress is overwhelmed or impaired.

The adrenal glands - which are specialized components of the peripheral nervous system like the hypothalamus is a specialized component of the central nervous system - are one of the main components of our body which allows us to adapt to stress.

When the adrenal glands are well-functioning, but stress is very high, the excessively high cortisol levels produced can cause depression, mood instability, and psychosis. The high cortisol levels can cause insulin resistance, which then lower testosterone production and cause sexual dysfunction.

When the adrenal glands are worn down by chronic stress, the low cortisol levels produced (as well as low levels of the about 150 different neurotransmitters and hormones produced), lead to mood instability, depression, anxiety, low testosterone production - and sexual dysfunction.

 

[marianco]

Adrenal Fatigue and Stimulants

are you saying a longer acting stimulant would protect me from potential adrenal fatigue ? is it only seen with short acting drugs like ritalin? can using these drugs cause PERMANANT damade to the adrenal glands?

Would you please point to the post where you came to your conclusion? Thanks.

All stimulants (both short and long-acting) demand more output from the adrenal glands. One metaphoric way of looking at this issue is that the adrenal glands are like the engine of a car. Using a stimulant is like pressing the accelerator pedal of the car.

All stimulants can eventually wear down the adrenal glands causing adrenal fatigue. Longer-acting stimulants can also cause adrenal fatigue. However, because the peak blood levels are lower, there is a lower risk of doing so. However the higher dose dose, the higher the risk of adrenal fatigue.

I do not know if they can cause permanent damage to the adrenal glands. I have yet to see a case of that in my more than 15 years of practice.

Total failure of the adrenal glands - an Addison's Disease crisis - quickly causes death (in about a day) since cortisol is absolutely necessary for life.

I haven't seen cases of Addison's disease (severe adrenal insufficiency) in patients treated appropriately with stimulants.

 

[marianco]

Adrenal Fatigue and Cortisol Levels

Cortisol is low normal, so it cant be that....

When a person has a low normal blood cortisol level, Adrenal Fatigue may be suspected.

The problem of using blood tests to determine the presence of Adrenal Fatigue is that the tests are designed for determining the extremes of adrenal function - such as Addison's Disease (where there is near zero cortisol produced) or Cushing's Disease (where there is excessive cortisol produced).

Adrenal fatigue is a deviation from the mean which is not recognized by endocrinologists as an illness because it is not extreme, but which can cause devastating behavioral symptoms and impairment, nonetheless. The signs of Adrenal fatigue are not far from normal - thus a primary care physician may not find anything wrong.

Blood test findings may include (not all may be abnormal - its the pattern that clues us in):
1. low normal cortisol
2. low to low normal DHEA
3. low to low normal progesterone
4. low potassium
5. low sodium
6. low normal blood sugar
7. low normal hemoglobin A1c - with a low normal mean blood sugar

The best test I've found so far is doing a saliva test at least four times in a day for cortisol and DHEA. The saliva test is more sensitive than the blood test for deviations near the mean. Here, adrenal fatigue sticks out like a sore thumb.

In adrenal fatigue, the adrenal glands have not failed - like in Addison's Disease. Rather, then "sputter" - unless severe - where they may sometimes work, and sometimes not.

Other clues to adrenal fatigue (without other illnesses such as diabetes or hypertension):
1. low normal blood pressure (for which a person would receive praise and told they will live long - with the primary care physician totally missing the presence of adrenal fatigue by not doing further investigation).
2. sugar cravings
3. salt cravings
4. fatigue or sleepiness in the late afternoon
5. insomnia
6. occasionally feeling lightheaded when changing position
7. feeling cold often; low body temperature
8. a tendency to tremble, particularly under pressure
9. feeling better after a meal (unless severe)
10. low libido
11. lack of energy - in the morning making it difficult to get out of bed.
12. wanting to sleep in late
13. feeling better when stress is reduced - such as by going on vacation
14. needing coffee or stimulants to function
15. frequent colds
16. PMS symptoms in women
17. depressed or anxious mood, irritability, difficulty handling strress
18. irritable bowel symptoms
19. asthma-like symptoms
20. difficulty in concentrating, impaired memory

Many symptoms of adrenal fatigue are similar to the symptoms of having low testosterone - e.g. low sex drive, depression, fatigue, poor concentration, anxiety, irritability, etc.

