Abstract
Aviva Romm, MD, is an integrative and functional medicine physician practicing in western Massachusetts, the medical director of the American Herbal Pharmacopeia, in Scotts Valley, CA, and an advisory board member at Yale Integrative Medicine, in New Haven, Connecticut. Dr. Romm is also the recent past president of the American Herbalists Guild, a founder of the Yale Integrative Medicine program, and the author of seven books on natural medicine for women and children. An internationally respected expert in botanical and integrative medicine, Dr. Romm has spent nearly 30 years as a health care practitioner. In this column, Dr. Romm discusses an integrative treatment approach for adrenal fatigue syndrome.
It is important to keep in mind that irritable bowel syndrome [IBS], fibromyalgia, and chronic fatigue syndrome [CFS] were also initially considered to be fringe diagnoses in much the same way. However, these are now are now formal medical diagnoses, with etiologies that are understood better and with consistent methods for evaluation of symptoms. Yet, patients who visited their physicians 20 years ago and said, “I think I have CFS,” might have received an “eye-roll” response from their doctors. Today, many patients who tell their doctors, “I think I have adrenal fatigue,” might receive a similar response.
Quite typically, if a patient's laboratory results and physical examination do not meet criteria for an established diagnosis, the patient is told that he or she has a somatic or psychiatric diagnosis. So, for example, a woman may go into her doctor's office with dry skin, constipation, depression, low energy, fatigue, and hair loss. Yet, when her thyroid stimulating hormone [TSH] test result comes back at 4.7, and the upper limit of normal is 4.8, she may be told by her doctor that she does not have a thyroid problem and may receive a prescription for an antidepressant. Interestingly, even just 5 years ago, women whose TSH values were between 5 and 10 were told that they were fine and they did not have thyroid problems until that value exceeded 10. Then, the accepted laboratory value upper limit for TSH was halved when it was recognized that values over the new lower range indicated hypothyroidism. As a result, a large number of women were told they were fine when, in fact, they had hypothyroidism or Hashimoto's thyroiditis.
Too often, people presenting in clinician's offices, with what we call a functional diagnosis, have their symptoms attributed to depression, anxiety, or hypochondria, and are given antidepressants, anxiolytics, muscle relaxants, or sleep medication for these syndromes. Unfortunately, clinicians using this approach do not consider the possibility that a new syndrome is arising in our society and do not assess these patients for the root causes of this constellation of symptoms.
Part of what has happened in our culture is that disease syndromes sometimes arise as a function of what is going on in our culture at any given time. For example, 100 years ago, IBS was a rare condition. Fibromyalgia was considered a “garbage can diagnosis” by the medical establishment in the 1980s and 1990s. In the 1800s, hay fever was an anomaly and not a household term. However, as people became urbanized and lifestyles changed, people became more allergic to their environments. As a result, hay fever became a recognized syndrome. A culmination of things happen that cause new conditions to arise, and it is not until we see enough of them that somebody finally proclaims the existence of that phenomenon. Also, in Western medicine, if we cannot measure it yet, it does not really exist.
The term adrenal fatigue describes a state of chronic exhaustion after prolonged hypervigilance or persistence of the alarm phase of the stress response. It is similar to leaving the light on all the time. Eventually one is going to burn out the bulb. Fatigue, depression, immune dysregulation, insulin resistance, chronic inflammation, hypertension, severe insomnia, and cognitive problems are but a few of the many symptoms. Weight gain around the abdomen is common as a result of this same primitive danger-response mechanism protecting us from famine by holding onto fat as an energy reserve when danger is perceived. Hormonal dysregulation is another side-effect of the body's warning system being in chronic overdrive; the body diverts energy away from reproduction when there is perceived danger. Other effects include osteopenia or osteoporosis, because chronic cortisol exposure increases bone turnover. Prolonged exposure to cortisol also changes neuronal wiring and blunts the dendrites in the brain, preventing optimal executive function and execution of willpower. So, it is harder to make decisions and there is an increased the risk of impulsive or addictive behaviors.
The term adrenal fatigue describes a state of chronic exhaustion after prolonged hypervigilance or persistence of the alarm phase of the stress response.
A review of the fairly specific set of criteria that exist for CFS should help the practitioner differentiate between it and adrenal fatigue. Clinicians should consider adrenal fatigue in patients who report long periods of stress and prolonged periods of hypervigilance. This syndrome may present along with other conditions, including CFS. Patients with adrenal fatigue are apt to describe themselves as experiencing “burnout,” being overwhelmed, and exhaustion. The exhaustion may have peaks and nadirs, being more predominant in the early morning and late afternoon. At bedtime, people with adrenal fatigue are often very tired but may have difficulty falling asleep because they feel overstimulated or “wired.”
Tests to consider when a patient is reporting fatigue include a complete blood count (to rule out anemia or even leukemia), a TSH and thyroid panel (to rule out hypothyroidism), and an autoimmune panel. A pregnancy test and menstrual history should be obtained in women of childbearing age to rule out pregnancy. I often include conventional cortisol testing to assess for frank adrenal disease (such as Addison's disease), although this will have a specific set of symptoms that differ from adrenal fatigue.
