Adrenal Fatigue

What is Adrenal Fatigue?

Adrenal fatigue is a name used by some practitioners and in the media for a set of symptoms said to be caused by chronic stress wearing out the adrenal glands. It is not recognized by any endocrinology society.^[1]

A systematic review of 58 studies found no solid evidence that it exists as a medical condition.^[1] A short commentary reached the same conclusion and found no support for supplements said to "support" adrenal function.^[2] Tiredness is real, and it deserves a real explanation, which is why we start with a medical evaluation.

Common symptoms

People who use the term describe ongoing tiredness, difficulty getting up, a need for caffeine, poor sleep, low mood, trouble concentrating and cravings for salty or sweet foods. These symptoms are nonspecific and overlap with many conditions.^{[2, 3]}

Fatigue is also the most common symptom of true adrenal insufficiency, reported in about half to nearly all patients, together with nausea, poor appetite and weight loss.^[4]

Causes and risk factors

The adrenal fatigue idea holds that long-term stress exhausts the adrenal glands. Studies of cortisol levels in people with fatigue have given conflicting results, and the methods used were often not endorsed by endocrinologists.^[1]

Real causes of fatigue include sleep problems, depression and anxiety, thyroid and other hormone disorders, nutrient deficiencies, other illnesses and some medicines, and these are the first things a physician looks for.^[2] True adrenal insufficiency is a different, diagnosable condition with its own causes.^{[4, 5]}

How it is diagnosed and treated conventionally

There is no accepted test or treatment for adrenal fatigue itself. Doctors look for treatable causes of fatigue, and when adrenal insufficiency is suspected, it is diagnosed with early-morning blood measurements of cortisol, corticotropin and DHEAS, sometimes with a stimulation test.^[4]

Adrenal insufficiency can be primary (adrenal gland disease such as autoimmune Addison disease), secondary (a pituitary problem) or caused by steroid medicines. It is treated with replacement glucocorticoids, and people with it must learn how to prevent an adrenal crisis.^{[4, 5]} Glucocorticoid-induced adrenal insufficiency is common in people who have recently reduced or stopped steroid medicines.^[4]

Why Adrenal Fatigue calls for a whole-person approach

Fatigue rarely has a single cause. Stress, sleep, mood and physical health all feed into how tired a person feels, and a medical workup is needed before assuming any one of them is the cause.

Supportive care is aimed at stress, sleep and daily energy, not at the adrenal glands.

Stress and the stress-hormone system

Stress affects the body's cortisol system, but how this relates to fatigue is poorly understood. Reviews of the cortisol research in people with fatigue found conflicting results and poor-quality methods.^[1] Some authors use the term "adrenal asthenia" for fatigue from ongoing stress, and they note it is not part of the medical vocabulary.^[3]

Sleep

Poor sleep is one of the nonspecific symptoms that people attribute to adrenal fatigue, and it has its own causes and treatments.^[2] Evidence on acupuncture and herbs for sleep is discussed below.

Mood and anxiety

Low mood, anxiety and irritability often accompany ongoing fatigue. They are medical issues in their own right and are worth raising with your physician.

Medical causes that must not be missed

True adrenal insufficiency can be mistaken for tiredness and can become life-threatening in an adrenal crisis.^[4] Hormone, thyroid and other conditions can also cause fatigue, so testing by a physician comes first.^{[2, 5]}

Acupuncture as supportive care in Adrenal Fatigue

What the research shows

We found no clinical trials of acupuncture for adrenal fatigue, and the condition itself is not recognized. The evidence below is for related symptoms, not for the adrenal glands.

A meta-analysis of 16 studies of acupuncture for chronic fatigue syndrome found a better response rate than with sham acupuncture and with Chinese herbal medicine, but the certainty was low, most studies were of low quality, and the authors said no firm conclusion could be reached.^[6] For sleep, a meta-analysis of 24 trials in insomnia found acupuncture improved sleep scores compared with medicines after more than three weeks, with high variability between studies.^[7]

How acupuncture may work

How acupuncture might ease fatigue or poor sleep is not known. There is no evidence that it changes adrenal function or cortisol in people with fatigue, and we do not claim that it does.

What treatment involves

Treatment uses fine, sterile, single-use needles placed at points on the body, usually left in place for about 20 to 40 minutes. A course of several visits is followed by a reassessment of whether it is helping with sleep, stress or energy.

Serious problems are rare. In prospective studies, about 9 in 100 patients had a minor reaction such as bleeding, soreness or redness at a needle site, and serious events occurred in about 1 in 10,000.^[8] Tell the practitioner first if you have a bleeding disorder, take blood thinners, are pregnant, or have a pacemaker (relevant to electroacupuncture).