One of testosterone's roles is to prevent overdriving the adrenals. It limits the stress response so that stress is not chronic. It reduces pituitary ACTH secretion, which reduces cortisol production. It also directly reduces adrenal gland output, independent of ACTH.

Thus, when a person develops low testosterone (or low progesterone for women), such as with age, he is also susceptible to developing adrenal fatigue.

 

[SPE]

How to address testosterone in the presence of adrenal insufficiency/hypothyro?

1. low normal cortisol - yes, 17 for am range 2-22
2. low to low normal DHEA - BELOW MINIMUM W/O SUPPLEMENTATION
3. low to low normal progesterone
4. low potassium - VERY LOW
5. low sodium
6. low normal blood sugar
7. low normal hemoglobin A1c - with a low normal mean blood sugar


2. sugar cravings - as a kid I lived on sugar
4. fatigue or sleepiness in the late afternoon - yup
7. feeling cold often; low body temperature - upon waking this morning it was 96.7
10. low libido - yes!
11. lack of energy - in the morning making it difficult to get out of bed. - used to HATE mornings before starting isocort and armour
12. wanting to sleep in late - see above
14. needing coffee or stimulants to function - I would live on quad shot iced americanos. The stronger the better
15. frequent colds - sinus infections
17. depressed or anxious mood, irritability, difficulty handling strress - yes
20. difficulty in concentrating, impaired memory - yes

Which brings me to my question. Prior to any supplementation, my levels hormone levels were as follows:

Test - 302 (241-827)
LH - 1.6 (1.6-9.1)
FSH - 1.6 (1.4-17)
DHEA - 218 (250-650)
Cortisol - 17 (2-22)

Looking at these, many progressive doctors would say I have secondary hypogonadism. BUT, my cortisol and DHEA are both low. Which brings me to treatment. Upon going on testosterone and getting my levels into the UPPER 3/4's, I still felt blah. It wasn't until the addition of armour, then isocort that I really began to feel better. In a case such as this, WHY ARE TESTOSTERONE LEVELS TREATED WITH TESTOSTERONE? Isn't this treating the secondary effect and NOT the cause? Would treating testosterone with an LH analog be more appropriate? I have now doubt that improving both cortisol and thyroid will improve the above testosterone number. Adding in something like HCG, Selegiline, or tamox/clomid would address part of the cause, wouldn't it? Maybe I'm just rambling.

 

[marianco]

Hormone replacement priority

Looking at these, many progressive doctors would say I have secondary hypogonadism. BUT, my cortisol and DHEA are both low. Which brings me to treatment. Upon going on testosterone and getting my levels into the UPPER 3/4's, I still felt blah. It wasn't until the addition of armour, then isocort that I really began to feel better. In a case such as this, WHY ARE TESTOSTERONE LEVELS TREATED WITH TESTOSTERONE? Isn't this treating the secondary effect and NOT the cause? Would treating testosterone with an LH analog be more appropriate? I have now doubt that improving both cortisol and thyroid will improve the above testosterone number. Adding in something like HCG, Selegiline, or tamox/clomid would address part of the cause, wouldn't it? Maybe I'm just rambling.

Having one hormonal deficiency does not exclude having others.

It is possible to have low testosterone and reproductive hormone imbalances, adrenal fatigue, insulin resistance, low thyroid, etc. all at the same time.

Low testosterone due to low LH means either there is a pituitary tumor or the pituitary gland is aging, among other causes.

The choice of testosterone replacement therapy is really up to the doctor and the patient. Each type of replacement therapy has benefits, risks, advantages, and disadvantages. The treatment has to be individualized.

Direct exogenous testosterone replacement via injection or transdermal solutions have one advantage of being easy to do, directly replacing what is missing. The primary disadvantage being shutting down testicular production.

Human Chorionic Gonadotropin injections may also work. But as the testes age, they may not respond as well over time to HCG. HCG is also very fragile and sometimes is in short supply. When it works, it does have the advantage of having nearly full function of the testes - with the production testosterone and other hormones, sperm production, etc.

Selegiline increases dopamine, which can increase testosterone production. The problem is that it also may increase serotonin and norepinephrine, has interactions with other medications and foods, which complicates treatment. It is not as clean as simply adding back testosterone.

