Todd:
Hi, and thank you for joining us at EmpowHer – Women’s health online. Now let’s talk about adrenal fatigue or hypoadrenia, a pituitary health disorder in which the adrenal glands are claimed to be exhausted and unable to produce adequate quantities of hormones, now primarily cortisol. To clear up some of the confusion, let’s talk right now with Dr. Theodore C. Friedman. He is a member of EmpowHer’s Medical Advisory Board. He specializes in, well, you guessed it, hard-to-diagnose and treat cases of adrenal, pituitary, thyroid and fatigue disorders–a perfect person for us to talk with.
He has been with the University of California, Los Angeles, the School of Medicine since 2005, serves as the Chief of Endocrinology, Metabolism, Molecular Medicine Division at Charles R. Drew University of Medicine and Science and served as the Director of the Multidisciplinary Chronic Fatigue Clinic at Cedars-Sinai Medical Center from 1998 to 2000. Hi, Dr. Friedman.
Dr. Theodore Friedman:
Hi, how are you doing, Todd?
Todd:
Dr. Friedman, I am doing great, but I hear there are a lot of people who have adrenal fatigue issues that might not be doing so good. So give me an overview. What is adrenal fatigue?
Dr. Theodore Friedman:
Okay, so first this is a very controversial topic, and I think this topic has sort of polarized mainstream endocrinologists, of which I’m certainly mainly in that camp, and the more alternative providers, of which I am open to and I try to work with, but I think in this area, we don’t have enough evidence supporting their claims.
So, let me try to talk about how the adrenal hormones, what they are, what they do, and in what condition they may be low in, and then I’ll try to tie into this idea about adrenal fatigue. So there is clearly a disease, adrenal insufficiency, which is often called Addison’s disease.
Addison’s disease is when the adrenals are attacked by antibodies, and former President John F. Kennedy had Addison’s disease, and he was known as being sort of handsome and bronze. That’s because when your adrenals don’t work, your pituitary makes extra hormone, – the hormone called POMC which increases your skin pigmentation. President Kennedy was eventually placed on cortisol, and he did quite well and led our country to several years of glory as a president.
However, the diagnosis of adrenal insufficiency is one that has to be made very clearly and precisely. Let me explain that. So the adrenals make two hormones that are crucial to the health; one is cortisol, and cortisol is a life-threatening hormone. If you have zero cortisol you could potentially die. Cortisol regulates your glucose; that’s what’s called a glucocorticoid. It also is involved in the “flight or fright” response, so, when ancient man was chased by a sabertooth tiger and had to run away, his ACTH made by the pituitary and then his cortisol made by the adrenal glands goes up. So it reacts to stress; it goes up in response to stress.
Todd:
And Dr. Friedman…
Dr. Theodore Friedman:
It also goes up in the different times of the day; it’s higher in the morning.
Todd:
Sorry about that. I mean, and cortisol, also, when we get in arguments, like with our spouse or our boss, our cortisol generally goes through the roof.
Dr. Theodore Friedman:
It does go up with stress, and most of the time it usually goes down fairly quickly, and it’s appropriate to go up with stress. So one of the important issues is that the body is really good at regulating the amount of cortisol it makes at the right time and under the right stress. So you don’t want to sort of give the body exogenous or cortisol in a pill unless it really needs it because the body is so good at determining when it needs more and when it doesn’t.
So cortisol again, is this important hormone, and when people that have low cortisol suffer from a very concrete set of symptoms: they are very tired, they have a lot of joint pain, they have weight loss, they have nausea and vomiting, they have abdominal pain and diarrhea, and this is fairly consistent with most patients with very low adrenal levels, very low cortisol levels such as somebody that has Addison’s disease.
The next hormone the adrenal makes is also crucial. People really don’t understand this that well; it’s called aldosterone. Aldosterone is a hormone that regulates salt. Somebody with low aldosterone will lose salt in the urine, and therefore, the water sort of goes out with the salt and they will be dehydrated. By being dehydrated, they might be thirsty; they may try to compensate by liking salty food and trying to eat more salt. They may have fatigue because they don’t get enough blood going to their brain. They may feel worse after exercising because more blood goes to the muscles when they exercise and even less will go to their brain. They usually have low blood pressure; can have a high pulse; can be dizzy; can be light-headed when they stand up, and this, as you can see, is a completely different set of symptoms and signs than the person with the cortisol deficiency.
