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“Every Afternoon At About Four I’m So Tired I Could Sleep At My Desk”

“Exhaustion is my reality. At four o’clock, I’m wiped, totally wiped.”

Patricia is 33, happily married as far as marriages go, one kid, steadily employed in the usual American less-­than-­satisfying corporate job, good eating habits, and, until recently, a health club goer a couple/three times a week. Now she’s too tired for that. Just looking at her, you can tell she’s dragging. Circles under her eyes and she needs to blink a couple of times to bring a thought to the surface.

One tuckered out woman.

Patricia brought in blood tests from her primary care doc and everything looked fine. Blood count, metabolic profile (checking for diabetes and kidney or liver disease), thyroid function, iron level. He even did screening tests for mono, autoimmune inflammation, and, because it’s the new hot topic, Lyme. At a sleep lab, she was told there was no evidence of a sleep disorder.

Nada. Nothing. She exhaustedly absorbed the mantra of contemporary medicine: “We can’t find anything wrong with you. All your tests are normal. Do you think you might be depressed?”

Patricia told me she didn’t think she was depressed, though contemplating feeling like this for the rest of her life could send her in that direction. Really, if she had the energy to call a babysitter she’d love to go out with her husband.

The 4 pm crash gives us a clue
Although Patricia had never been an energizer bunny in the morning, now she wakes up feeling like she hasn’t slept at all. To snap her brain into gear for work, these days she downs a couple of extra shot lattes. She knows she’ll function at two thirds capacity until 3 or 4 in the afternoon, when she becomes so tired she melts like a warm ball of Silly Putty. Then, a few hours later, at 8 or 9 (much to her annoyance, since it’s just before bedtime), she’ll get a strange burst of energy, just enough to interfere with sleep. Recently, though, even this energy burst is history.

My bet was on her adrenal glands, two walnut-sized structures that sit atop the kidneys. If you put your hands on your hips, your thumbs will be just about where your adrenals are located.

Your adrenals are actually two separate glands. The first, called the medulla, is within, surrounded by the second, the adrenal cortex. Envision a plum. The seed of the plum is the medulla, the fruit the cortex. Both the medulla and the cortex are your front-line responders to stress. However, the medulla, connected to your brain and nervous system, is your first responder and it works really fast.

Threatened by a mugger? Signals from your brain to your adrenal medulla trigger a burst of adrenalin that turns you into a temporary superwoman. (“Here’s a face full of pepper spray, punk!”)

The adrenal cortex, indirectly connected to your brain through the pituitary–the master gland that also controls your thyroid and ovaries (or testicles, depending)–is the slower, second responder.

The cortex deals with chronic stress, and its several hormones regulate metabolism (especially glucose for energy), reduce inflammation, and control blood pressure by balancing sodium.

Your adrenal cortex is good for a day’s work before it needs to be charged up at night. Think of it as a one-day battery you recharge during sleep. Its hormone, cortisol, starts the day at a high level and then dwindles out by evening. It trusts that you’ll sleep at night in order for it to be at the top of its game in the morning.

Since you don’t encounter many major stressors in a day, like a mugger or having to lift a car off someone, it’s the adrenal cortex that’s more involved in the daily stress you experience. But–and here’s the big but–when you’re beset by relentless low-grade stress your adrenals will poop out. Exhausted, tired, fatigued. And since adrenal function normally starts winding down in the late afternoon, if you’re experiencing adrenal fatigue it’s at this time with your especially low cortisol levels that you’ll first feel symptoms.

Your adrenals are fine—they’re just overworked
It’s important to understand there’s nothing actually wrong with your adrenal glands. They’re just running on empty. If they could talk, they’d plead, “Overworked! Give us a rest! Charge us up! We need a vacation!”

Typically, adrenal fatigue occurs as a consequence of unchecked physical or emotional stress. To return to Patricia, she’d had more than her share during the previous year. Her mother had died of ovarian cancer after a long illness, and with Patricia an only child her father had needed her help constantly. Patricia’s husband had been “a rock,” but her young daughter needed her, and then there were the work demands. She’d been stretched so thin she would have snapped, but instead sat numbly in front of the TV sipping pinot noir, waiting for bedtime.

Adrenal fatigue is not a difficult diagnosis if your doctor has it on her mental “check­-for-­this” list. The challenge patients face is that most conventionally trained endocrinologists don’t believe adrenal fatigue is real. My guess is they can’t tolerate a diagnosis that emerged from natural medicine practitioners. The best book on the subject, Adrenal Fatigue: The 21st Century Stress Syndrome, was written by a (heaven forfend!) chiropractor, James L. Wilson, DC.

