Dr. Friedman discusses the endocrine problems that cause fatigue and explains how salt impacts this.
Thyroid disease would be certainly one of the most important things to look for. But it’s not the only reason and I have plenty of patients that came to either an endocrinologist or primary care doctor or naturopath doctor who complained of fatigue and they had normal thyroid test and the doctor nevertheless put them on thyroid medicine and it almost never works.
So you can’t just treat somebody with fatigue with thyroid medicine because there are other endocrine causes and there are other causes of fatigue.
The next area to discuss is adrenal causes of fatigue. The adrenals make two very important hormones – one called cortisol, and another one called the aldosterone.
Cortisol is probably the more famous hormone and it’s a stress hormone. When you are under stress it goes up and when you are under less stress it goes down and it works for most patients very well.
Patients with an adrenal problem can have low cortisol, that’s often called and if it’s due to an autoimmune attack of the adrenals it’s called Addison’s disease.
And patients with low cortisol levels, adrenal insufficiency can be very fatigued. They also have weight loss, nausea, vomiting, abdominal pain, diarrhea, joint pains, muscle pains.
So in any patients that will come to me with fatigue as one of their symptoms I would look for some of those other associated problems. However, the adrenal insufficiency is somewhat rare, at least the cortisol insufficiency.
And again, I think many doctors sort of, because they don’t know what else to do they can often put patients on cortisol. When you put somebody on cortisol who doesn’t really need it their own adrenal stops making it, and if their patients are worse off and sometimes they get addicted to cortisol and have to go off of it and they can’t go off of it. So you want to be very careful on who you put on cortisol and who you don’t.
As I mentioned before the adrenalin also makes a hormone called aldosterone which is a salt regulating hormone. And I think we understand aldosterone much less than we understand cortisol, but I find aldosterone a very important hormone in women and patients with low aldosterone can have very severe fatigue.
As I said, aldosterone regulates salt. So somebody with low aldosterone will lose salt in the urine. Therefore their blood volume is going to be low and they are going to feel dehydrated.
They don’t get enough blood going to their brain and that lack of blood going to the brain, at least according to many doctors, can give some of the symptoms of fatigue.
The blood may also go more to the muscles so when somebody exercising for example, they even get less blood going to their brain and they might feel worse.
Patients also with aldosterone deficiency try to compensate the fact that they lost the salt in the urine and therefore what they do is they crave salt.
You can ask a patient with aldosterone deficiency, what type of foods they eat, and they’ll say, “Well I love pickles and I even sometimes drink the juice from the pickles. I salt everything. I love potato chips and pretzels,” and they sort of go on list their food and every single one of them contains salt.
I then ask the patient sometimes does the salt help you? And they say, “Yeah, it really helps me a lot but my doctor said I shouldn’t take it or I don’t want to have too high a blood pressure.”
So most patients with aldosterone deficiency have very low blood pressure, sometimes they can have a high pulse and so when I come in and I see a woman with a blood pressure of 90 systolic and 60 diastolic they have a high pulse.
They also maybe complaint of palpitations because the heart is trying to work harder to compensate for this low blood volume, and they say they are dizzy when they stand up and they say they are very tired.
In those types of patients I would measure their aldosterone. Aldosterone again is a hormone made by the adrenals and I would measure their rennin which is a hormone made by their kidneys.
In a lot of patients with chronic fatigue they have low rennin and low aldosterone; they don’t get the message going from their brain to their kidneys properly.
And some patients may have a primary adrenal problem of which case they have low aldosterone and the rennin made by the kidneys that regulates aldosterone goes up as compensation. So sometimes they see a low aldosterone and a high rennin and sometimes a low aldosterone and a low rennin.
And in those patients and especially the ones who have low aldosterone and high rennin I want to make sure their cortisol is okay. Most of the time their cortisol is okay, but sometimes both the cortisol-producing cells of the adrenal are affected, as well as the aldosterone-producing cells.
But if just their aldosterone producing cells are affected and I find they have low aldosterone there’s a couple of treatments I can use for them. The most benign treatment is giving them more salt, and again people are conditioned not to have salt, but because they’d only get high blood pressure, but most medical conditions, both too much and too little is bad.
So certainly if you have high blood pressure it’s bad but if you have a low blood pressure and you are not getting enough blood going to your brain it’s bad, and you can correct that often by just giving the person more salt.
You can either have them salt their foods; some patients like to take sea salt, or you can give them salt tablets and some patients don’t want to bother remembering salting their food, they can just pop a salt tablet twice a day or so.
This usually helps a great percentage of patients. However, some patients you have to give a little bit more and you have to give them synthetic aldosterone which is called fludrocortisones or Florinef. Florinef is the brand name; fludrocortisone is a generic name and it’s only available generic now.
So you can often give patients salt plus the fludrocortisone and unlike giving patients cortisol, fludrocortisone is a very benign medicine. The main thing is you have to watch out is it will raise your blood pressure. So you don’t want to raise it too much or otherwise the person will be getting a high blood pressure.
So let’s say a person starts out with a systolic pressure of 90. I might give him enough salt and/or the fludrocortisone to get it up to about 100-110 and the patient will often feel very much better on that and they’ll say, well you know I am more alert.
That’s the idea about brain fog, maybe also you don’t get enough blood going to your brain then you give them some Florinef and some salt and their blood pressure goes up. Their systolic blood is around 110 and they feel great. Then their palpitations go away; their dizziness will go away and even their salt craving goes away.
So I use that fludrocortisone and if the patient, they can also get swelling in their legs and some people get a headache on it, usually goes away in about two weeks. But if the patient is not responding to it or decides they want to stop it for a reason, you can stop it.
It’s not like taking the cortisol that you get addicted to and you have taper it down but you can stop it. So this aldosterone deficiency I feel is an under diagnosed endocrine problem that affects a lot of women and it’s very easily treated.
About Dr. Theodore Friedman, M.D., Ph.D., M.Phil.:
Dr. Theodore Friedman, M.D., Ph.D., M.Phil., specializes in hard-to-diagnose-and- treat cases of adrenal, pituitary, thyroid, and fatigue disorders. He's been with the University of California Los Angeles School of Medicine since 2005 and serves as Chief of the Endocrinology, Metabolism and Molecular Medicine Division at Charles R. Drew University of Medicine and Science. He also served as Director of the Multi-Disciplinary Chronic Fatigue Clinic at Cedars-Sinai Medical Center from 1998-2000.
Dr. Friedman has a private practice near Beverly Hills, California as well as privileges at Cedars-Sinai Medical Center and Martin Luther King Medical Center.