This is part of an adrenal series that starts here. In this post we dig into “adrenal fatigue” and how to test for it. The term “adrenal fatigue”was coined by Dr. James Wilson in 1998, and it’s been a popular term ever since. Many of us functional practitioners use this term for convenience – even though “adrenal fatigue” is not actually a thing.
Move over adrenal fatigue
Yup, “adrenal fatigue” is not a real medical condition. Chronic or acute stress does not make your adrenal glands poop out. Your adrenal glands are not intelligent on their own. They simply make hormones when instructed by your brain to do so. The entire stress response involves much more than your adrenals. It first starts in your brain and goes like this:
In your brain:
- You first perceive fear in the amygdala.
- Then your hypothalamus gland makes CRH (corticotropin-releasing hormone).
- Next your pituitary gland makes ACTH (adrenocorticotropic hormone).
ACTH travels to your adrenals to activate a stress response:
- Norepinephrine and epinephrine (part of the catecholamine neurotransmitters) are released from stores inside your adrenal.
- Cortisol is made on demand in the mitochondria, after about 10 minutes of sustained stress.
In your body cells and tissues:
- These adrenal hormones bind to receptors on your cells so they can get inside and do their work.
- Then they break down (metabolize).
Rinse, lather, repeat if the stress trigger continues.
Meet HPA-D, the real clinicial entity
This stands for hypothalamus-pituitary-adrenal axis dysfunction. This more accurately portrays the breakdown of the whole stress response. This condition is a real thing, and it’s written about extensively in the medical literature. However, your conventional doctor or endocrinologist has not been trained in this. They only recognize severe HPA-D disruption at both ends of the cortisol spectrum:
- The autoimmune disease Addison’s disease, which is abnormally low production of cortisol (and aldosterone, an adrenal hormone that regulates salt and water).
- Cushing’s syndrome (high cortisol) and Cushing’s disease (high cortisol due to a tumor).
If your HPA-D is not at either severe end, you’re deemed as normal, and may get an eye roll or two if you bring up “adrenal fatigue” to your regular doctor.
In functional medicine, we assess and treat the HPA-D spectrum between Addison’s and Cushing’s. Like many conditions, we are concerned with the entire spectrum – not just when you’re at the extreme end and really sick. We want to prevent that from happening. We assess the health of your HPA axis, and we can also assess other things involved with the stress response, such as:
- The flexibility of your amygdala – is it overactive? Are you a “highly sensitive person?”
- Your mitochondrial function (where cortisol is made).
- The cofactors your adrenals need to make hormones, such as vitamins B5, B6, and C, and the mineral magnesium.
- How cortisol and catecholamines metabolize, which is affected by liver and thyroid health, inflammation, insulin, and specific genetic SNPs like COMT.
How do we test the HPA axis?
We do this by testing cortisol! However a single cortisol reading on a blood test doesn’t tell you much. It’s important to see what your cortisol is doing throughout the day and overnight, as it fluctuates a great deal. This means taking cortisol measurements at least four times in a 24-hour time frame. You can do this with urine or saliva samples, or both. Here’s what an healthy cortisol curve looks like:
Here cortisol is very low during the night, which is ideal for sleep. In the morning, 50% of your cortisol is secreted in the first 30-ish minutes you’re awake. This is called your cortisol awakening response (CAR). Cortisol responds to daylight and gives you your get-up-and-go energy. This is why it’s harder to get up in the dark by the way. In perimenopause the CAR can be disrupted and try to wake you up at 3 or 4 AM.
Saliva, which measures free cortisol in the moment, is best for measuring your CAR. Urine measures metabolites and is best for seeing:
- Your total cortisol production over a day.
- The cortisol diurnal curve – when it’s high and when it’s low.
- How cortisol metabolizes – this is affected by things like liver and thyroid health, inflammation, and insulin levels.
What does the DUTCH test assess?
The DUTCH adrenal test collects urine samples that measure free and total cortisol, metabolites, and your diurnal curve. You can see if you actually have HPA-D, and if so, what type. Then you can treat according to your type. Here are examples:
- Early onset HPA-D often shows high cortisol throughout the day but still low at night. Daytime energy and stress are high and sleep is good.
- Chronic HPA-D that’s been going on for a while can show cortisol getting lower during the day, and going up during the night. Lower energy during the day, wired in the evening with a second wind, and awake at night.
- Advanced HPA-D often has low cortisol across the board, and possibly a slight elevation at night. The CAR can be nonexistent. Dragging, frequently sick, and wiped out by exercise.
This is somewhat simplistic, and there are many more nuances to the DUTCH test results, including DHEA levels (another adrenal hormone important for energy and immunity), and how you breakdown and recycle your cortisol.
Different versions of the DUTCH test
You can get the adrenal test for $299, however, I typically bump it up to the Complete or the Plus, both of which add many more markers.
- The Complete is the one I typically order. It adds all sex hormones (estrogen, progesterone and testosterone), melatonin, and organic acids. Read Why All Women Should Take the DUTCH Complete Hormone Test.
- The Plus is the Complete plus your cortisol awakening response (CAR) which is measured with saliva samples. This is for you if you want a close-up on your CAR.
The information from these test results is invaluable. Instead of just guessing whether or not you have “adrenal fatigue,“ you can find out if you do, and exactly what’s going on with your HPA axis so that you can properly treat it.
If you want help with your results, you can book a new patient appointment with me, get 20% off your test, and have the results in hand at your appointment. Book 3-4 weeks out to give enough time.
Wonder if this test is for you? Check out Who Should Take the DUTCH Adrenal Test?
The next post is how to heal from HPA-D.
Questions about the DUTCH test? Please ask below,