Tamoxifen/Clomid work for some men, by blocking estrogen receptors at the hypothalamus, increasing production of LH. The question with an aging pituitary is if the LH can be increased enough. Can the testes produce enough testosterone. Tamoxifen and Clomid are both weak estrogens, and thus pose risks of excessive estrogen activity including blood clots.

Arimidex and other aromatase inhibitors can increase testosterone, while minimizing estrogen. Is the increase enough - is one question. Does the low estrogen activity pose a risk (e.g. high cholesterol, osteoporosis, etc.) - is another question.

In regard to balancing hormones, there is a priority in treatment to consider. For example:
1. Diabetes - when insulin resistance is severe enough to be type-2 diabetes. Diabetes is as serious neuroendocrine condition. It impairs other neuroendocrine balances - e.g. contributes to low testosterone. It impairs neuron signal transmission - impairing psychiatric and hormonal treatment.
2. Adrenal Fatigue. Adrenal dysfunction causes more severe mental illness and physical impairment than testosterone deficiency. One cannot feel well when receiving testosterone replacement when adrenal fatigue is present. Increasing DHEA can help reduce insulin resistance. In women, adding progesterone can also address adrenal fatigue. Addressing adrenal fatigue with a serotonergic medication when depression and anxiety are present also helps improve thyroid hormone activity.
3. Thyroid hormone. I would usually not add thyroid hormone until after addresing Adrenal fatigue, unless thyroid hormone levels are extremely low (e.g. TSH >30-50 - due to risk of delirium, psychosis with extremely low thyroid hormone). Thyroid hormone demands an increase in adrenal production. If there is adrenal fatigue, thyroid hormone can cause a person to crash by worsening adrenal fatigue.
4. Reproductive hormones - i.e. adjusting testosterone, progesterone. Improving testosterone activity can reduce insulin resistance, partially help reduce adrenal fatigue. Addressing low progesterone in women can help reduce adrenal fatigue and improve thyroid hormone effectiveness.
5. Adding estrogen (in women). Given estrogen's risk for clots, heart attacks and stroke, I would replace estrogen last. The addition first of testosterone and progesterone reduces the risk for these problems.

 

[love_en]

Isn't high potassium the indicator for adrenal insufficiency? I was under the impression that a lack of corticosteroids caused loss of sodium and retention of potassium.

 

[Legenden1999]

1. low normal cortisol - yes, 17 for am range 2-22

17 on a scale from 2 to 22 is low. Howcome ?

JH

 

[marianco]

Adrenal Fatigue and Salt balance

Isn't high potassium the indicator for adrenal insufficiency? I was under the impression that a lack of corticosteroids caused loss of sodium and retention of potassium.

Remember that the body tries to maintain balance when something is out of balance.

In adrenal fatigue, there is an initial loss of sodium due to the lack of production of aldosterone. This can result in low blood pressure and feeling faint.

The body eventually compensates by retaining sodium by sacrificing potassium. This results in the low potassium level I most often see in long term adrenal fatigue, compared to low sodium, high potassium seen in early stages.

When some clinicians see the low potassium, they try to compensate by increasing the patient's potassium intake. This only worsens the problem. The patient with adrenal fatigue actually needs sodium more.

 

[SPE]

17 on a scale from 2 to 22 is low. Howcome ?

JH

Basically because the range is flawed. In range would indicate adrenal insufficiency. Men need a morning am cortisol in the mid-upper 20's. I wouldn't have believed this, but since adding isocort, I've been able to tolerate my thyroid meds much better. Also, I had AWEFUL dry skin. This has cleared up tremendously with the isocort addition. This is because the increased cortisol puts water back into the skin, rehydrating it.

 

[love_en]

17 on a scale from 2 to 22 is low. Howcome ?

JH

Yes that is. Because that scale is derrived from the values taken from physically ill people. Just like the Total Testosterone levels, serum cortisol tests falsely indicate all is well. Dr William McK. Jefferies was the pioneer for the diagnosis and treatment of adrenal problems. He found that the AM cortisol in men was closer to 30 and an ACTH stimulation test produced a result of 50+ in most subjects. I tend to agree with that. My AM cortisol is 28, an ACTH stimulation test results in only 38, and I have had adrenal symptoms long before I realized I was hypogonadal.

