“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.
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.
David Edelberg, MD