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Mary Shomon

The Scientific Validity of Adrenal Fatigue and Mild Adrenal Insufficiency

By November 4, 2010

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The Hormone Foundation -- part of the Endocrine Society -- has released a controversial "fact sheet" series, titled "Myth Vs. Fact". One of their sheets is titled"Adrenal Fatigue" and attacks the very existence of the condition, stating, "Adrenal fatigue is not a real medical condition. There are no scientific facts to support the theory that long-term mental, emotional, or physical stress drains the adrenal glands and causes many common symptom." (You can read the entire "fact sheet" as a PDF: Myth Vs. Fact: Adrenal Fatigue.)

In Part 1 of this Q&A, Richard Shames, MD commented on the controversy, and in Part 2 of this Q&A, Dr. Shames addressed the validity of adrenal insufficiency and fatigue as a genuine diagnosis. Dr. Shames is a graduate of both Harvard and the University of Pennsylvania, and trained extensively with the National Institutes of Health. He is a well-respected integrative physician and hormone expert in private practice for more than three decades. Dr. Shames is also co-author of the books ThyroidPower, and Fat Fuzzy and Frazzled.

Mary Shomon: You have stated that you totally disagree with the Endocrine Society calling adrenal fatigue a myth. What hard science underlies the disagreement?

Richard Shames, MD: The long careful history of hard science on this topic goes back to the1930s and progresses continuously to the present day. In 1939, Fuller Albright, MD had already become famous as a pioneer investigator of adrenal function at the prestigious Harvard Service of the Massachusetts General Hospital. FYI, this is where the New England Journal of Medicine is published. Dr. Albright wanted to publish some studies on a promising new and as yet un-named substance, tentatively called Compound F. The name later became hydrocortisone, with impressive benefits and usefulness reported at the Mayo Clinic as well.

Mary Shomon: Did the researchers find side effects to hydrocortisone?

Richard Shames, MD: Yes, and that's where William Jeffries, MD stepped in to save the day. As a student of Dr. Albright, Dr. Jeffries discovered that low doses of hydrocortisone did NOT result in negative side effects and were extremely helpful to people who had mildly low adrenal levels -- aka, "adrenal fatigue" -- and not just the severe form called Addison's disease.

Mary Shomon: So it was Dr. Jeffries that helped start the idea that there could be mild adrenal dysfunction, something in between the two extremes of the very low adrenal called Addison's disease and the very high adrenal levels called Cushing's disease. But, did he get it published?

Dr.Shames: He did. The article was called, "The present status of ACTH and cortisone in clinical medicine," and was published in the New England Journal of Medicine in 1955. (Volume 253, p.441-446.) Dr. Albright was in agreement with and proud of his student.

Mary Shomon: Have there been other publications?

Richard Shames, MD: Yes, Dr. Jeffries wrote a more recent book called Safe Uses of Cortisone. He has been a professor of endocrinology for many years, and early on had a strong influence on the great adrenal researcher and popularizer, Hans Selye. The Stress of Life, by Selye came out first in 1956, but like Jeffries' book, it has had updates to include more and more of the recent research on mild adrenal insufficiency. Selye famously and painstakingly proved to the satisfaction of the vast majority of scientific opinion that that long-term mental, emotional, or physical stress drains the adrenal glands and causes many common symptoms.

Mary Shomon: Given the science, how can the Endocrine Society say that this condition doesn't exist?

Richard Shames, MD: If I were not a doctor trained in this area, I might be having a touch of understandable "cognitive dissonance." But instead, I am a physician with both research and clinical experience spanning over thirty years. I can assure you and your readers that the above-mentioned collections of adrenal research contradict and prove that the Endocrine Society is wrong in failing to accept the existence of adrenal fatigue.

Mary Shomon: But the Society's "Fact vs Myth" sheet also states that "tests for adrenal fatigue" (apparently they mean the popular saliva tests) "are not supported by good scientific studies." Can you point readers in a good direction to refute that?

Richard Shames, MD: Yes. One fairly recent decisive study came out of the well-respected University of Colorado Health Sciences Center and was published by Gozansky in the equally well-respected and peer-reviewed Journal of Clinical Endocrinology, September 2005. The article title says it all: "Salivary cortisol as measured by immunoassay is preferable to serum (blood) cortisol for assessment of dynamic hypothalamic-pituitary-adrenal axis activity."

In other words, saliva tests for adrenal fatigue ARE based on scientific facts, supported by good scientific studies.

Basically, the Endocrine Society has refuted itself. I found one of their "Clinical Practice Guidelines for Doctors" that actually ADVISES physicians to use a late night saliva test for cortisol in an adrenal diagnostic situation. How could they be so against something that they also recommend? That little gem is on my website.

Mary Shomon:In the end, what should patients do?

Richard Shames, MD:I want patients to understand that adrenal fatigue is certainly a real illness, but not the accepted medical name for it. People are likely to obtain attention from practitioners and reimbursement from insurance companies simply by calling it "Mild Adrenal Insufficiency." (Yes, call it that, even though it feels anything but mild; stubborn people in authority still insist that true, severe adrenal insufficiency is Addison's disease) In this way, you are at least in the running for the official ICD-9 diagnostic category of 255.4, which could be the magic number with insurance.