And let me explain one of the crucial areas and then we will go on to some more questions, is the pituitary governs the adrenals in terms of making cortisol and may have a little role in governing the aldosterone, but the aldosterone in general is regulated by a kidney hormone call renin. So if you have an adrenal problem your renin will be high, your aldosterone will be low. Your pituitary hormone HGH will be high, and your cortisol would be low.
If you have a pituitary problem you would have fairly normal, might be little bit low renin and normal or low aldosterone. You would have low ACTH and low cortisol. Now, the adrenal can have the aldosterone could be deficient; the cortisol can be deficient or both can be deficient. However, the pituitary is usually affected in a certain order. First hormone to be affected if your pituitary is damaged is growth hormone; then it’s often the LH and FSH which regulate in a woman her periods and also regulate testosterone.
The next hormone is TSH which regulates the thyroid, and only very severe cases of whether when your pituitary is damaged, such as if it’s completely removed during surgery, is your ACTH and hence the cortisol low. So it’s very rare for a person with a pituitary problem to have low cortisol.
Now the practicers that claim about adrenal fatigue, they base their work on the idea that if somebody is under severe stress, let’s say they are in starvation and they have a very limited amount of calories to eat, or let’s say someone, you know, was in the concentration camp, sort of as a prisoner of war, that their stress will be so high that after a while their adrenals will stop functioning, and they’ll get adrenal insufficiency.
However, what usually happens is stress, especially someone with sort of consistent stress--and everybody in our society has stress--stress causes the adrenals to work more. And as we talked about, when you are under stress and you’re arguing with your spouse, the cortisol goes up; it doesn’t go down. So the providers that are advocating this adrenal fatigue really are sort of missing the point of how the adrenals work, that they would need, usually when you are having the sort of stress, as long as it’s not sort of the life-threatening stress, your adrenals actually make more cortisol, not less.
So what happens if you give somebody that doesn’t really need cortisol, if you give him cortisol and you think you might be doing him a favor. Often they will feel a little bit better at the beginning; cortisol does make people feel a little bit better mood, but their own adrenals will stop working. When their own adrenals will stop working, they won’t be able to get off the cortisol. They will need to take it for the rest of their life. Excess cortisol gives them osteoporosis, increased infections, diabetes, waking, bruise.
So cortisol is a very dangerous drug, and as a physician, I always try to look at the risk and benefits of things. So giving somebody who has the aldosterone problem, either more salt, is a very benign condition, especially if the blood pressure is low, giving him aldosterone, a synthetic aldosterone, it’s called Florinef. We give him that, it’s also pretty benign; they can stop that. It’s a very benign medicine. But giving someone cortisol is really a very serious medicine that is very hard to get off of and will prevent their own adrenals from making the cortisol at the right time of the day and the right amount and regulating the stress.
So I think only on somebody who is very clear-cut, there’s real insufficiency, should they get cortisol.
Todd:
Dr. Friedman, earlier you mentioned that adrenal fatigue is often considered a controversial diagnosis like in the medical mainstream, but non-mainstream doctors are diagnosing people with it all the time. Can you talk about that?
Dr. Theodore Friedman:
Yes, I can. So, again, I think, there’s been no published articles on treating adrenal fatigue. There was one article that did show that, you know, patients under more stress, their adrenals were basically normal; it didn’t show their adrenals were low. The way, in general,the endocrinologists and conventional doctors test their cortisol is first of all, they can either measure a morning cortisol, and if its very low, say less than five, they are pretty sure they have adrenal insufficiency and cortisol insufficiency. If their cortisol is pretty normal, let’s say it’s greater than 12, they are pretty likely not to have it, and then if it’s in gray zone between say 5 and 12, they may have cortisol, they may not make enough under stress-like circumstances. And I think that testing should only be done if somebody has the symptoms and sort of the etiology to have an adrenal problem or pituitary problem, but if you measure a cortisol in the morning that’s somewhere between 5 and 12, we do what’s called a cosyntropin test.