Spot serum cortisol testing is not reliable when assessing for adrenal fatigue, because cortisol has a diurnal pattern, so a single test might miss the problem. Normally, cortisol should be elevated in the morning when we wake up and then should start to decline. The peak is in the morning, and then there is a nadir late at night. A morning cortisol level by itself might look relatively normal, but a person's afternoon cortisol level might be lower than it should be, or the afternoon cortisol level might be normal, but the evening cortisol level might be high. If all that a clinician ordered was a random spot cortisol test, he or she could miss the abnormality in the rhythm.
The two tests that I will usually order are a 24-hour urine cortisol, which does not provide a sense of the diurnal rhythm but does provide an overall picture of the total cortisol load. I also order salivary cortisol testing, which, even by conventional medical standards, is considered to be reliable and valid, although many physicians are unaware of its value. Salivary cortisol is obtained (by the patient) several times throughout the day, so that the cortisol pattern may be observed.
Discerning these patterns can help explain the patient's symptomatology. Noting such patterns also can help clinicians start to work with their patients to identify what might be going on in their lifestyles that can perhaps be modified to address the problems. For example, a skipped breakfast with ensuing hypoglycemia at midmorning could be reflected as a high late-morning cortisol level caused by stress on the system, or a high evening cortisol-level could indicate that a patient's sleep difficulties are caused by trouble in the HPA axis. If a 24-hour urine cortisol level, or even a salivary cortisol level, is extremely high, then I refer the patient to an endocrinologist for an adrenocorticotropic hormone [ACTH] challenge test to see if there is an underlying diagnosable adrenal disease, but those instances are quite rare.
Some of the functional medicine laboratories that perform salivary cortisol testing also include additional related tests along with the salivary cortisol test. These include: secretory IgA, which assesses for the impact of stress on the immune system, particularly in the mucosa; progesterone, which, if low in conjunction with disruption in cortisol, suggests that hormonal pathways are being diverted away from sex-hormone production toward stress hormone production; and insulin, which, if high, also points toward chronic stimulation of the stress response as the body is attempting to keep up with disruption in sugar metabolism. Chronic HPA axis stimulation and production of cortisol is a risk factor for metabolic syndrome and diabetes.
So the first thing that I do with a patient is to help that patient understand the connections between the stressors in his or her life and the set point. I also explain that that, although an individual has certain set point, it does not mean that he or she always has to react from that place. A patient can begin to recognize that stress is putting him or her into a certain state. By using mindfulness techniques and tools that draw from cognitive behavioral therapy [CBT], a patient can learn to modulate reactions to calm down the sympathetic nervous system [SNS] reactions triggered by HPA axis activation, and deliberately move into a more parasympathetic state. Lack of control and autonomy have been shown to be the highest triggers for HPA activation as well as being among the highest factors for all-cause mortality. Helping people to develop a sense that they actually have some control over how they react is important.
A patient can begin to recognize that stress is putting him or her into a certain state.
People with adrenal fatigue are stuck in a SNS pattern, which changes their heart rate variability and causes chronic constriction of their vascular systems. This pattern can also lead to hypertension. It is complicated picture, so I help my patients find ways to identify their symptoms that show that these patients are in sympathetic mode. I teach my patients the tool that I call “permission to pause.” I tell my patients: “Let us start to learn what your symptoms are. Your heart is racing a little bit. You may feel anxiety. Maybe you are sweating or are irritable. You feel agitated. When you feel these symptoms, give yourself permission to pause, literally take 10 seconds, and take some deep breaths.” I will teach patients to do a simple meditation that they can use to remind themselves to take it down, and breathe. I often recommend HeartMath® or other biofeedback systems. CBT can also help people start to understand their reactivity and how to get out of that reactive mode. Clinicians can teach people to rewire their responses from chronic hypervigilance into a more relaxed mode.
I also work with my patients to improve their sleep quantity and quality, because lack of sleep is a bidirectional problem leading to a vicious cycle of being more tired and then more wired. I work with sleep hygiene and specific nutritional supplements and botanicals to support sleep.
I also work with my patients to understand their food cravings and blood-sugar regulation. Again, we have a bidirectional situation with cravings and blood sugar. When one is in sympathetic overdrive, one is pumping out sugar and breaking down fat and producing more sugar. The idea is that one either has to fight off something that is attacking one, or one has to be able to run away from it. So the body needs a lot of glycogen to fuel the muscles. At the same time, a lot of insulin is being pumped out in an attempt, after the stress response ends, to take up whatever glucose has not been utilized. So, blood sugar that is constantly rising and falling, partly because of the stress response, and also partly because of what a person is eating in reaction to stress, can have truly damaging effects and can ultimately lead to insulin resistance and even diabetes.