The anti-­alternative website quackwatch.com lists adrenal fatigue among its unproven “fad diagnoses,” joining candida overgrowth, Gulf War Syndrome, and multiple chemical sensitivity. The even more unsympathetic Endocrine Society (I inadvertently typed “Endocrime”) dismisses adrenal fatigue as a myth.

Their intellectual curiosity is a shameful less than zero.

Dr. Wilson created a questionnaire that you can take, but keep in mind that a lot of the symptoms listed are not specific for adrenal fatigue. The idea behind the quiz is for you (and your doctor) to at least consider adrenal fatigue as a diagnostic possibility and order further tests.

However, unless your doctor thinks of ordering the simple test that measures cortisol levels in your saliva you could go undiagnosed for years. The Endocrine Society actually advised insurance companies not to pay for this test, but, fortunately for you, the price has dropped considerably and it’s available for less than $100, the remainder covered by virtually any health insurance in its out­-of-­network benefit list.

When you look at the test results at these two links, you’ll wonder how endocrinologists could be so dense. Here’s a graph showing normal cortisol levels, taken from saliva specimens in the morning, at noon, and in the afternoon and evening.

And here’s the graph of a person with all the symptoms of adrenal fatigue.

Patricia’s adrenal stress profile was pretty much a flat line. Classic adrenal fatigue. Next week, I’ll outline my approach to help worn out Patricia get her life back.

Be well,
David Edelberg, MD

Leave a Comment

  1. Teresa Strong says:

    Thank you! I have been diagnosed with adrenal fatigue. Does one ever get over it? Does it get worse with age? I had to laugh at your endocrime joke. They do indeed like to jump to the “depression” diagnosis!

  2. Teresa says:

    Thank you. Your crack about the endocrimologists was true and funny!

  3. cliffmaurer says:

    Hi Teresa –

    Patients with adrenal fatigue often do well with some supplementation and lifestyle change regarding diet, sleep and their stressors. As we age, all of our glands tend to show signs of wear and tear, but making good choices earlier in life can help this process along so that we age healthfully. Next week, Dr. Edelberg will discuss his treatment approach to adrenal fatigue. We hope you stay tuned!

    In good health,
    Dr. M.

  4. thanks a ton. i will patiently wait till next weeks post.
    (no pun intended)

  5. MK Gilbert says:

    I’m quite sure I have it…Did the saliva tests a few wks ago~will see the CNP next week to see my results. Took it 7 yrs ago, but I reacted badly to the suppplements the chiro that ordered the test had me take for low thyroid and adrenals. (I was also taking levothyroxin.) They gave me panic attacks and I’ve gotten much worse since the. Hopefully this CNP will be wiser. She said something about possibly supplementing with DHEA, I think…I’m super-sensitive to so many things. Can’t handle much caffeine, cold meds or any stimulants. Have had multiple drug failures, and yes, I do have severe depression plus some anxiety. I’m beginning to feel desperate, like there’s no hope for EVER getting better. A chiro/nutritionist said I had adrenal fatigue when I was in my mid-twenties and now I’m almost 60. Have had 3 sleep studies, started using a c-pap a few months ago, STILL feel dragged out when I get up in the AM. Seem to need 10 hrs sleep/nite but often have difficulty getting to sleep. Afternoons are real hard~bad brain fog. Severe mood swings.

  6. Dawn says:

    Can you please tell me if I go back to my primary care dr. And request a cortisol level done via saliva, do I need to have 3 tests done morning, non and night??? I’d offer to pay for one out of pocket, and that’s even if she will do it! But 3 would be steep. Also, I think 2-3 yrs ago I brought an article into my dr. Describing a lady with adrenal issues. I told her I felt the lady was me! The dr dismissed it and said no I don’t think that’s your issue and wouldn’t test my cortisol levels. Told me to get more sleep. It’s been yrs of feeling like crap, but I push myself and talk to myself daily that I can get thru the day!!

  7. Gina Pera says:

    Great job, as usual, Dr. Edelberg.

    Yes, many endocrinologists are dense. Same with sleep specialists, psychiatrists, rheumatologists, etc. It’s downright discouraging to people who suffer from chronic illness.