Ayurvedic medicine as supportive care in Adrenal Fatigue

The Ayurvedic view

Ayurveda does not have a condition called adrenal fatigue. Practitioners may describe long-term tiredness and depletion as reduced ojas or an imbalance of the doshas, and plan care around a person's constitution, routine and symptoms. These are traditional categories, not biomedical diagnoses.

Therapies that may be used

Care is chosen for the individual and may include:

• Diet and daily routine, such as regular meals, a consistent sleep schedule and limiting stimulants
• Gentle warm oil massage and relaxation practices
• Breathing practices and yoga suited to the person's energy level
• Herbs traditionally used for stress and low energy, prescribed individually after review of your medicines

Panchakarma is not appropriate during pregnancy, acute illness or frailty, and it is generally not suited to someone who is already depleted. The clinic can also discuss a herbal preparation applied to the skin (transdermal therapy), but no research supports it for fatigue.

What the research shows

We found no clinical trials of Ayurvedic treatment for adrenal fatigue. Evidence for individual Ayurvedic herbs exists only for stress, anxiety and sleep in other groups of people. A meta-analysis of 12 trials with 1,002 participants found ashwagandha reduced anxiety and stress scores compared with placebo, though the certainty of evidence was low and results varied widely.^[9] A smaller meta-analysis of 5 trials found improvements in anxiety and some sleep measures, and called for larger studies.^[10]

Herbal medicine as supportive care in Adrenal Fatigue

Herbs and formulas that have been studied

No herb has been shown to treat adrenal fatigue. Herbs sometimes called adaptogens, such as ashwagandha and rhodiola, have been studied for stress, mood and physical or mental performance in people who do not have an adrenal disorder.^{[11, 12]}

What the research shows

The evidence is limited. A systematic review of 9 studies found that short-term ashwagandha lowered cortisol in stressed people, but none of the studies looked at adrenal function or long-term effects, and the authors advised medical supervision.^[11] A review of 11 placebo-controlled trials of rhodiola suggested possible benefits for physical and mental performance and some mental health conditions, with few mild side effects, and noted a lack of independent replication.^[12]

Ashwagandha also appears to have some benefit for sleep in a meta-analysis of 5 trials.^[13] None of this shows that these herbs restore adrenal function.

Safety and herb-drug interactions

Herbs are active substances and can interact with medicines. This matters especially here because ashwagandha lowers cortisol and may change thyroid hormone levels, which could affect someone with an undiagnosed or treated hormone condition, or someone taking hydrocortisone or thyroid medicine.^{[11, 14]} Ashwagandha has also been linked to liver injury, which was severe in people who already had liver disease.^[15]

More generally, interactions between herbs and prescribed drugs can have serious consequences, including bleeding with warfarin.^[16] Herbal and dietary supplements account for about 20% of drug-induced liver injury in the United States.^[17] In one study, about one fifth of Ayurvedic products bought online contained detectable lead, mercury or arsenic.^[18] Herbs should come from tested sources and be prescribed individually. Tell us if you are pregnant or breastfeeding, or have liver or kidney disease.

Translating traditional medicine into modern biological language

The links drawn here are interpretation, not equivalence. Chinese medicine often describes long-term tiredness as deficiency of qi or of the kidney or spleen, and Ayurveda describes depletion of ojas. Neither framework describes the adrenal glands as "exhausted".

What researchers can measure are stress, sleep, mood and fatigue scores, and cortisol patterns, though the cortisol research on fatigue has been inconsistent.^{[1, 6, 9]} Supportive care here is about stress and sleep, not about restoring an adrenal gland.

How this care fits with your medical care

Please see a physician about ongoing fatigue before or alongside any complementary care. We do not diagnose the cause of fatigue, order or interpret hormone tests, or replace your physicians. Do not stop or change prescribed medicines, especially hydrocortisone, prednisone or thyroid medicine, without your prescriber.

Please bring any recent blood test results, a list of your medicines and supplements, and the name of the physician who is evaluating your fatigue.

When to seek urgent medical care

Fatigue can sometimes signal a serious problem, so some symptoms need prompt attention.^[4]

• Severe weakness, dizziness or fainting, especially on standing
• Persistent vomiting, severe abdominal pain or diarrhea with weakness
• Confusion, extreme drowsiness or a very low blood pressure
• Fatigue after stopping or reducing steroid medicines
• Fatigue with unexplained weight loss, fever or night sweats
• Feeling hopeless or thinking about harming yourself; call or text 988 (Suicide and Crisis Lifeline)

If any of these occur, call 911 or go to the nearest emergency department.