Validity of Adrenal Fatigue and Mild Insufficiency

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 symptoms." (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 unnamed substance, tentatively called Compound F. The name later became hydrocortisone, with impressive benefits and usefulness reported at the Mayo Clinic as well.

MS: Did the researchers find side effects to hydrocortisone?

RS: 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.

MS: 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?

RS: 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.

MS: Have there been other publications?

RS: 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.

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

RS: 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.

MS: 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?

RS: 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.

MS: In the end, what should patients do?

RS: 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 Saliva 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, an 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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