To forestall the stress response I educate my patients, again, about those breathing exercises and the relaxation activities patients can do and ways to actually manage their lives so these patients are not chronically overwhelmed, so I can and help them maintain steady blood sugar levels. I encourage my patients strongly to never skip breakfast, to always have a good protein and a good-quality fat, because that is where they are going to get the most long-term, sustained energy. I recommend that they not have too many carbohydrates in the morning, and, if these patients are going to have carbohydrates in the morning, then they should be whole grains and be a small complement to a breakfast that contains healthy sources of protein and fat. Examples are eggs and breakfast meat or scrambled tofu. I recommend that people avoid food emergencies, meaning that the blood sugar sinks down and these patients have nothing to eat. Ideally, people should pay attention to when they are hungry, eat high-quality food, and have emergency foods in their purses, backpacks, cars, or their desks at work.
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The brain registers blood-sugar crashes as a “four-alarm fire,” and the brain will do everything it can to conserve energy for itself—a person will grab for anything to conserve that energy. Typically what people will grab for, however, is food that is high in sugar or fat. So, I encourage patients to keep raw or roasted nuts, organic meat jerky, or other high-protein foods such as hard-boiled eggs handy at work and at home for snacks. Eating regularly throughout the day helps to keep blood sugar level steady. I recommend that patients stop eating around 7:00 o'clock in the evening to let the body go into the parasympathetic system's rest-and-digest mode, which supports the natural decline in cortisol as the day progresses and allows the body to settle down into sleep more easily later that night.
Interestingly, many of these same herbs are the botanicals that various cultures consider the “kings and queens” of herbs. In Ayurvedic medicine, ashwagandha [Withania somnifera] is considered to be one of the supreme herbs for treating the nervous system, while in China, ginseng [P. ginseng] is considered to be one the supreme herbs for promoting energy, stamina, and vitality. Other adaptogens include licorice [Glycyrrhiza glabra], holy basil (Ocimum tenuiflorum; tulsi), American ginseng [P. quinquefolius], and maca [Lepidium meyenii], which is a Peruvian herb that is used as a nourishing botanical, almost like a food. Then there are medicinal mushrooms, particularly reishi [Ganoderma spp.] and Cordyceps [Cordyceps sinensis], which also act as adaptogens.
To be defined as an adaptogen, an herb or substance has to meet the following criteria: • It has to have a nonspecific effect in that it increases resistance to a broad spectrum of physical, chemical, and biologic stressors. • It has to have normalizing effects in that it counteracts or prevents disturbances brought about by stressors. • It has to be innocuous to the normal functioning of the organism, thus being nontoxic.
The definition of adaptogens by Panossian, 2 who is one of the leading researchers on botanicals, is herbal preparations that increase attention and endurance in fatigue and reduce stress-induced impairments and disorders related to the neuroendocrine and immune systems. These herbs all have activities that modulate the underlying disruptions and downstream effects associated with hypervigilance—linked with chronic activation of the HPA axis—helping prevent adrenal fatigue and reverse its symptoms.
Overall, the purported benefits of adaptogens are that they increase energy, relieve fatigue, improve mood, and decrease anxiety and depression. These herbs can improve stamina and sleep. Adaptogens are immunomodulators and are considered to be amphoteric, so they can upregulate or downregulate various aspects of the immune system. They can increase exercise capacity, improve cognitive function and mental alertness, increase resistance to stress, improve energy metabolism, and improve tissue repair. These are all the benefits that have been looked at in a variety of clinical trials.
The effects that adaptogens have are based on various compounds, some of which are thought to resemble catecholamines and some which are thought to be similar to corticosteroids. Some of the constituents are believed to help modulate ACTH and corticosteroid formation, and are thought to regulate some of the triggers, such as corticotropin-releasing factor. Adaptogens may limit overproduction of catecholamine and regulate the central nervous and immune systems. Adaptogens are thought to promote faster recovery of mitochondrial RNA after excessive exercise, to improve protein synthesis, and to increase recovery of leukocyte counts after exposure to stressors. There is also a whole other constellation of effects on reduction in oxidative stress and lipid peroxidation.
There are proprietary blends on the market that incorporate a number of different adaptogens, although a couple of the different adaptogens may be contraindicated in individual cases. Licorice, for example, is contraindicated in people with high blood pressure. Rhodiola is contraindicated in patients with bipolar depression.
Each adaptogen also has activities that make it specific for addressing certain symptoms and conditions. For example, Rhodiola has been found to be particularly helpful for individuals with generalized anxiety disorder. Ashwagandha, which is relaxing to the musculoskeletal system, and is calming, thus helping relieve sleep disruption. Eleutherococcus has been found to be especially beneficial for patients needing support for cognitive function and mental stamina, for example, people with overnight jobs that require mental concentration, such as medical residents.
For patients struggling with frequent reduced immunity and frequent illness caused by stress I consider medicinal mushrooms, such as reishi or Cordyceps, as the polysaccharides in these are supportive for the immune system. Ginseng has specifically been found to help with blood-sugar regulation and may be helpful for addressing insulin resistance.
I am very cautious about using adaptogens with patients who are taking medications for mood disorders, blood-sugar disorders, and immunosuppression, because of potential interactions.