Many patients will find it difficult to talk a doctor into testing for this diagnosis. My recommendation is to order the test yourself. You can go to the patient advocacy organization Canary Club, to order your own ZRT 4-sample Ssaliva Adrenal Function Panel. If you show any abnormal results from this certified, CLIA-designated lab to your practitioner and/or insurance company, and encounter resistance, I invite you to tell them that Richard Shames, MD, investigative author and adrenal patient advocate, will be wanting to know why. I am prepared to inquire with state medical boards and/or state insurance commissions if necessary, on behalf of patients who are facing stonewalling on adrenal diagnosis.

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November 5, 2010 at 1:12 pm
(1) Lucine says:

Just wanted to thank Dr. Shames for his work and his dedication to helping those of us suffering from adrenal issues. It’s refreshing when doctors advocate for their patients, and not their pocketbooks. :)

November 5, 2010 at 3:53 pm
(2) penny says:

I agree with u Lucine

November 5, 2010 at 8:51 pm
(3) Jen says:

Mary, thanks so much for publishing this, and Dr. Shames for providing some common sense to ill patients!

November 12, 2010 at 11:43 am
(4) sofie marie says:

I’m interested in adrenal (dys)function relative to lengthy bipolar manic episodes (7 months, recnetly) characterized by little or no sleep, heightened (understatement!) physical/mental activity, et cetera. What happens when the adrenaline finally runs out, resulting in the inevitable “Crash”? Does this result in permanent adrenal damage?

November 13, 2010 at 11:51 pm
(5) Nick says:

Mary, the title of your post had me looking for references to studies that showed the scientific validity of adrenal fatigue, but doesn’t list any. Do you know of any controlled trials that have studied it?


March 19, 2012 at 5:08 pm
(6) Phil says:

I find some of the arguments presented by Dr Shames circuitous and obfuscating (confusing the facts). He states and makes the point very clearly that saliva tests are considered by the medical community and accepted by the Endocriine Society as a means of determine adrenal activity. Somehow, the fact that they accept the test is then construed that they should accept the diagnosis of adrenal fatigue.

A search on PubMed shows that there is no published or proven research that Adrenal fatigue exists as a condition.

May 17, 2013 at 3:09 am
(7) Louisa says:

What a brilliant, no nonsense, common sense approach to an issue that is plaguing many people for a very long time.

Phil – perhaps you need to go back and re-read the entire interview. You seem to have misconstrued what was said in order to justify your own position.

That is a typical defense of the medical establishment.

August 9, 2013 at 2:46 pm
(8) Mare says:

I really appreciate this article, especially since you’ve provided us with Thank you so much for providing the the ICD code that is required by most doctors since every ailment and subsequent diagnosis must have a “code” that is acceptable to insurance companies for it to be considered a plausible diagnosis and symptom for testing. I have a primary care doctor that believes in Eastern & alternative medical practices but also has to play the pharmaceutical prescription game. Her “primary care physician” is a neurologist that practices acupuncture, acupressure and chiropractic adjustments as part of his method of treating patients. When all of my blood results and test for any kind of hormonal and autoimmune lab work came back someone “normal” but she believed my symptoms but knew it was beyond what she could properly diagnose and treat, she suggested I go see her doctor (I now see both of them). He (the Neuro doctor practicing alternative medicine) looked over my lab work and spotted some interesting finds with my electrolytes, my blood pressure, my new allergies (I’d never had allergic reactions until within the past few years), daily headaches, extreme fatigue, very low blood pressure, exteme sensitivity to cold, dry skin, …so many of the signs that something wasn’t right with my adrenal system. I had many more symptoms than this, but I’ll spare you the details.

August 9, 2013 at 2:50 pm
(9) Mare says:

(continued from previous post) This new doctor didn’t prescribe any prescriptions but was concerned about getting my blood pressure and my blood chemistry back on track and changing my lifestyle. He told me I had moderate adrenal fatigue. He did not suspect it had gone so far as Addison’s and as long as I began responding well to the lifestyle and dietary changes (I had to minimize potassium and start drinking salt water–using natural sea salt with all of the trace minerals), minimize (not eliminate completely) caffeine and chocolate–he said eliminating these cold turkey would create more stress but I would need to cut back and try not to rely on them to get through my day. And a lot of sleep…no matter what. This therapy worked! I saw results within 6 weeks and it lasted with my blood pressure, headaches, fatigue, sensitivity to light, sound, normal stressors, etc. normalizing. That lasted approximately two years. 6 months ago I had the flu and was very slow to recover, lost energy, couldn’t get my strength back (prior to the flu I was running half-marathons and competing in triathlons), insomnia and fatigue hit again, my blood pressure has since become very low (my primary care physician was worried last week & put me on a high-sodium intake diet), headaches have returned, easily irritated by normal things, etc.–all the classic adrenal fatigue symptoms.