This test relies on the fact that ACTH is given, and ACTH stands for adrenocorticotrophic hormone, notice that word ”trophic” in it. So if you have low ACTH, either from a pituitary problem, your adrenals start atrophying. It takes a couple of weeks or maybe a month or so, but if you have a problem with your ACTH, your adrenals will atrophy and if you give ACTH, the adrenals will not respond. Similarly, if you have an adrenal problem itself, you give ACTH; they won’t respond either. So people do this cosyntropin test very frequently, and that’s usually the main test done to diagnose adrenal insufficiency in Western medicine.
In the more alternative doctors, what I have been seeing them doing is measuring salivary cortisols. The salivary cortisol assay is pretty good for picking up high cortisol at night, but I don’t think it’s that good for picking up low cortisol in the morning, and also the labs that do it vary dramatically. There is some conventional laboratories that do a very good job of it, but there’s a lot of companies that are Internet-based, that appeal directly to either patients or to alternative providers that measure it, and I have seen some of their data. Their assays are not reproducible. They measure one day, and it seems like it’s low; they measure the same patient, the same sample even, and the next day it’s high.
Most of the times the tests run very low, and they try to do it four different times of the day and have a nice little printout of little graph, and almost always in my patients, they are low when I do other tests like blood cortisol or the cosyntropin test or even some urine test–they all come out normal.
So I think some of the doctors place too much emphasis on these salivary tests that are not reliable, and then if they come out low they would give cortisol back. I have seen also another major problem is a lot of doctors, either they want to be more natural or either they are more holistic, instead of giving cortisol back, they give adrenal extract. This is called IsoCort. This is, again, a very potent, potent drug because it’s giving ground of adrenal glands and has cortisol in it; it has aldosterone in it. It has DHEA which is a hormone that can cause increased hair growth and acne, and they give these ground of adrenal glands and who knows exactly how much the patient is getting, and these patients can get signs and symptoms of cortisol excess very easily from taking these ground of adrenal glands. I think this is extremely dangerous and I think even giving cortisol to patients that have these low salivary is also somewhat on the danger side.
Todd:
It sure sounds like it is, so how does a patient know if their doctor is, well, I guess up to speed on what is the proper treatment in the mainstream?
Dr. Theodore Friedman:
Right, so I would probably go to a board-certified endocrinologist if I was a patient. At least get a second opinion from one if I was a patient that had some provider suggest that their cortisol is too low and, you know, have the doctor do the conventional tests, and if the conventional tests agree with the alternative test, then I think it would be reasonable, but I think if they disagree, I think I’d be very reluctant to take cortisol or adrenal extracts.
Todd:
Right, well, that sounds like that’s really good advice. What else do we need to know about adrenal fatigue while we are here?
Dr. Theodore Friedman:
Right, so I think a lot of it is confused with this aldosterone deficiency. The patients are low on this hormone aldosterone; the treatment can be very simple, like taking more salt. I see many, especially women, have very low blood pressure. They are very dizzy; they are light headed; they may have palpitations and just having them take, and their blood pressure again is low, so taking a little more salt is not harmful; it’s often very helpful. They can add an extra teaspoon or take some salt tablets and that gets their blood pressure up instead of like 90/60, maybe get it up to 110/80 and they’ll feel much better. It’s not dangerous for them at all as long as they monitor the blood pressure.
So I think this aldosterone deficiency is probably under diagnosed and this adrenal fatigue is over diagnosed, an overlap between the two.
Todd:
Sorry, if you go to an endocrinologist, they should be able to straighten that out for you.
Dr. Theodore Friedman:
I think so, yes.
Todd:
Well, he is Dr. Theodore C. Friedman. He is a member of our Medical Advisory Board here at EmpowHer. He specializes in fatigue disorders and hard-to-diagnose and treat cases of adrenal, pituitary, and thyroid disorders. Dr. Friedman, thank you so much for helping us empower women.
Dr. Theodore Friedman:
Okay, thanks, Todd.
Todd:
Now for those who’d like more information on Dr. Friedman, one of the best ways you can get it is to go to EmpowHer, search “Dr. Friedman,” and his profile will pop up and you will have all the information and the interviews right there and also a link to Dr. Friedman’s website. Dr. Friedman, again, thank you so much.
Dr. Theodore Friedman:
Thank you, Todd.