 

[wildfox]

14. needing coffee or stimulants to function

Marianco, coffee is such a prevalent habit, and for me it's 3 cups a day.

Would you say that in general one could always benefit from giving up coffee all together, or is it really ok to have one? Or is the picture just too complex to expect benefits from changing that one factor?

Thanks,

WF

 

[marianco]

Adrenal Fatigue and self-treatment.

A word of concern about self-treatment without physician monitoring:

Unlike some of the other treatments for adrenal fatigue, taking hydrocortisone (including Isocort or adrenal extracts) can be dangerous.

Taking excessive amounts can shut down the adrenal glands, giving the person essentially Addison's disease - which can be fatal if left untreated. It is like running a car engine's battery down until it is dead.

Unfortunately, it may take at least 2 years repair and restart the adrenal glands once this happens. And sometimes, it can't be restarted at all - leaving the person with a permanent disability.

Some people's tendency to think that if something works, more is better. This would be dangerous when it comes to treating the adrenal glands. More is clearly not better.

 

[SPE]

A word of concern about self-treatment without physician monitoring:

Unlike some of the other treatments for adrenal fatigue, taking hydrocortisone (including Isocort or adrenal extracts) can be dangerous.

Taking excessive amounts can shut down the adrenal glands, giving the person essentially Addison's disease - which can be fatal if left untreated. It is like running a car engine's battery down until it is dead.

Unfortunately, it may take at least 2 years repair and restart the adrenal glands once this happens. And sometimes, it can't be restarted at all - leaving the person with a permanent disability.

Some people's tendency to think that if something works, more is better. This would be dangerous when it comes to treating the adrenal glands. More is clearly not better.

I definately agree that more is not better. I have been self treating, however. What I've heard is that if you stay <35-40mg hydrocortisone/day, then it's a pretty safe dose. Thoughts?

 

[1cc]

I definately agree that more is not better. I have been self treating, however. What I've heard is that if you stay <35-40mg hydrocortisone/day, then it's a pretty safe dose. Thoughts?

I am on 5mg hydrocortisone once daily in the morning and it is sufficient for me.

 

[SPE]

I am on 5mg hydrocortisone once daily in the morning and it is sufficient for me.

Why are you on it? Have you had your cortisol checked? My am cortisol was at 17 and I am doing ok with 20-25mg/day.

 

[1cc]

Why are you on it? Have you had your cortisol checked? My am cortisol was at 17 and I am doing ok with 20-25mg/day.

I did Saliva cortisol a while back. It indicated I was low in the morning, noon, and before bed. I have found that taking hydrocortisone in the morning, which is the time when the adrenals are most taxed, is best for me. I found, doing this, it was not necessary for me to take anymore for the other times of day. I also take 25mg DHEA, which I believe has been the most helpful to me, perhaps more so than the H/C.

 

[Vforcer2]

I worked my way up to 20 mg a day of Isocort, and had to stop due to the development of acne on face.
I have no idea why. I was thinking I must have been overdoing it, and have been considering starting again at a smaller dose. I did worry that I might be shutting down the adrenals.

I have been diagnosed with stage II adrenal fatigue per my salivary cortisol tests. My N.D. told me to continue on the Adrenal extracts I have, and supplement with 50 mg DHEA.

I have been loosing some hair and am not sure if it is the DHEA or my Armour dosing.

 

[1cc]

I forgot to mention that drinking salted water helps tremendously. I do not drink any water that is not salted. If I do, I will start to have low adrenal symptoms within a day or so.

Marianco,

What is your opinion of using fludrocortisone to help maintain salt in the body. I have read some place that fludrocortisone does not work well in adults. Is this true?

 

[SPE]

Have you noticed a difference with the isocort?

 

[marianco]

Florinef (fludrocortisone)

What is your opinion of using fludrocortisone to help maintain salt in the body. I have read some place that fludrocortisone does not work well in adults. Is this true?

Fludrocortisone (Florinef) is used to treat Addison's Disease. It is a highly potent medication with properties of both cortisol and aldosterone. It acts on the kidney to conserve sodium and excrete potassium. It can be highly dangerous to use unless closely monitored by a physician.

Note that Adrenal fatigue is not Addison's Disease.

Treatment with "big guns" like Prednisone or Florinef may be a lot more than required, entailing more risk. It would be similar to using anabolic steriods for testosterone replacement.