August 9, 2013 at 2:53 pm
(10) Mare says:

(continued again from previous post): What I find interesting is both alternative medical physicians and “traditional/western” medical physicians all describe the same symptoms but call this syndrome/disease by a different name with different treatment methods. I’ve read books on this, successfully treated this at one time (and starting treatment again). I have had traditional doctors dismiss my symptoms and refuse to run any specific tests other than a general blood and urine test to screen for a wide/general range of possible other underlying causes of my symptoms. They’ve continued to say, other than my low blood pressure and electrolytes being out of normal range, that I’m perfectly healthy. I had one doctor dismiss me altogether and refuse to do any testing. He told me my fatigue and headaches were all normal for being a working mom at my age and that I simply needed to accept that I wasn’t in my 20s anymore. This was somehow the new “normal” for a woman in her mid-to-late 30s. That was such an insult to both me and my intelligence when I knew something physically was wrong with my body.

August 9, 2013 at 2:54 pm
(11) Mare says:

(continued…): My whole family has a history of autoimmune issues (hay fever, severe and long list of allergies leading to asthma, fibromyalgia, psoriasis, positive test results for ANA tests, arthritis, and alzheimer’s) So, its possible my adrenal issues are part hereditary. I could be predisposed to hormonal/immune issues, but life stressors have put me at an increased risk and increased stress on my adrenals with constant “fight or flight” situations. No one disputes the serious nature of adrenal disfunction. It seems what the medical community is divided on is the method of treatment. One group dismisses adrenal fatigue as real because it doesn’t necessarily require pharmaceutical drug treatment unless its severe enough (meaning Addison’s Disease). But, if they can code it by an insurance company-accepted ailment (call it “adrenal disfunction”), then they can test for it (and the insurance company will cover the test) and they can prescribe hormone therapy treatment. In that scenario, everyone makes money off of the same ailment. The other way, adrenal fatigue, which has not been widely accepted by the medical community as being real (only because it doesn’t have an ICD code), is not a money-maker. A person with adrenal fatigue may still be producing hormones–the adrenal glands are functioning–just not properly. But for many, they can repair the adrenal system without use of pharmaceutical medication (a.k.a. hormone therapy), so not so many people can make money off of this–even if it is the appropriate diagnosis and treatment for the patient.

August 9, 2013 at 2:58 pm
(12) Mare says:

(Cont.) My conclusion: listen to your body. If you know something is wrong, ask your doctor to run tests. If the tests don’t reveal to your doctor that anything is abnormal (you could be in the very low or the very high range of “normal” and they will say you are normal…but you could be almost out of normal range–all of these are possible clues to a possible cause of how you are feeling). Don’t stop looking for the underlying cause & appropriate treatment if your doctor dismisses your symptoms. Play the game. Tell them you suspect adrenal insufficiency & give them the code. As far as the debate over using the saliva test. I find it interesting that Aetna even posted online that they do not support medical tests for possible hormone therapy using saliva hormone tests to check your hormone levels. Yet on the exact same site, they accept the use of saliva hormone tests to test for Cushing’s syndrome: http://www.aetna.com/cpb/medical/data/600_699/0608.html I find it very interesting that the same test (a saliva hormone test) is accepted to test for hyperadrenia (Cushing’s Disease) but not the opposite spectrum of the adrenal dysfunction of hypoadrenia (Addison’s Disease). For Addison’s, they want to do a blood test. For Cushing’s they want to do a saliva test). I wish someone could shed some light on the rationale of this. Wouldn’t a salivary hormone test show whether the same hormone levels are either too high or too low? I’d appreciate any comments regarding this question. In the meantime, I really appreciate this article and for providing the ICD code! Thank you! The book that helped me was: Adrenal Fatigue: The 21st Century Stress Syndrome. Also, there are still plenty of doctors out there that will understand and are willing to test and treat you for adrenal fatigue (adrenal insufficiency or mild Addison’s Disease)–whichever name you prefer to call it. If your primary care physician doesn’t take you seriously, find another doctor!

December 19, 2013 at 3:35 am
(13) Kim C says:

Thank you Mare for your very detailed and candid discussion of your symptoms and treatment. I have been struggling for years and I know I am unwell with very similar symptoms but after all the tests and various treatments produced no improvement, I have been constantly beating myself up that I am imagining myself being sick and causing all these symptoms ! I have just been asked by my rheumatologist to do a 9am bloodtest for cortisol level. Not sure if they will find significant abnormality but I genuinely believe that I do have adrenal fatigue due to years of prolonged mental and emotional stress!
The question that I need to research more is how do I improve my adrenal situation without doctor’s help!

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April 7, 2014 at 12:57 pm
(16) Marci says:

I wonder what the rational behind denying the diagnosis of adrenal fatigue? What good would for the medical professonals of the endocrine society to shut down on this information, if indeed valid, well conducted studies are actually there. I’m being treated for adrenal fatigue, and low dose cortef has helped immensely, so I’m asking this from a place of true curiosity.

April 10, 2014 at 12:22 am
(17) Diane J says:

Thank you Mary and Dr. Shames.

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