  8. MK Gilbert says:

    I also wasted time and $ on an endocrimologist who told me there was no such thing as adrenal fatigue! I just don’t understand why different branches of practitioners can’t work together for the patients’ benefit! I’ve also been told the regular MD’s don’t believe in “leaky gut” syndrome which I also have symptoms of…If all the test results look “normal” we are “OK” even tho we feel like crap! SO stupid. I’m a very intelligent person plagued with brain fog and memory problems mostly due to the chronic fatigue, I think…but in over 25 yrs I haven’t been to anyone except a couple chiros who have taken my complaints seriously, but we’re paying so much for health insurance now I really can’t afford to go to ones that aren’t covered by our insurance. I did go to an open-minded gastroenteologist who actually suggested I try acupuncture for the “fibromyalgia”. The 1st consultation is covered, but nothing after that…so I didn’t bother. I hate needles, but am desperate enough to try just about anything to feel better…except shock therapy. That scares me!

  9. Dr E says:

    Hi Dawn
    This is the test you should get. Call the lab and ask about the price. They can mail you a kit. If your doctor agrees to sign the form ordering the kit, your cost will be abut $99 but you’ll need to send them a copies of all your insurance cards so they can bill your insurance for the difference. Your cost will be no more than the $99

  10. Dr E says:

    Hi MK
    See if you can get this test
    Your out of pocket will be about $99.
    Since you are so chemically sensitive, you might respond nicely to homeopathy. You can Google to see if there is a homeopath near you

  11. Beth says:

    Mayo clinic wrote on their website a few years ago that adrenal fatigue did not exist and that quote has been used all over the Internet. Doesn’t help. One of the earlier commenters brought up cost–I found the cost of supplements for AF to be unaffordable. While conventional medicine has a lot to answer for, I have to say that the often blithe way supplements are rather aggressively recommended shows a lack of understanding. Many of us with AF got it due to other chronic conditions and chronic pain. Our careers are not on fire, if we’re able to work at all. We’re out of money and have no choice but to see the doctors who take insurance and take whatever med is covered by insurance. This is a huge problem that needs to be addressed system-wide by you and your colleagues, Dr. E.

  12. MK Gilbert says:

    Yup, that’s SO true! I have had some bad reactions to “natural” supplements as well.

  13. Dr E says:

    Hi Beth
    I’ll be writing about adrenal fatigue treatment next week but as I checked the prices of the supplements I was recommending (there are only two), the combined price came to $43 a month and usually only for 3-4 months of treatment. However, I also recommend a maintenance adrenal supplement which is about $23 a month. Sometimes for severe fatigue, a prescription med is needed, almost always covered by insurance, but without insurance it is $19 a month, again used for 2-3 months at most.
    To put things in my own perspective, I recently saw a TV ad for Kerydin,the new prescription nail polish for toenail fungus. The price for a 10 ml bottle (two teaspoonfuls) is $1,400. Yes, you read that correctly.
    I personally think nutritional supplements are reasonably priced BUT the problem I see frequentlynis that practitioners over-prescribe and patients themselves over-buy and ultimately spend too much $$ on products that may not even be helpful
    See the attached link I wrote several years ago about just this topic

  14. Beth says:

    Thank you for responding, Dr. E. I must say there a months when I am 50 dollered to death, and I would not be able to pay 43 dollars. Currently cannot work, treating several symptoms. However, I may possibly be over-supplemented, as you stated. In any event, I very much respect you and what you do. Thank you!

  15. Kem says:

    Thanks again, Dr. Edelberg. My (deceased) mother had adrenal gland issues, but it wasn’t until this post that I had thought to connect that family history with my own current lethargy issues. I’m eagerly looking forward to the next blog post.

  16. Donna Dufner says:

    Dr. E.
    Loved the article! Now I understand my fatigue. I get so tired in the afternoon I fall asleep sitting up, then feel like working at night. I ordered supplements from the Apothecary.


  17. Annabel Grey says:

    Good article but your recommendation of Dr Wilson’s book is a bit out of date.

    Check out the new book from Dr Eric Wood and Fawne Hansen instead — its called The Adrenal Fatigue Solution.

    It has much newer and up to date information than the old Wilson book. Highly recommended.

  18. Christina DeMeola says:

    Hi – I got a workup with Dr. Kelley at WholeHealth about two years ago, and my cortisol was high, DHEA was low. I’ve been on DHEA supplements since then. Thyroid function still tests WNL. And I’m still so tired despite limiting caffeine to the morning, getting to bed a decent time (continuity of sleep is an issue even with melatonin.) I’m in graduate school, working three days, doing an internship, and those are stressors that aren’t changing any time soon. I try to get sleep and exercise but sometimes – like today – I’m too tired to exercise. Looking forward to reading more about the treatment…zzzzz….

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